Chapter 49: The Child With an Alteration in Tissue Integrity

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Welcome back to the Deep Dive.

We are really glad you're here with us today.

It is good to be back.

Today we are tackling a topic that I think a lot of people initially dismiss as,

you

have a stack of research and specifically chapter 49, the child with an alteration in tissue integrity from the maternal child nursing textbook in front of us.

And let me tell you, the story is much deeper than that.

It really is.

That is the formal textbook way of saying we were talking about skin.

Right.

Skin.

But if you think skin is just about putting on a bandaid or, you know, dealing with a little rash, this deep dive is going to completely change your perspective.

That is exactly the mission today.

We want to take this textbook chapter on pediatric skin disorders and turn it into a practical high stakes guide for nursing practice.

Because when you actually dig into these sources, it becomes obvious that for a child, the skin isn't just a wrapper.

It is a sensitive alarm system.

I like to think of it as a map.

A map.

I like that.

Unpack that for us.

Well, skin disorders are statistically some of the most common issues you will see in But the stakes range wildly.

I mean, we are talking about everything from a diaper rash.

Which is miserable for everyone involved.

Oh, absolutely.

Miserable for the baby and the parents, but, you know, medically minor to life -threatening fluid loss from burns or systemic infections that start with just a tiny scratch.

The skin is the visible map of the child's internal health.

And the psychological element is huge here, too, right?

You can't hide your skin.

You can't.

Whether it's acne in a teenager or a large birthmark on a toddler, these things affect how a child sees themselves, how they interact with the world.

So, okay, what's our plan today?

How are we navigating this map?

So here's our roadmap.

We will start with the physiology, specifically why a baby's skin is

essentially a ticking time bomb compared to an adult's.

Okay.

That will move into the common terrain,

birthmarks, dermatitis, the infections that invade that barrier, and the infestations that, well, they drive everyone crazy.

And we'll finish with the heavy hitters, trauma and burns.

Exactly.

But we have to start with the architecture.

The anatomy.

Let's get our bearings.

Right.

We need to review the intagumentary system.

Most nursing students can list the functions in their sleep.

Protection, temp regulation, water excretion.

Vitamin D production, sensation, the basics.

The basics.

But for the nurse, the focus has to be on the layers.

You have the epidermis on top, the dermis below it providing the blood supply and nerves, and then the subcutaneous fat at the bottom for insulation.

Standard biology.

Yeah.

But the sources highlight a massive, and I mean massive discrepancy between a newborn and an adult regarding that top layer, the epidermis.

It is the critical difference.

In a newborn,

the epidermis, specifically the stratum corneum, which is that tough outer layer of dead cells,

is significantly thinner.

So it's just not as thick.

Not just that.

The cells aren't as tightly packed together.

The attachments between the cells, the little junctions, they're weaker.

So what does that mean practically?

If I'm a nurse holding a baby, why do I care that their cell attachments are weak?

It means you aren't holding a sealed container.

You're holding a sponge.

A sponge?

Wow.

That thin barrier means increased permeability.

Think about it this way.

If you put a topical medication on an adult, it absorbs at a certain, you know, slow rate.

If you put that same medication on an infant, it absorbs rapidly and completely.

So a topical dose becomes a systemic dose.

Effectively, yes.

This is why we are so, so cautious with things like corticosteroids or even certain soaps in the NICU.

And it works both ways.

Things get in fast, but water gets out just as fast.

Their transepidermal water loss is massive compared to ours.

Which brings us to the math of it.

The body surface area.

This seems to be a concept that comes up constantly in pediatrics.

It trips up a lot of students, but it is just physics.

Infants have a much larger body surface area relative to their total weight than adults do.

So pound for pound, they just have more skin exposed to the world.

Correct.

So combine a massive surface area with a thin permeable membrane.

It's a recipe for rapid dehydration and rapid hypothermia.

They lose heat way faster than they can generate it.

And the sources mention that their internal thermostat isn't even fully wired yet.

The hardware is there, but it is not mature.

The Akron sweat glands, the ones that cool us down, they don't function at full capacity until a child is two or three years old.

That explains so much about toddler behavior in the summer.

I mean, they aren't just being cranky.

They are physically overheating and can't cool off.

They are physiologically trapped.

They can't sweat efficiently to cool down.

And if it's cold, they lose all that heat through that massive surface area.

And there's more?

Oh yeah.

On the flip side, they have fewer melanocytes.

Those are the pigment cells.

So they have basically zero defense against UV rays.

And their IgA levels, the immune defense in the skin, are low.

So they burn faster, infect easier, dehydrate quicker, and absorb toxins better.

Exactly.

Skin care in pediatrics is essentially critical care.

You are maintaining their fluid balance and their temperature regulation just by keeping their skin intact.

That is a massive perspective shift.

Okay, let's move on to reading the map.

One of the first things a nurse does, sometimes minutes after birth, is assess for marks, birthmarks.

And the parent's first question is always, is this normal?

And usually, it is.

But looking at the notes, the documentation seems to be where the legal and medical safety nets come in.

Let's distinguish between the vascular ones and the pigmented ones.

Vascular D's with blood vessels.

The most common one you'll see is the salmon patch or the stork bite.

Nape of the neck, eyelids, pink and flat.

I feel like half the babies I've seen have these.

It is extremely common.

They are benign.

They usually fade.

Parents don't need to worry.

And as a nurse, you can offer that reassurance confidently.

But, and this is a big but, you have to distinguish that from a port wine stain.

Okay, so visually, how do I tell them apart?

They are both red.

Port wine stains are darker, usually a deep red to purple.

And critically, they do not fade.

In fact, they darken and can even thicken as the child grows.

The skin can actually become pebbly over time.

And unlike the stork bite, the location of a port wine stain matters.

It matters immensely.

If a child has a port wine stain, we need to assess for underlying syndromes.

Specifically, if that stain is on the face,

following the distribution of the trigeminal nerve think forehead and upper eye, we have to worry about Sturge -Weber syndrome.

You're talking about a neurological condition.

Yes.

Sturge -Weber involves vascular malformations on the brain itself.

It can lead to seizures,

developmental delays, and glaucoma.

So a skin mark can actually predict seizures.

It predicts structural brain issues, yes.

That is why the phrase just a birthmark is a dangerous phrase if you haven't done your assessment.

Okay, what about hemangiomas, the strawberry marks?

The notes say these are often not present at birth, which seems counterintuitive for a birthmark.

That is what scares parents.

The baby is born with clear skin.

Then, two or three weeks later,

this bright red raised lump appears and starts growing rapidly.

It looks aggressive.

It looks like a tumor, which technically it is.

It's a benign tumor of endothelial cells, the cells that line blood vessels.

The good news is they usually run out of gas.

They grow for a few months, they plateau, and then they involute.

They shrink down over years.

By age five or nine, most are gone.

So the nursing intervention is mostly watchful waiting.

Usually,

unless, and this is the big nursing consideration, unless it interferes with function.

If a hemangioma is on the eyelid, it can cause blindness just by physically blocking vision or pressing on the eye.

And if it's on the airway?

Then it's life -threatening, absolutely.

The notes mention treating the problematic ones with propranolol.

I thought that was a heart medication.

It is.

It's a beta blocker used for high blood pressure.

It was actually discovered by accident.

Kids on heart meds saw their hemangiomas shrink.

We now know it constricts the capillaries in the hemangioma.

That's why it's still a heart drug.

It is.

So the nurse has to monitor for bradycardia, which is a slow heart rate, and hypotension.

You are slowing the heart to clear the skin.

That is a fascinating trade -off.

Let's switch to pigmented marks.

I want to highlight Mongolian spots because the notes have a specific warning about abuse allegations.

This is a major cultural competency issue and a documentation priority.

Mongolian spots, or congenital dermal melanocytosis, are deep blue or gray patches.

They look exactly like a deep bruise.

And they are common.

Incredibly common in black, Asian, and Native American infants.

Much less common in white infants.

I can see the scenario.

A nurse who has only seen lighter -skinned babies sees a blue mark on a baby's buttock and calls social services.

It happens.

And it is so traumatic for the family.

The nurse's job is to identify them at birth and document them clearly as Mongolian spots.

This puts a time stamp on them.

This was here when the baby was born.

That documentation protects the family later if someone questions the bruise.

And they fade eventually.

Usually by age four or five, they just kind of blend in.

What about cafe au lait spots?

Coffee with milk?

Light brown patches, one or two.

Yeah, it's normal.

Completely normal.

But if you are doing an admission assessment and you count six or more, and they are larger than about five millimeters.

You are literally counting spots on a baby.

You have to.

Six or more is the diagnostic threshold for neurofibromatosis type 1.

It is a genetic disorder that causes tumors to grow on nerve tissue.

Wow.

Again, the skin is the map to the genetic code.

If you miss the spots, you miss the diagnosis.

All right.

Let's move from things children are born with to things they acquire.

Dermatitis.

Inflammation.

The itch.

The itch.

Let's start with the one that looks the worst but apparently feels the best.

Seborrheic dermatitis.

Cradle cap.

Oh, it looks terrible.

Thick yellow oily crusty scales all over a newborn scalp can even be on the eyelids.

But the baby, totally unbothered.

It is not itchy at all.

It's just oil and fungus, right?

A little malicentia yeast and some overactive sebaceous glands because of mom's hormones still circulating in the baby.

The mistake parents make is trying to pick it off dry.

Which leaves raw skin.

Ouch.

And opens the door for infection.

The nursing education here is all about technique.

You tell the parents to massage the scalp with warm mineral oil to soften the crust.

Then use a soft brush, a fine tooth comb, or even a soft toothbrush works great.

To gently list the scales while shampooing, it's a slow process, not a one -time fix.

Contrast that with diaper dermatitis.

That one definitely hurts.

Oh, yeah.

That is a chemical burn.

It's irritant contact dermatitis.

You have urine, which contains urea.

Bacteria in the stool break urea down into ammonia and ammonia is caustic.

The baby is basically sitting in a caustic chemical bath.

Exactly.

Plus friction from the diaper, plus moisture holding it all against that thin permeable skin we talked about.

The advice here is all prevention, but looking at the treatment protocols, there is a specific warning about steroid creams in the diaper area.

Why is that?

This goes right back to the thin skin and absorption.

A diaper acts as an occlusive dressing.

It creates a seal of heat and moisture.

If you put a steroid cream on a baby's bottom and then slap a diaper over it, you are basically force feeding that steroid into the bloodstream.

You could suppress their adrenal glands just treating a diaper rash.

You absolutely could.

It significantly increases systemic absorption.

So we usually avoid steroids there unless absolutely necessary and prescribed.

Instead, we use barrier creams, zinc oxide.

Think of it as spackling.

You are putting a thick layer of paste between the skin and the ammonia.

And air.

And air.

Let the baby go diaper free.

Air is the medicine here.

Speaking of contact dermatitis,

poison ivy.

There is a huge myth we need to bust here.

The contagion myth.

Don't touch the blisters.

You'll catch it.

False.

Completely false.

The fluid in the blister is just serum.

It is the body's own inflammatory fluid.

It contains zero poison ivy oil.

You cannot catch poison ivy from the rash itself.

So why does it always seem to spread?

Because the oil, the urushiol is sneaky.

It's on the dog.

It's on your shoelaces.

It's under your fingernails from scratching.

So you touch the dog.

You get a rash.

Three days later, you tie your shoes.

You get a new rash.

It looks like it is spreading from the body.

But it is just re -exposure from the environment.

So the nursing intervention isn't just put cream on the rash.

It is decontaminate the entire world.

Pretty much.

Wash the dog.

Wash the shoes with alcohol.

And wash the skin within 15 minutes of exposure if you can.

Once that oil bonds to the skin proteins, the reaction is locked in.

Now the big one.

A topic, dermatitis.

Eczema.

This isn't just a rash.

This is a lifestyle for these families.

It is.

We call it the itch that rashes.

The scratching comes first, then the skin breaks down.

It's genetic, usually part of the atopic triad.

Asthma, allergies, and eczema.

If a kid has one, you should be looking for the others.

The source material describes the skin barrier here as a crumbling brick wall.

That is the perfect analogy.

Healthy skin cells are the bricks.

The lipids and oils are the mortar.

In eczema, the mortar is defective.

So water escapes, leading to that awful dryness.

And irritants and bacteria get in, leading to infection.

And the management seems to swing back and forth on the to bathe or not to bathe question.

It is settled pretty firmly on the wet approach.

We want to hydrate the skin.

So lukewarm baths, not hot.

But, and this is the critical step that parents almost always miss, the seal.

The three minute rule.

Yes.

You take the child out of the bath, pat them damp, do not dry them fully.

While they are still damp, within three minutes, you slather them in an emollient.

Something thick.

Vaseline.

Eucerin.

No lotions with pumps.

If it pumps, it has too much water.

You need grease.

You are physically trapping the water in the skin cells.

Exactly.

If you wait 10 minutes, the water evaporates and the skin is actually drier than before you started.

You have to catch the moisture.

And when we do use steroids for flare ups, we have to talk about potency.

Right.

Steroids come in classes.

Class one is super potent.

Class seven is weak, like over the counter hydrocortisone.

You never ever put a high -potency steroid on the face or genitals.

The skin is too thin there.

You will cause atrophy thinning of the skin and stretch marks.

What about the bleach baths mentioned in the text?

That sounds medieval.

It sounds harsh, but for these kids, it is a lifesaver.

Their skin is heavily colonized with staph shureus because of all the cracks and scratching.

The bleach bath is very diluted.

It's like swimming pool level chlorine.

It just lowers the bacterial count on the skin so it can finally heal.

It isn't about burning the skin.

It is about disinfecting the wounds.

Which is the perfect segue to infections.

When the barrier fails, the bugs get in.

We are dealing with staph and strep.

The usual suspects.

Let's talk impetigo.

This is the one with the honey -colored crusts.

That's the classic presentation.

Usually starts around the nose and mouth.

A little vesicle pops and this golden sticky crust forms.

It just looks messy.

And it is wildly contagious.

Incredibly.

In a daycare or a kindergarten, it spreads like wildfire.

The nursing education is all about hygiene.

Keep the fingernails short so the kid doesn't scratch the bacteria into new places.

Wash hands constantly.

Separate towels and washcloths.

And the school rule.

24 hours of antibiotics before they can go back.

Usually, a topical muperosin is enough for small areas, but they need that 24 -hour window to stop being infectious.

Now, if that bacteria goes deeper,

we get cellulitis.

Right.

Impetigo is surface.

Cellulitis is subcutaneous.

The skin is red, hot, swollen, and tender.

It looks angry.

And the red line I sometimes see?

Streaking.

That's lymphangitis.

That means the infection has hit the lymphatic system and is traveling away from the site.

That is a sign to escalate care immediately.

The notes highlight periorbital cellulitis specifically?

Why is an infection around the eye such a red flag?

Location, location, location.

The veins around the eye drain directly back into the cavernous sinus in the brain.

An infection there can lead to meningitis or blindness very, very quickly.

So a swollen red eye isn't a wait -and -see situation?

No.

That is often an admission for IV antibiotics.

We do not mess around with infections near the brain.

Let's switch kingdoms.

From bacteria to fungi.

The yeasts and the dermatophytes.

Candidases and tinea?

Candidases in the mouth is thrush, white patches on the tongue, and gums, but milk leaves white patches too.

How does a nurse tell the difference?

The scrape test.

If you scrape it gently with a tongue depressor and it comes right off, it's milk.

If it sticks, or if it bleeds when you try to move it, that is thrush.

And treating it in an infant is tricky because you can't tell them to swish and spit?

Right.

We use oral nystatin.

But you don't just squirt it in the back of the throat and hope they swallow it.

It is a contact medication.

You have to paint it on the lesions, you take the applicator, and literally rub it on the gums and tongue.

And check the source.

Always.

If the baby has thrush, check the breastfeeding mother for nipple pain or redness.

They can pass it back and forth.

You have to treat both or it never goes away.

Then we have ringworm.

Teeny, which is not a worm.

No worms involved, just fungus.

Tinea corporeis body ringworm is pretty easy.

Topical cream, apply an inch past the border, but tinea capitis scalp ringworm seems much harder to treat.

It is.

The fungus is way down in the hair follicle.

Topical creams just can't reach it.

You have to use systemic oral medication, usually greasofulvin.

And here is the deep dive nugget for this section.

The absorption of greasofulvin.

This is where treatment fails.

Greasofulvin is insoluble in water.

If you give it a glass of water, it just passes right through the digestive tract.

You have to give it with fat.

So this is the ice cream prescription.

Literally.

Right.

Or peanut butter.

Or whole milk.

You have to tell the parents, this medicine must be taken with a high -fat meal.

If the nurse doesn't teach that, the drug won't absorb, it won't work, and the kid keeps losing hair.

That is a critical takeaway.

Okay, let's talk about things that crawl.

Infestations.

Lice.

The chelosis capitis.

The bane of every elementary school nurse's existence.

The stigma is so real here.

Only dirty kids get lice.

Complete myth.

Lice actually prefer clean hair.

It is less oily and it's easier to attach their eggs to.

They don't jump and they don't fly.

They crawl.

So it is head -to -head contact.

Selfies, sleepovers, sharing helmets.

Exactly.

Now, diagnosing it, you are looking for knits.

The eggs, they are tiny white specks on the hair shaft.

Which look just like dandruff.

But dandruff flicks off.

Knits are cemented on.

They have a glue.

If you try to pull it and it is stuck tight, it's a knit.

Treatment is permethrin shampoo.

But the failure rate seems high.

Why is that?

Two main reasons.

One, resistance is growing.

But two, and this is the big one, improper usage.

Permethrin kills the live lice.

It does not kill 100 % of the eggs.

So the eggs hatch a week later.

And the infestation starts all over again.

You must retreat in 7 to 10 days to kill the newly hatched nymphs before they can lay new eggs.

That second treatment is non -negotiable.

What about the no -knit policies in schools?

The sources suggest a shift in thinking there.

This is controversial.

The CDC and the American Academy of Pediatrics now say kids should not be sent home for knits.

They shouldn't miss education for what is really a nuisance condition that doesn't carry disease.

That is a tough sell for other parents, I'd imagine.

It is.

But scientifically, by the time you see knits, the kid has had lice for weeks.

Sending them home now doesn't prevent spread that already happened.

But good luck explaining that at a PTA meeting.

Fair point.

Now, scabies.

This sounds like a horror movie.

Mites burrowing into the skin.

It is parasitic.

The female mite burrows into the epidermis to lay eggs and poop.

Gross.

It is gross.

And the immune reaction to the waste products causes this intense, severe itching.

And there is a timing clue.

Night time.

The itch is significantly worse at night.

If a child is scratching specifically at night, you need to look at the wrists, between the fingers, and in the armpits.

You are looking for fine, grayish, thread -like lines.

Those are the tunnels.

And the treatment is permethrin again, but applied very differently.

Very differently.

For lice, it's a shampoo.

For scadies, it is a full body cream.

Neck to toe.

And for babies, it's head to toe.

Every single inch.

Under the nails, in the crack of the butt, everywhere.

It has to stay on for 8 to 12 hours, usually overnight.

And you treat everyone?

Everyone in the house.

Even if they aren't itching yet.

Symptoms can take weeks to appear.

If you treat just the kid, dad will reinfect him next week.

Let's fast forward to adolescence.

Acne vulgaris.

It is almost a rite of passage, but we really shouldn't minimize it.

The pathophysiology is a perfect storm.

It is.

You have puberty hormones, the androgens ramping up sebum production.

You have sticky skin cells clogging the pores.

And you have bacteria, cutobacterium, acnes feeding on that sebum.

Oh, so it's in.

It is not dirt.

Scrubbing harder actually makes it worse by irritating the skin and spreading the bacteria.

The pharmacological approach requires some chemistry knowledge.

We use benzoyl peroxide and tretinoin, which is retin -A.

Both great drugs.

Yeah.

Benzoyl peroxide kills the bacteria.

Tretinoin unflugs the follicles.

But if you apply them at the same time, benzoyl peroxide can oxidize and deactivate the tretinoin.

So they literally cancel each other out.

And you just have an irritated face.

The nurse has to teach.

Benzoyl peroxide in the morning, tretinoin at night.

And tretinoin makes you photosensitive.

Very.

You will burn in the sun.

Sunscreen is absolutely mandatory.

Now for the severe cystic cases, we have isotretinoin, Accudane.

This is the nuclear option.

It shrinks sebaceous glands, effectively curing the acne.

But the side effect profile is massive.

Specifically, teratogenicity.

It causes severe life -altering birth defects.

Because of this, we have the IPL -Bi's program.

It is a risk management distribution program.

How strict is it?

Incredibly.

A female patient of childbearing age cannot just pick up a prescription.

She must agree to use two distinct forms of birth control.

She must have a negative pregnancy test every single month in a certified lab before the pharmacist can even dispense the pills.

And the mental health component.

There is a known correlation with depression and suicidal ideation.

We have to monitor the mood as closely as we monitor the skin.

Finally, let's talk about trauma.

Bites and burns.

Starting with bites.

If it is a bee sting, the mechanics of removal matter.

Don't squeeze it.

Right.

The stinger usually has a venom sac attached.

If you pinch it with tweezers or your fingers, you are literally pumping the rest of the venom into the child.

You have to scrape it out horizontally with a credit card or a finger down.

And for spiders.

In North America, you really watch for the brown recluse and the black widow.

The recluse venom is necrotoxic.

It kills tissue.

You get a central blister that turns into a necrotic ulcer.

It can take months to heal.

The widow is neurotoxic.

You get muscle cramps, tremors, vomiting.

Both require medical attention.

Okay, burns.

This is the section where anatomy, physiology, and safety all collide.

It is.

And unfortunately, toddlers are the prime demographic for scald burns.

They reach up and grab pot handles or they pull on cords for coffee pots.

Let's talk about the assessment of abuse here.

The skin tells a story.

It does.

An accidental scald pulling a pot of water down is messy.

You'll see splash marks, irregular borders, varying depth.

It happened in chaos.

Versus an intentional immersion burn.

If a child is dipped into hot water as punishment, the burn is uniform.

You see a clear line of demarcation on the ankles or wrists.

We call it a stocking or glove distribution.

And the donut hole.

If a child is held down in a tub of hot water,

their bottom is pressed against the cool porcelain of the tub.

So the center of the buttocks is spared, but the surrounding skin is burned.

That pattern is, it's pathognomonic for abuse.

That is chilling, but recognizing it saves lives.

It does.

It initiates the protective response from the healthcare system.

Now, medically managing the burn,

we need to calculate the total body surface area, the TBSA, that's burned.

In adults, we use the rule of nines.

Which works because adults are proportional.

But remember what we said at the very beginning.

Kids have giant heads.

A baby's head is like 19 % of their body surface area.

Exactly.

If you use the rule of nines on a baby, you will vastly underestimate the burn on the head and overestimate the burn on the legs.

You will get the fluid resuscitation math wrong.

So use the London Browder chart.

Yes.

It adjusts the percentages based on age.

It accounts for the shrinking head to body ratio as a child grows.

It is the gold standard for accuracy in pediatrics.

And why is that accuracy so vital?

We're just hanging fluids, right?

But remember the physiology.

Children have limited glycogen stores and high metabolic rates.

If they have a major burn, say over 10 % TBSA, they start shifting fluid out of the blood vessels into the tissues almost instantly.

Hypovolemic shock happens so fast.

So we are replacing massive amounts of fluid.

Based on the Parkland formula.

But we also have to add maintenance dextrose.

Adults don't usually need sugar in their burn fluids.

Kids do.

Or they will become hypoglycemic and crash.

It is a delicate balance.

Not enough fluid.

Shock and kidney failure.

Too much.

Pulmonary edema.

Which is why burn nursing is one of the most technical specialties there is.

We have covered a massive amount of ground today.

I mean, from the permeability of a preemie's skin to the intricate chemistry of acne meds and the critical math of burn care.

It brings us back to the start.

The skin is a map.

It really is.

Whether you are counting café au lait spots to catch neurofibromatosis, checking the pattern of a burn to catch an abuser, or recognizing that a simple rash is actually a systemic infection.

The nurse is a cartographer.

You are reading the map.

And the educator.

Absolutely.

So much of this.

The eczema care, the lice treatment, the acne regimen happens at home.

The success of the treatment depends entirely on how well the nurse explains the why and the how to the family.

If you don't explain the fat absorption rule for grizzofolvin, the treatment fails.

If you don't explain the re -treatment for lice, the bugs come back.

Knowledge is the intervention.

It always is.

Here is something for you to think about as we sign off.

We tend to think of skin as the boundary between us and the world.

But as we've seen today, for a child, that boundary is incredibly fragile.

It is porous.

The world gets in easily.

And the child's resources leak out easily.

In a way, caring for pediatric skin is really about reinforcing the child's boundaries until they are strong enough to stand on their own.

That is a beautiful way to put it.

Thanks for diving deep with us today.

See you next time.

This is the Last Minute Lecture Team signing off.