DCH March 2004

Paper 1

Instructions

1. Answer each of the following FIVE (5) questions in separate books.

2. Each question has 4 sub-questions. Answers to each sub-question should be approximately 100-150 words (not more than 1 page) in length.

3. Each question is worth 40 marks and each sub-question is worth 10 marks.

The whole paper is worth 200 marks.

4. The aim is to check your ability to express objective knowledge with precision. Each question has a standard (model) answer and the mark you are awarded depends on the number of correct statements/points made matching the model answer.

Question 1

a) Management at a primary health clinic of an 8-month-old previously well child who has crossed centiles and is now under the 3^rd centile on a Road-to-Health card growth chart.

1. This child has shown growth faltering.

2. Confirm that the weighing and charting are correct.

3. Seek causes for growth faltering which reflect either failure to ingest adequate nutrition or failure to be able to utilise the nutrition.

Ø Failure to ingest adequate nutrition:

· Assess the nutritional situation of the child.

· Feeding practices

· Content of food – energy, protein, micronutrient quality and quantity

· Frequency of feeding. Needs about 5 feeds a day if on energy non dense diet

· Suitability of food for age

· Purchasing and food production options

· Use of affordable foods

· Use of nutrient supplementation

· Use of own grown foods

· Use of adult diet to supplement child’s diet

· Assess social situation and economic factors

· Is family life chaotic (alcoholism/ abuse etc).

· Is their an adequate income

· Is social support use appropriately (grants, nutrition schemes, NPO’s etc)

Ø Failure to utilize offered nutrition by child

· Are chronic anomalies present eg chronic cardiac, renal, respiratory disease, etc

· Are chronic infections present eg TB, HIV, UTI.

· Is gastrointestinal absorption normal

· Is the child normally developed and able to eat and swallow normally.

· Is the child dysmorphic with abnormal growth potential eg Foetal Alcohol Syndrome, Turners Syndrome, growth hormone deficiency or disproportionate short stature.

219 Words

b) Methods and implications of HIV testing of abandoned children, including how the necessary pre-test consent can be obtained.

HIV tests may either be for:

· HIV Antibodies – ie Elisa, rapid test, western blot

· HIV Antigens – HIV DNA PCR or HIV RNA copy count, p24 Antigen

Ø Antibodies reflect the body’s response to HIV infection in the child except where they are from and external source – usually trans-placental from a HIV +ve mother.

Ø Trans-placental antibodies may be detectable in child’s serum up until 18 months age, usually gone by 15 months.

Ø Test thus not definitive in until 18 months age if positive.

Ø If negative after 3months post delivery and cessation of breast feeding this reflects the absence of infection.

Ø Antigen detected in serum of children indicates infection. This test is sensitive for HIV infection after the 1^st 6 weeks of life with HIV DNA PCR. Should be repeated to confirm diagnosis. Negative test in the 1^st month(s) of life may not fully exclude infection. Negative test 3 months after delivery and cessation of breast feeding would largely exclude infection with HIV.

Ø Consent must be obtained from the parent(s) of the child when possible, they must have adequate counselling of the implication of positive or negative results both for the child and parents / family. Consent should be formally documented.

Ø Where the parent(s) of the child are not contactable after reasonable efforts including the use of the police consent for testing would depend on the circumstances of the child and its placement.

In the case of non urgent consent the superintendent of the placement institution, or foster parents, or adoptive parents may give consent if assigned this role by the children’s court. Otherwise consent should be obtained from the minister of social development (welfare) by means of delegation of authority, usually to local authority or provincial social development manager.

In case of urgent consent for life threatening situations, where the above are not possible the superintendent of the hospital to which the child is admitted may give consent with the advice of his/ her senior staff, if test is vital for the welfare of child.

Ø Where children for adoption are tested the effect depends on the result.

· Usually children who test negative for HIV infection will be more easily adopted, fostered or place. At times there are people and institutions who would prefer to take children who are HIV infected as part of their service intention.

· Usually children who test positive for HIV infection are less easily placed.

· Children who are not tested are often less easily placed.

c) Management of a 2-year-old child with generalised tonic-clonic epilepsy who is having about three seizures monthly while on phenytoin treatment.

Ø This level of control is unacceptable.

Ø The diagnosis of idiopathic epilepsy should be questioned if regression of development, or development of neurological findings occur. If these are present, search for neurological anatomic lesion, progressive neurological disease or metabolic diseases.

Ø Confirm convulsions by checking the history.

Ø Debate exists over the most desirable anticonvulsant for a child of this age - due consideration should be given to ease of adherence, to taking medication (frequency of dosage etc), effect of non adherence (T ½ ), cost, effectiveness, side effects (including life threatening, behavioural and cognitive).

Ø Dosage against weight & administration processes should be confirmed to be correct.

Ø Co-administration of recognized pharmaceuticals and alternative medications should be sought to exclude interactions.

Ø Adherence should be assessed (frequency of missed follow up, pill counts, body language of care give & self evaluation). Adherence can be improved with caregiver education.

Ø Blood levels should be checked.

Adequate levels suggest anticonvulsant is ineffective, change to another agent should be considered. Consideration includes Phenobarbitone, Sodium Valproate and Carbamazepine. New agent can be initiated at full therapeutic dose as liver enzymes are already induced. Phenytoin should be stopped only after at least 5 T ½ lives of the new agent have been administered to assure therapeutic levels.

Low serum level infers incorrect dosage/administration, non compliance, drug interaction or unusual metabolic situation. The ability of the family to adhere to treatment should be considered and attended to.

Ø Due vigilance for side effects of all new drugs must be maintained with the aid of the parents and active medical follow up.

d) An approach to assessing children with school failure from the medical point of view.

Children who fail school should be assessed for:

Poor educational setting:

Inadequate or threatening school situations

Poor social Setting

Poverty

Chaotic home circumstances

Poor nutrition

General Hunger

Iron deficiency (often parasite associated)

Lack of breakfast

Developmental Disabilities

Mental Retardation

Dysmorphic or other syndromes

Physical disability impeding learning

Cerebral Palsy

Behavioural Abnormalities

Immaturity

Conduct disorder / oppositional disorder

Attention Deficit Hyperactivity Disorder

Post Traumatic Stress Syndrome

Pervasive Disorder (Autism etc0

Affective disorders

Substance abuse

Special Senses Problems

Hearing

Vision

Specific Learning Problems

Dyslexia, Dysgraphia, Computational disorders etc.

Underlying chronic ill health

Asthma, Epilepsy, Cardiac, Renal, HIV, TB (detected or occult)

Sleep Deprivation

Oropharyngeal obstruction, excessive TV or other social involvement.

Abuse

Sexual, physical, emotional or nutritional

Over-commitment

Parents who have their children committed to too many activities.

125 words

Question 2

a) The management of a child who has just been stung by a bee and is known to have previously had an anaphylactic reaction to a bee sting.

1. A brief enquiry about the history and nature of the reported anaphylaxis.

2. A medicalert bracelet to this effect may already be present on the child.

3. Close observation of the patient with a particular attention to expected symptoms such as urticarial rash, itch, sensation of warmth, laryngeal oedema with stridor and bronchospasm with wheezing or feeling of tightness of the chest. The development of hypotension may develop very rapidly as a result of severe and intense vasodilatation and needs to be preempted.

Pre-hospital

4. The aim of immediate management is to avoid severe complications that may be fatal.

5. In the pre-hospital situation, enquire as to whether the child or caregiver have adrenaline in a pre-filled syringe such as Epipen® or Anaguard® that needs to be administered immediately intramuscularly (not subcutaneous as no longer a recommended route and not intravenously either).

6. The emergency medical services need to be activated i.e. a call to either 10177 on a land line or 112 on a cellular phone for an ambulance.

7. Should it be easier and quicker to transport the patient to the nearest healthcare facility, this option would need to be considered.

Hospital/Casualty Dept

8. In the emergency department of the healthcare facility the following needs to be done.

9. Vitals assessed – BP/Pulse/Resp rate/ Oxygen saturation

10. Oxygen mask placed and maintain airway (consider requirement for intubation)

11. Adrenaline given IM in a dose of 0.3mls of 1:1000 (undiluted) (Paediatric dose). If child > 12years give 0.5mls.

12. IV line inserted

13. Promethazine (antihistamine) IM/slow IV (Dose range 6.25 – 25mg depending on age)

14. Hydrocortisone (steroid) IM/slow IV (Dose range 50 – 200mg depending on age)

15. Fluid bolus of crystalloid administered – 20mls/Kg (if no response to drug treatment). May need repeating.

16. Salbutamol (beta₂-agonist) inhalations if bronchospasm present.

17. Note guidelines of management of an anaphylaxis have been put out by the Resuscitation Council of Southern Africa that follows an algorithmic approach depending on response to a stepwise series of interventions.

On discharge

18. On discharge, child and parents need to be educated about the condition.

19. Refer for a medicalert bracelet.

20. Recommend a pre-filled adrenaline syringe.

21. Consider referral to an allergy specialist.

b) Measures to improve the control of asthma in a child whose symptoms are worsening.

History

An in-depth enquiry from the child and parents about the following:

· Check basic understanding of disease mechanism

· Type of treatment, including dosages

· Adherence with instructions (ask for availability of asthma diary card)

· The involvement and supervision of the caregivers

· Nature –including frequency and timing of symptoms

· Trigger factors including an environmental enquiry

· Any TB contact

· Recent medical history (admissions)

Examination

- Check technique of drug administration

- Growth parameters of child

- Examine for any other underlying respiratory condition such as TB

- Look for other signs of an allergic disposition such as allergic rhinitis or atopic eczema.

- Check and record peak expiratory flow rate if child capable of performing this test. Compare this reading with the expected for the child’s height.

- If peak expiratory flow rate less than expected, may repeat after giving a bronchodilator.

Action steps

- Rule out any other obvious underlying cause for the deterioration

- Classify the patient as either mild, moderate or severe according to the history above. This will enable appropriate management.

- Provide education and counselling about asthma and it’s control

- Teach correct drug administration technique and confirm.

- Choice of drugs will depend on what the severity of the asthma is, nature of past adherence and response as well as the timing of symptoms.

- Use a stepwise approach to management using appropriate guidelines such as those put out by the South African Asthma Working Group.

- Consider a short course of steroid in selected cases (Prednisone)

- Avoidance or elimination of trigger factors such as cockroaches or housedust mites.

- Selective use of long-acting beta₂-agonists for nocturnal symptoms. (Serevent)

- Consider change of drug delivery device. Use of spacer such as an aerochamber ensures more adequate delivery than an inhaler (MDI) on its own.

c) Advice to parents wanting to take their 16-month-old child on holiday to a malarial area.

§ Consult treatment and prophylaxis guidelines such as that put out by the National Department of Health (South Africa).

§ First advise against travel into malarial area with a minor < 5 years of age if this trip can be avoided.

§ If travel to area is unavoidable, then advise planning of trip in low malaria season

§ If travel has to take place during risk period the following steps need to be recommended.

§ Avoidance of mosquitoes – keep indoors after dusk, avoid swampy areas

§ Avoidance of mosquito bites – insect repellents, body lotions acting as repellents, special coils, insecticide impregnated nets, long sleeve and pants.

§ Chemoprophylaxis

ü Chloroquine + Proguanil – may be used (even in infants)

ü Mefloquine – may be used (for children > 5kg or 3 months) particularly for areas with high chloroquine resistance.

v Doxycycline is not recommended for children.

Either regimen must be taken one week before, weekly whilst in area and for four weeks on return from area.

§ High index of suspicion whilst in area if staying longer than a week or on return of malaria, by ensuring that child has blood sent for malaria investigation if any symptoms that may be suggestive. These are often non-specific such as fever, vomiting, diarrhoea, flu-like illness, or even meningeal/cerebral signs.

d) Essential elements of care in the follow-up of children with HIV infection.

§ Medical

- General care of the child by treating the complications resulting from the immune deficiency.

- Ensuring that prophylaxis against Pneumocystis jeroviki pneumonia (PCP) by placing children on co-trimoxazole from 6 weeks of age. (This may be discontinued after infancy if child is asymptomatic)

- Treatment of common skin disorders with referral to a dermatologist for more difficult cases.

- Monitor growth and developmental milestones. Dietician needs to deal with specific nutritional disorders.

- Close monitoring for TB and prompt treatment for this if strongly suspected.

- Monitor CD4 % of child as well as clinical stage child according to the WHO staging (modified paediatric).

- If criteria for antiretrovirals (ARVs) met, to initiate treatment, after ensuring adequate education and that adherence counselling has occurred.

- Treatment with ARVs according to the national guidelines (triple therapy) and monitoring the outcome and course of treatment.

- Check the immunization status of the child and ensure all vaccines received. (BCG contraindicated in AIDS patients).

- It is recommended that children get a de-worming agent such as Zentel® at regular intervals.

§ Psychological

- Provide counselling support for the family. This is an ongoing activity.

- May encourage caregivers to be part of a support group.

- Help parents with issues of disclosure to children with age appropriate messages.

§ Social

- Enlist the help of a Social Worker to facilitate the acquisition of a child support grant and/or a care-dependency grant where indicated.

- Refer family to appropriate NGO support structures if in need of assistance.

§ Nutritional

- Dietary advice to all.

- Nutritional supplements – Micronutrients such as regular vitamin A (6 monthly where available), multivitamins and iron where indicated.

- Nutritional supplements of appropriate foods such as Epap (vitamin and mineral fortified maize meal), PVM mixture (Protein, Vitamin, Mineral).

§ Dental

- Care of the oral health of the child, by ensuring that the teeth and gums are examined at each follow up visit.

- Referral to the dentist/oral hygienist where indicated.

Question 3

a) The medical management of a 13-year-old girl who presents 24 hours after having been raped by a stranger.

1. History of incident to determine sites for collection of forensic specimens and highlight risk factors for the development of complications.

2. Examination to determine mental and physical well-being and to identify existing complications.

3. Collection of forensic specimens.

4. Complete medical-legal documentation (J88).

5. Baseline investigations for medical management – HIV, WR & Hepatitis serology and pregnancy test.

6. Treatment:
1. Mental: debriefing for prevention of post traumatic stress disorder.

2. Physical:

i. Treat acute injuries.

ii. Prophylaxis for prevention of complications:

1. ATT for tetanus (if skin or mucosal integrity breeched)

2. STI prophylaxis –

a. Ceftriaxone – stat dose.

b. Erythromycin – for 14 days.

c. Metronidazole – for 7 days.

3. HIV prophylaxis –

a. HIV –ve, AZT & 3TC for 28 days.

b. HIV +ve, refer to appropriate service for ongoing care & support.

4. Pregnancy prophylaxis if pregnancy test –ve, Ovral 28 2 stat and 2 in 12 hours.

b) Advice regarding future pregnancies that you would offer to a 23-year-old primigravid woman who has given birth to a baby with a myelomeningocoele.

Following one baby with myelomeningocoele there is an increased risk of neural tube abnormalities in subsequent pregnancies – from 1 - 6:1000 to 1 - 6:100.

1. Strategies to reduce recurrence risk:

Planned pregnancy whilst on folate supplements.

Contraception until ready to fall pregnant.

Stop contraception and start daily Folate supplements until at least the end of the first trimester.

2. Management of next pregnancy:

Early detection / exclusion of neural tube abnormality:

AFP levels

Ultrasound examination at 14 – 18 weeks.

Reassurance if above normal.

Counseling, support and assistance with management decisions if above abnormal.

c) Necessary precautions before transferring a 1200g preterm infant with severe respiratory distress from a district hospital to a referral centre 150 km away.

1. Contact referral center to:

1. Discuss case.
2. Ensure acceptance of transfer.
3. Obtain advice on interim management.

2. Stabilize and manage neonate:

1. Stable vital signs especially temperature and blood sugar.
2. Provide oxygen.
3. Establish IVI.
4. Insert NG Tube.
5. Initiate treatment recommended by referral center.

3. Copy and transfer relevant documents to referral center:

1. Detailed referral letter.
2. Mother’s ANC record.
3. Record of labour and delivery.
4. Neonatal record, including results of all investigations.

4. Hand over neonate to escort accompanying baby en route:

1. Ensure appropriate monitoring available – people, skills and equipment.
2. Ensure appropriate resources are available for use en route – incubator, oxygen, IV fluids etc.

5. Ensure mother accompanies her baby.

d) Anticipated health problems in an 11-year-old street child who has been living on the streets for six months.

1. Age related problems (adolescent):
1. Musculoskeletal.
2. Vision – myopia.
3. Psychological.

2. Background problems relating to circumstances that precipitated entry onto the streets (poverty, abuse, exploitation and neglect):

1. Malnutrition.
2. Trauma.
3. Psychological – depression, enuresis, psychosomatic symptoms.

3. Problems arising from the environment of the streets (living, working and social environment):

1. Malnutrition.
2. Infections and infestations.
3. Trauma and toxins.
4. Psychological.

4. Problems arising from coping strategies employed on the streets:

1. Complications of substance abuse – neurological, respiratory, naso-pharyngeal, psychological, trauma.
2. Sexual exploitation – STIs, HIV, psychological.

Question 4

a) Antibiotic prophylaxis for infective endocarditis.

Bacterial endocarditis is one of the most serious forms of cardiac disease and the morbidity and mortality from this condition remain high despite advances in antimicrobial therapy.

Cardiac conditions for which endocarditis prophylaxis is recommended:

• Most congenital cardiac malformations
• Rheumatic and other acquired valvular dysfunction
• Prosthetic cardiac valves (including biosynthetic valves)
• Surgically constructed systemic – pulmonary shunts
• Previous history of bacterial endocarditis
• Idiopathic hypertrophic sub aortic stenosis

(Mitral valve prolapse with insufficiency, data on prophylaxis is limited)

[Cardiac conditions for which prophylaxis is not needed:

Isolated secundum ASD

Patient in whom a VSD had closed spontaneously

Postoperative ASD, PDA and VSD repair with residual shunt.]

Procedures for which endocarditis prophylaxis is indicated:

• Dental procedures likely to induce gingival bleeding (not simple

adjustment of orthodontic appliances or shedding of deciduous teeth)

• Tonsillectomy / adenoidectomy
• Bronchoscopy, biopsy of respiratory mucosa
• Incision or draining of infected tissue
• Genitourinary and gastrointestinal procedures (urethral catheterisation,

cystoscopy, any GI tract surgery or dilatations)

Prophylactic regimen for dental and respiratory procedures:

Standard regimen: Amoxycillin 50mg/kg (max 3 gram) per os 1 hour before and half of this dose 6 hours later, those unable to take oral medication Ampicillin 50mg/kg is given IV or IM 30 minutes beforehand and half of the initial dose 6 hours later IV or per os.

Those allergic to penicillin or those on long term penicillin prophylaxis for rheumatic cardiac disease (organisms might be resistant to penicillin) should be given 1 g erythromycin 1 hour before and 500 mg 6 hours later.

In those not able to take oral medication, 1 g vancomycin one hour before the procedure.

Special regimen: When maximal protection is desired (prosthetic valves) the penicillin is replaced by 1 – 2 g ampicillin IM or IV plus 1.5 mg/kg gentamicin IM or IV 30 minutes before and repeated one 8 hours later.

Prophylactic regimen for GI tract and genitourinary procedures:

Standard regimen: Ampicillin 2 g IM or IV plus gentamycin 1.5 mg/kg IM or IV 30 – 60 min before the procedure with one repeat 8 hours later. In penicillin allergic patients the ampicillin can be replaced by vancomycin 1g.

Special regimen: Oral procedures in low risk patients, amoxycillin 3 g per os one hour before and 1.5 g 6 hours later.

b) The technique for performing a suprapubic bladder aspiration (tap).

Equipment needed:

All equipment must be sterile

Gloves

Cup with antiseptic solution together with sterile swabs

Syringe 5 ml or 10 ml

Needle, any size 21 to 25 gauge

Precautions and procedure

Use a strict aseptic technique

Determine urine in the bladder:

Make sure the infant has not passed any urine in the previous hour, (no wet diaper).

Palpate or percuss bladder.

Have an assistant restrain the infant in a supine frog leg position.

No local analgesia is required.

Wash hands and put on gloves.

Clean the pubic and suprapubic areas 3 times with antiseptic solution

(Iodine and wash with alcohol, blot dry with sterile gauze).

Locate landmarks and insert needle:

Palpate the symphysis pubis

Insert the needle 1 to 2 cm above the symphysis pubis in the midline.

The needle is angled 30^o towards the fundus of the bladder.

Advance needle 2 to 3 cm

A slight decrease in resistance may be felt when the bladder is penetrated.

Aspirate gently.

Withdraw needle if no urine is obtained.

Do not probe or attempt to redirect it to obtain urine.

Wait at least one hour before repeating procedure.

Withdraw needle

Apply gentle pressure over puncture site with sterile gauze to stop any bleeding

Remove needle and transfer urine to sterile container.

[Possible complications:

Bleeding:

Transient microscopic or gross haematuria

Abdominal wall, bladder wall or pelvic haematoma.

Infection:

Abdominal wall abscess, sepsis or osteomyelitis of pubic bone

Perforation

Bowel or pelvic organs]

c) “Growing pains” in children.

Idiopathic limb pain, commonly called “growing pains”, affects a significant number of normal children.

The actual cause of the “growing pains”, is not clearly understood. What is quite clear, however, is that it has nothing to do with growth. Involuntary muscle spasms during rest are most probably the underlying cause of the pain.

Growth pains are more commonly seen in children between the ages of 8 and 12 years of age. The pain is experienced in the limbs, usually the legs.

The pain occurs at night and is not associated with any daytime disability or objective clinical findings. These children typically do not have any symptoms at bedtime, only to wake up 1 to 3 hours later complaining of severe bilateral calf, shin and or thigh pain. Joints are not involved. Often there is a history of the parents having had similar symptoms as young children.

A single dose of acetaminophen or massaging of the legs often result in pain relief. This is in contrasts with pain caused by an underlying pathological condition where the parents are almost never asked to rub the child’s legs. A hot bath immediately before bedtime also seems to help in preventing the pains in some children.

Although this condition is not caused by any underlying pathological condition, these children should be examined thoroughly to exclude possible pathological causes of leg pain such as leukaemia or cardiac conditions such as coarctation of the aorta and rheumatic fever. Rheumatoid arthritis affecting the joints must also be excluded.

Some association has been found between “growth pains” and emotional problems in children suffering from this condition. These children are also more inclined to be suffering from bouts of headache and stomach pain.

d) The psychological effects of hospitalisation on children.

Most children admitted to hospital undergo intense emotional insecurity, mainly as a result of separation from their mothers. Whether a child is emotionally disturbed during or after an admission to hospital depends on three factors:

1. The age of the child (with children between 6 months and 4 years being the most severely affected)

2. His or her personality and past life experiences (children exposed to traumatic experiences prior to hospitalisation react with greater distress. The same goes for children, whose relations with their parents are poor, as they have less chance of independent adjustment away from home).

3. What actually happens to the child in hospital (the stress of operations, treatment as well as the impact of special techniques to combat the effect of hospitalisation, admitting the mother with the child, preparing the child psychologically prior to hospitalisation)

Although children of different ages respond differently to hospitalisation, one can normally recognise a three-phase reaction to hospitalisation:

1. Objection phase:

During this phase that can last from a few hours to a couple of days, the child intensely grieves the loss of the mother, is afraid, confused and may display panic or anger attacks as the parents leave. The child normally cries a lot and vocalises little, looks around seeking the parents and may throw itself about. During this stage they reject any attention from the nursing staff.

2. Despair phase:

During this phase the child is less active, but still has a feeling of despair due to the loss of the mother. They are quite apathetic or may groan monotonously. This resigned behaviour may wrongly be interpreted that the child is adapting to his/her environment.

2. Denial phase

The child shows more interest in its surroundings, this interest is however just superficial and it may even appear that the child is happy, but in reality the child suppresses its strong feelings towards the mother. The child will pay little attention to the mother during visits, might refuse to let go of the nurse to go to the mother and will also no longer cry when the mother leaves. The reaction of the child can wrongly be interpreted that the child is happy in hospital.

Apart from being separated from the mother the child is also subjected to disturbing experiences, such as being isolated, not being attended to when having a need, or being subjected to painful experiences all which impacts on the child emotionally. No wonder many a child still has some psychological disturbance for months following hospitalisation. Some of the disturbances that are seen following hospitalisation include:

Nightmares

Enuresis

A negative attitude

Insomnia

Unfounded episodes of fear

Temper tantrums

Anorexia

Although it is not possible to prevent psychological trauma completely, it can be minimised by admitting the mother with her child and also preparing the child beforehand through visits to the hospital and, by play sessions, teaching the child what to expect when hospitalised.

Question 5

a) Vitamin and mineral supplements currently offered to South African infants and children at primary health care clinics.

Vitamin and mineral supplements are offered to infants and children in various settings/situations:

• Premature babies for normal catch-up growth due to decreased stores
• Full-term babies on formula feeds or breast-feeding
• Food fortification programmes-salt + iodine, maize meal & flour with vitamin

A, thiamin, riboflavin, niacin, folic acid, pyridoxine, iron + zinc.

• Routine supplementation adopted by the country to improve stores and prophylaxis in infants and children.
• Children with malnutrition or chronic disease.

Vitamins :

1) Vitamin A – essential for vision and preserves integrity of epithelial cells wound healing and growth

2) Vitamin D – regulates absorption and deposition of calcium and phosphate in bone.

Given to premature babies, chronic liver disease, malabsorption and rickets.

3) Vitamin B complex – thiamin (B1), riboflavin (B2), pyridoxine (B6), pantothenic acid, nicotinamide.

Given to children with malnutrition and chronic diseases.

4) Vitamin C – integrity/maintenance of all intracellular materials, collagen biosynthesis iron absorption and some amino acid metabolism.

Given to premature babies and iron deficient patients.

5) Folate – essential in biosynthesis of amino acids – nucleoproteins.

Deficiency – neural tube defects.

Minerals and Trace Elements

1) Iron – structure of haemoglobin and myoglobin.

Given to premature babies, malnutrition and chronic diseases.

2) Fluoride – protects against tooth decay. Not routinely given.

Toothpaste contains fluoride.

3) Iodine – component of thyroid hormone.

4) Zinc – co-enzymes. Skin healing.

b) The diagnosis and management of scabies

Caused by an itchy mite – sarcoptes scabies.

Highly contagious

Adult female – burrows into skin – eggs deposited + brown fecal pellets (scybala)

Rapid spread within 10 days. Lives + 1 month.

Clinical features: Itchy papular eruptions

Common sites: Finger webs + digital sides, anterior wrists, outer border of hands, extensor surface of elbow, axillae, nipples, genital areas.

Infants and children : Head, neck, palms, soles.

Norwegian crusted scabies – huge no's of mites. Immunocompromised or debilitated individuals.

Diagnosis : Clinical + skin scrapings of a papule for microscopy.

Treatment : Rx all members of the household or if a house pet is the source.

Topical acariades - Benzyl benzoate (Ascabiol)

Gamma benzene hexachloride (Quellada) – topical absorption + neurotoxicity.

Eurax cream (Crotamin) < 1 year infants

Tetmosol soap (sulfiram) – prophylaxis in outbreaks

Wash bedding and clothing with hot water.

Complication : Excematization

Bacterial infection – glomerulonephritis

c) The pathophysiological mechanism for neonatal jaundice (hyperbilirubinaemia).

Jaundice = ↑ level of conugated and/or unconjugated bilirubin.

Unconjugated hyperbilirubin – lipid soluble – neurotoxic.

Haemoglobin/Myoglobin → Biliverdin ← Biliverdin reductase → unconjugated bilirubin (some albumin bound) → Liver – uridine diphosphoglucuronic (UDPG) → conjugated bilirubin

Conjugated bilirubin

↓

Excretion in biliary system ← → Entero-hepatic circulation

↓

De-conjugation in gut

↓

Liver

↓

Excretion in the urine/stool

Aetiology :

1) ↑ Red cell mass – plethora, bruising, cephalhaematomas

2) ↓ Red cell survival – haemolytic anaemia, infection, enzyme defects

3) Immaturity of the liver enzymes or ↓ enzyme function due to anoxia, hypothermia and thyroid hormone deficiency.

4) Drugs/substances compete or block glucuronic acid conjugation.

5) Decrease uptake of bilirubin by liver cells – genetic defects/prematurity.

6) Increased enterohepatic circulation – bowel obstruction, dehydration.

Factors associated with ↑ bilirubin toxic effects

Prematurity, asphyxia, haemolysis, acidosis, hypothermia,

d) Causes of infective bloody diarrhoea (dysentery) and its management in children.

Definition : Diarrhoea with blood, mucus and pus in the stools

Aetiology:

1) Bacterial : Salmonella, shigella, E-coli-enerinvasive, campylobacter, yersinia

2) Protozoa : Amoebiasis

Clinical features : Variable depending on infective organism + load of infection as well as host factors. Fever. Dehydration, Abdominal tenderness.

Management:

1) Investigations : Blood – serology (salmonella and amoebiasis), FBC, cultures

Stool – culture and microscopy

2) Non-drug treatment – Monitor and maintain hydration Correct electrolyte disturbances and nutritional support

Improve personal hygiene, water supply and sanitation

3) Drug treatment : Depends on clinical condition and suspected causative agents

Nalidixic acid – given as outpatient for possible Shigella

Bactrim – no longer preferred

Cephalosporins – very effective

Flagyl for amoebiasis

Erythromycin for campylobacter.

Paper 2

Instructions

1. Answer each of the following FIVE (5) questions in separate books.

2. Each question is worth 40 marks. The whole paper is worth 200 marks.

3. The aim is to check your ability to express objective knowledge with precision. Each question has a standard (model) answer and the mark you are awarded depends on the number of correct statements/points made matching the model answer.

Question 1

You are called urgently to the labour ward by the midwife who informs you of an impending delivery. From the history you have the following information:

The patient is a 19-year-old primiparous woman. The gestation is 42 weeks, there is thick meconium in the liquor and the second stage of labour has been prolonged with a vacuum extraction in progress. The mother was given pethidine two hours earlier.

a) Identify FIVE risk factors in this delivery and list TWO possible complications in the infant for each risk factor. (15)

1. Young primiparous – cephalopelvic disproportion, low birth weight

2. Postdates delivery – fetal distress (placental insufficiency), polycythaemia, SGA with increased tendency to hypoglycaemia.

3. Meconium stained liquor – meconium aspiration syndrome, persistent foetal circulation, birth asphyxia

4. Prolonged second stage – birth asphyxia, increased likelihood of assisted delivery, increased likelihood of episiotomy or perineal tears.

5. Vacuum assisted delivery – subaponeurotic haemorrhage (SAH), cephalhaematoma, marked caput succedaneum.

6. Pethidine administered (less than 4 hours from delivery)– neonatal apnoea, respiratory depression

b) Briefly discuss how you would handle the resuscitation, with specific emphasis on the management of anticipated complications in the newly born infant. (25)

· In light of the above scenario and listed complications the following steps need to be taken.

· Anticipation of the complications must lead to adequate and appropriate preparation for resuscitation.

· Preparation includes staff readiness with prior roles assigned, drugs drawn up and diluted to appropriate strengths i.e. adrenaline in dilution of 1:10,000.

· Part of preparation entails that the ambient temperature is taken into consideration and more specifically that an overhead radiant warmer is preheated (i.e. switched on at least 10 minutes prior to the delivery)

· On delivery of the head suction the mouth, nose and pharynx.

· As soon as the baby is delivered wrap the baby in linen and prior to drying and stimulation assess the need to intubate.

· Generally two situations prevail. If the baby is vigorous and crying then there would not need deeper suction than the mouth and nose. However if the baby, as is likely in this scenario, comes out ‘flat’ and floppy then it is imperative that this baby is intubated rapidly for the purpose of suctioning.

· Using wall suction and a meconium aspirator (a device that allows the attachment of the suction tubing onto the end of a standard endotracheal tube), the trachea can be suctioned. The ETT is removed whilst applying suction so as to remove even the viscous meconium that does not enter the tube. Use of the ETT as the largest suction catheter prevents further migration of meconium down the tracheobronchial tree.

· This sequence of events of rapid intubation and suctioning whilst removing the ETT from below the cords is repeated in rapid succession, all within a period of about 30-60 seconds prior to the baby’s first breath.

· In most cases the baby will then require ventilatory assistance in the form of bag-valve-mask ventilation (‘bagging’), with 100% oxygen.

· The baby may be stimulated by drying its back or flicking its feet.

· Should there be respiratory depression or inadequate oxygenation, as may well be expected in this newborn then Naloxone (Narcan®) should be administered in a dose of 0.1ml/kg. This may need to be repeated at a later stage.

· In view of the possibility of an extracranial haemorrhage such as an SAH, there is a significant risk of haemorrhagic shock. Hence IV/umbilical vein access must be established as soon as possible and where indicated a fluid bolus of 10mls/kg of crystalloid given.

· Note that the development and progression of an SAH can be monitored by serial measurements of the newborns head circumference (HC).

· If haemorrhagic shock present- obtain an emergency supply of O-negative blood and commence transfusion. Administer a dose of vitamin K IV.

· Send blood for a cross-match for further transfusion requirements.

· The baby’s temperature must be maintained and a blood glucose checked by doing a dextrostix®.

· Should there not be adequate respiratory effort or poor oxygenation despite spontaneous breathing in 100% oxygen or bag ventilation the baby will need to be intubated and receive ventilatory support in a neonatal ICU.

Question 2

Discuss your approach to an 18-month-old child who presents with generalized oedema under the following headings:

a) Differential diagnosis (10)

b) Clinical assessment (15)

c) Management (15)

a) Main causes of generalized oedema in the child could be as follows (1 mark per fact), (10):

i. Increase in hydrostatic pressure which promotes filtration of fluid from the intravascular to the interstitial space e.g. congestive cardiac failure (congenital HD, paroxysmal tachycardia, myocarditis, CMO or severe anaemia)

ii. Decreased oncotic pressure:

§ Protein energy malnutrition (kwashiorkor and marasmic kwashiorkor). This is also associated with hypokalaemia and sodium and water retention.

§ Chronic liver disease (with impaired production of protein) e.g. cirrhosis

§ Protein-losing enteropathy e.g. chronic diarrhoea, TB abdomen, HIV, GI allergy or malignancy (lymphoma)

§ Steatorrhoea

§ Nephrotic syndrome (increased protein loss)

iii. Sodium and water retention:

§ Acute glomerulonephritis (consider but rare before age of 3 yrs)

§ Renal failure

§ Fluid overload e.g. excessive administration IV fluids especially saline

§ Administration of corticosteroids

iv. Increased capillary permeability

§ Allergic reactions e.g. angioedema

b) Clinical assessment (1/2 mark per fact)

History:

You would want to know the history and distribution of the swelling as well as previous possible episodes

Any history of cardiac problems or symptoms of shortness of breath, feeding difficulties, sweating, palpitations & cyanosis

Urinary symptoms e.g. haematuria or oliguria

Cough, loss of weight, TB contacts

Previous illnesses: Allergies, medication

Dietary history: intake, type of feeds and frequency, weight loss

Social: socio-economic circumstances, food security, income and support

Examination:

General

Measure and plot weight and length on NCHS growth charts

If weight between 60-80% expected weight especially in presence of other clinical features (see below) likely to be kwashiorkor.

Some children with kwashiorkor may be > 80% expected weight.

Also with kwashiorkor look for following clinical features:

o Apathy

o Hair: depigmented, sparse & pluckable

o Skin: hyperpigmentation, hypopigmentation, desquamation and ulceration

o Mucous membrane: cheilosis, stomatitis & glossitis

o Eyes: xerophthalmia

Check temperature (exclude hypothermia in severe PEM) and for pyrexia (e.g. TB or other infection)

Also look for signs of severe wasting: upper arms, gluteal folds

Assess hydration (especially if underlying diarrhoea)

Assess extent of oedema e.g. over dorsum feet, pretibial, sacral, periorbital

Assess for jaundice and signs of chronic liver disease: palmar erythema, clubbing, spider angiomata and for signs of liver failure

Examine skin for impetigo, dermatoses (kwash see above) & urticaria (angioedema)

Look for generalized lymphadenopathy (TB/ HIV)

ENT: thrush/ mouth ulcers (HIV), CSOM (HIV/TB)

Respiratory system:

Look for signs of:

LRTI (e.g. TB)/ cardiac failure: tachypnoea, SC recession and crepitations/ wheezes

Signs of pleural effusion (Nephrotic syndrome/ PLE): Tachypnoea, stony dullness on percussion, Decreased air entry and vocal resonance

Cardiovascular system:

Look for signs of cardiac failure:

Tachycardia, low pulse volume, Blood pressure (increased in AGN), raised JVP, Liver enlarged and tender, gallop rhythm and cardiac murmurs

Abdominal system:

Look for Hepatosplenomegaly (TB, HIV)

If liver enlarged assess all features (e.g. hard, nodular and irregular liver may occur in cirrhosis)

Feel for other masses (e.g. lymph nodes: TB/HIV & malignancy)

Assess for shifting dullness/ ascites (TB, Nephrotic syndrome or PLE)

Central nervous system:

Check level of consciousness

Part of examination especially if any of above signs suggest TB/ HIV/ PEM

Check for signs of increased IC pressure: AGN (encephalopathy)

c) Management (1/2 mark per fact) (15)

Investigations (marks allocated if considered also under (b) above):

Side room

Urine:

- Dipsticks for proteinuria (Nephrotic Syndrome) &

- Haematuria (AGN)

- Also examine microscopically for rbc (AGN) and hyaline/ granular casts (Nephrotic syndrome)

Check Hb/ Hct – decreased if underlying anaemia e.g. CCF

Mantoux (TB)

ESR (TB/ Infection)

Special investigations:

CXR: Look for adenopathy (TB), cardiomegaly (CCF), pleural effusions (TB, Nephrotic syndrome & PLE)

ECG: if suspect underlying cardiac disease

Full blood count: check Hb, MCV, MCH and RDW for anaemia and type

Electrolytes:

Check for hypoglycaemia & hypokalaemia (Kwashiorkor)

Raised K+, urea, creat (AGN/ RF)

Acid-base: check for metabolic acidosis e.g. AGN

Liver function tests:

Check for low albumen (e.g. Kwash/ Nephrotic syndrome)

Low total protein and albumen: PLE

Cholesterol: raised in Nephrotic syndrome; low in kwashiorkor

Liver enzymes: AST, ALT, LDH: underlying liver disease

Send off 24-hr urine for protein collection in nephrotic syndrome

Check for low C3 (AGN). Check Total complement, C3 & C4 (Nephrotic syndrome)

If Nephrotic syndrome suggestive, do other studies: e.g. Hep B, VDRL, ANF

If suspect AGN: ASOT; Anti-DNAse B & Anti-NADase

If suspect TB: gastric washings

Blood and urine culture especially in kwashiorkor

If suspect HIV ELISA test

If suspect PLE: Ultrasound of abdomen

If cardiac failure: Echocardiography

Treatment

This includes management of the underlying condition.

Kwashiorkor: Initial stabilization needed for 1-2 weeks; then rehabilitation 2-6 weeks. Follow 10 steps to recovery from malnutrition:

- Hypoglycaemia (BS<3): prevent by feeding early; if develops use 10% dextrose either PO or by NGT, monitor for this especially during first 48 hours

- Hypothermia (axillary temp < 35): prevent by clothing, covering with blankets and avoiding drafts and unnecessary bathing. If develops cover child and keep room warm with heater

- Antibiotics: usually broad spectrum (ampicillin and gentamicin/ 3^rd generation cephalosporin). If TB treat as above. Deworm with albedazole or mebedazole. Treat giardia with metronidazole. Give measles vaccine if not previously immunised.

- Feed: start with small feeds of F75 60 ml/ kg/ day (rest as ORF/ Resomal) and gradually increase by 20 ml/kg/day. Solids only introduced from D4 onwards.

- Electrolytes: K+ 3-4 mmol/kg/day; Magnesium 1-2 mmol/kg/day

- Micronutrients: vitamin A, folic acid, zinc, copper, MVT syrup; No iron initially, only during rehabilitation phase.

- Catch-up growth: usually after 7-10 days: Change to F 100 and increase protein intake to 4g/kg/d and energy to 150-200kcal/kg/day

- Stimulation: 15-20 min of structured play; involve mother in bathing and feeding

- Preparation for discharge: when child is gaining weight (10g/kg/d), has no oedema, no signs infection, mother understands cause of malnutrition and agrees to follow-up.

Cardiac failure:

- Oxygen (nasal prongs or nasal catheter)

- Semi-fowlers position

- Restrict fluid intake to 60%maintenance

- Digoxin

- Furosemide 1-2 mg/kg/d

- Potassium supplements

- If not effective consider after load reduction with captopril

AGN:

Fluid restriction: insensible loss (12ml/kg/d) and output, furosemide (1-2 mg/kg/dose 8h), penicillin 125 mg 6h for 10 days, nifedipine if BP > 95 percentile, strict intake and output, low salt diet, restrict protein if urea > 20 mmol/l; specific treatment for pulmonary oedema (see below), dialysis if fluid overload, uraemia, hyperkalaemia and severe metabolic acidosis.

Nephrotic syndrome:

Bed rest, salt restriction, high protein diet, if oedema severe give 20% salt free albumen with furosemide 1mg/kg IV towards end of infusion, prednisone and penicillin prophylactically while on prednisone or if develop relapse.

TB:

INH, Rif & PZA for 6 mo; notify

Question 3

a) List FIVE factors hindering the achievement of optimal child development in South Africa. (5)

Many factors hinder optimal child development. One approach could be:

· Antenatal Alcohol, Infections (Syphilis, HIV)

· Intrapartum Hypoxia, hypoglycaemia, shock, secondary to immaturity (CNS/RS)

· Postnatal Medical Poor nutrition, Stimulation, Recurrent Illness, Poverty, Education system, Poor control chronic illness (epilepsy, HIV, TB), lack of remedial care.

· Postnatal Social Poverty, disadvantage, rurality, family chaos, social disorder.

· Postnatal Environmental Lead, noise, lack of stimulation

b) How would you ensure that developmental delay is detected early in a primary care practice (private or public)? (5)

· Ensure time is available for practitioners to evaluate developmental progress during planned and incidental attendances.

· See that primary care is accessible to all – geographically and financially etc

· Introduce a time table for formal testing / assessment into primary care practice.

· Ensure primary care practitioners (nursing or medical) know the norms of development and have appropriate tools to help them apply this knowledge.

· Ensure the primary care practitioner has an effective and responsive referral route for children where he/she detects delayed development.

· Use parent questionnaires to identify delays while the parents await consultation.

· Ensure that parents in the community come to know the norms for development and how to access professional support and assessment when they believe their child is deviating from normal development.

· Identification of high risk children at birth or at the time of admission for serious illnesses. Arrange special targeted follow up and assessment.

c) How would you manage a child who shows signs of developmental delay? (15)

· Determine the domains of developmental delay and domains of normal development. Assess the degree of disability in each domains.

- The domains would include - Movement/Tone; thought; behaviour; special senses (hearing, sight); vegetative functions (eating, constipation, continence); teeth, etc etc

· Exclude or identify co morbidities

· Identify strengths of the child

· Plan intervention and investigation specific to identified areas – attend to these with a team approach. OT/PT/Psychologist/Paediatrician/Orthototist/etc

· Implement plan and follow up the results of this care plan.

· Plan ahead – begin life plan with age related interventions in mind eg schooling, placement, sexuality, income etc.

· Council parents at an appropriate level as to the meaning of their child’s condition and all the implications (including strengths) of the situation.

d) How may early detection of developmental delay benefit the child and his/her family? (5)

· Physical therapy Improves movement conditions and prevents secondary contractures etc.

· Co-morbidities can be corrected early to allow learning– eg deafness, visual disorders etc

· Adequate appropriate stimulation can be ensured to optimize learning opportunities. Occupational therapists / educationalists are important for Early Childhood Development in these children.

· Correct functional positioning to best interact with their environment and give opportunities to learn – orthototic / sitting appliances, physical positioning. Cheaper options eg Appropriate Paper Technology for poorer settings.

· Prevention of secondary medical conditions can be ensured – NB nutritional, aspiration, bed sores, contractures, behavioural conditions

· Support and advocacy to prevent secondary social conditions, involvement of social development and welfare.

· The prevention of exclusion of the child from society and learning. Tradition may lead to the “hiding” of “abnormal” children.

· Parental education and future planning eg education and placement

· Application of appropriate grants and support mechanisms

e) Discuss feeding in children with severe cerebral palsy including appropriate diets, methods of feeding and complications of feeding practices. (10)

Children with severe cerebral palsy often have imbalance of dietary requirements and what they eat with following factors of note:

· Route Because of variable affects on chewing, swallowing and retaining foods without gastro-oesophageal reflux the route of feeding will be either oral ( which often requires ensuring correct upright position, placement of food well back on the tongue, patience and active involvement in the process by the feeding) or by-passing normal swallowing process via oro/ naso gastric tube or where long term tube feeding is required, especially in the face of GO Reflux – via PEG (Percutaneous Endoscopic Gastrostomy tube feeds).

· Formulation Due to the limitations of the routes noted above feeds may need to be formulated liquid to pass through tube feeds. Oral feeds are often best taken if soft and aversion to particulate matter is quite common and needs to be overcome by gradual transition between food tastes and consistencies. Dysphagia may require more liquid or more solid consistency (to avoid aspiration from dys-co-ordinate swallowing).

· Constituents Adequate contents in terms of energy, protein, fat soluble vitamins, water soluble vitamins, micronutrients including Fe/ Fl/ Ca/ P and trace elements are important. Particular considerations include the balance between decreased energy expenditure (leading to obesity) versus difficulty of ingesting adequate volumes of food (with under-nutrition). Rickets is relatively common. Iron deficiency is common.

· Other hurdles to feeding include:

· Carious teeth which are common and relate to difficulty in cleaning teeth + pooling of food in mouth. Causes reluctance to chew and poor appetite due to pain.

· Caregiver feelings and demeanour – feeding and caring for children with severe cerebral palsy especially in settings of poverty and rurality places sometimes unbearable pressure on the time and energy resources of the caregiver giving rise to negative feelings and poor feeding practices.

· Complications

· Aspiration of food into the lungs from dys-co-ordinate swallowing or gastro-oesophageal reflux.-> Pneumonia

· Constipation – due to lack of fibre in soft diets and lack of physical activity.

· Iron deficiency – due to limited diet – soft diets are usually cereal & milk based.

· Rickets – quite common due to nutrition imbalance, lack of activity, lack of sun exposure and co administration of anticonvulsants.

· Severe or mild malnutrition – due to difficulty in providing adequate diet in the form required, and difficulty in getting the child to take enough food.

· Obesity – which occurs due to lack of activity relative to intake.

· Excessive financial and time cost to family

Question 4

Discuss the aims and implementation of the following public health programmes/ initiatives in South Africa:

a) Baby-friendly Hospital Initiative (10)

Aims

The Baby Friendly Hospital Initiative (BFHI) is a global initiative to encourage hospitals to adopt practices that protect, promote and support exclusive breastfeeding. Criteria for attaining BFH status are based on the Ten Steps to Successful Breastfeeding.

Implementation

The Ten Steps to Successful Breastfeeding include the following:

- Have a written breastfeeding policy communicated to all staff

- Train staff in skills necessary to implement the policy

- Inform pregnant women of the benefits and management of breastfeeding

- Help mother initiate breastfeeding within half-hour of birth

- Show mothers how to maintain lactation

- Give newborns no food or drink other than breastmilk

- Practice rooming-in and allow mothers and infants to stay together for 24-hours

- Encourage breastfeeding on demand

- Give no artificial teats to breastfeeding babies

- Foster and refer mothers to breastfeeding support groups

Procedure for achieving BFH status:

i. The hospital needs to become familiar with the Global Criteria document, which outlines the Ten Steps as above.

ii. There should initially be a an appraisal of current practices based on the UNICEF Hospital Self-Appraisal Tool

iii. When the hospital is satisfied that it meets the criteria, an external assessment can be made based on a Global Health Assessment Questionnaire

b) Food fortification (10)

Aim

Deficiency of micronutrients such as vitamin A is a significant public health problem in S Africa. A study done by the SAVACG showed that 33% of children < 6 years of age were deficient in vitamin A. The National Food Consumption survey of children 1-9 years showed that there was a deficient intake of a number micronutrients such as vitamins A, C, D E, B2, B3 and B6, zinc, iron, calcium and selenium.

While supplementation e.g. with VA is a good short-term strategy, food fortification is seen as a medium to long-term sustainable strategy to address micronutrient deficiencies.

Implementation:

The main factors that have to be taken into account when choosing a food vehicle for implementing a food fortification programme include the following:

- Wide consumption by at-risk population

- Affordability

- Accessibility

- Inability to be changed organoleptically by the fortification process

In SA the NFCS showed that the most commonly consumed foods by the at-risk population were maize meal, wheat flour and sugar.

Maize meal and wheat flour have been selected as the food vehicles for fortification. The reason for choosing 2 vehicles is because maize meal is the most commonly consumed food vehicle in rural provinces, with less consumption in provinces such as W Cape and Gauteng, where wheat flour is more commonly consumed. Fortifying these food vehicles is more cost-effective and will achieve greater adequacy in the at-risk population than sugar.

These food vehicles have been fortified with multiple micronutrients such as vitamin A, iron, zinc, vitamin A, D, calcium, thiamine, riboflavin and niacin.

It is also mandatory to fortify salt with iodine in S Africa.

The cost of fortification has resulted in an increase in the price of the fortified products, although the contribution of fortification to these costs is minimal.

Essential to the fortification process is monitoring of the fortified product and evaluation of its impact on the at-risk population.

c) Integrated Management of Childhood Illness (IMCI) (10)

Aims of IMCI:

The main aim of IMCI is to reduce morbidity and mortality from childhood illness (ARI, diarrhoea, measles, malaria, malnutrition and HIV) through cost-effective health interventions, and to contribute to improved growth and development. These conditions account for three out of four children seeking care at a health facility. Children often present with signs and symptoms relating to more than one of these conditions. This situation indicates the need for an integrated approach to the diagnosis and management of these childhood conditions. This is through improved management of childhood illness, nutrition promotion, immunization and the implementation of other preventative child health aspects.

Implementation of IMCI:

The IMCI strategy aims to improve the prevention and management of childhood illness by focusing on 3 components:

· improvement of case management skills of PHC service providers through provision of adapted case management guidelines on IMCI and training;

· improvement in the health service to allow effective case management;

· improvements in family and community practices.

In order to implement the interventions, WHO proposes a phased approach that includes:

· orientation to and adaptation of the IMCI strategy

· implementation in a limited/defined area

· expansion of activities geographically

In addition to the above, IMCI in the health setting ensures that the following aspects are addressed in the management of childhood illnesses:

· accurate diagnosis

· combined treatment

· counselling of caretakers

· disease prevention

· appropriate referral

IMCI interventions

The IMCI interventions aim at improving the management of childhood illness in both health facilities and in the home. The core intervention strategies include integrated case management of:

· diarrhoea

· ARI

· measles

· malaria

· malnutrition

· HIV

IMCI has numerous components that are linked to other programmes/interventions. These include immunization, vitamin A supplementation and essential drug supply management. The IMCI co-ordinating team ensures co-ordination between IMCI and the other programme activities.

The IMCI case management process follows an ordered sequence:

· The health worker first assesses the child through history taking and examination; nutrition and immunization status are also checked.

· The health worker then classifies the illness, using a colour-coded triage system. Illness is classified on the basis of whether the child needs:

- urgent referral

- specific medical treatment and advice; or

- simple advice on home management.

· After classifying the illness, the specific treatment (often incorporating a combined approach) is identified.

· Advice to the mother is given on treatment and follow-up; the mother is advised on how to recognise signs that indicate that the child should immediately be brought to the clinic.

· Mother is counselled about home care and feeding.

· Follow-up instructions are given.

d) Prevention of mother-to-child transmission (PMTCT) of HIV. (10)

Aims:

In Africa, in the absence of interventions, it is estimated that the HIV transmission rate is 25-45%. Transmission may occur in-utero, intrapartum or post-partum. The aim of the PMTCT Programme is to reduce the vertical transmission of HIV from mother to infant, especially during the intrapartum period.

Implementation:

The main components of the PMTCT programme includes:

Counselling:

This includes the counselling of all pregnant women about the benefits of HIV testing. At primary health care centres/ MOU’s pre- and post-test counselling is provided to pregnant women. Lay counsellors are the cornerstone of the PMTCT programme although there are provinces where they have not yet been employed. Women who agree to be tested can undergo rapid testing at the PHC facility and the result made available to them immediately (about 30 min).

Provision of nevirapine (NVP) to HIV positive mothers:

Mothers who test positive are provided with 200 mg NVP, which is self-administered in labour and their infants are given an additional dose 2mg/kg within 72 hours of delivery. NVP has been shown to reduce the rate of MTCT by almost 50%

Obstetric interventions to reduce MTCT include:

- Avoiding traumatic/ instrumental delivery

- Avoiding artificial rupture of membranes

- Avoiding prolonged rupture of membranes

- Avoiding prolonged labour

Post-delivery

Infant feeding

There is an additional risk of HIV transmission via breastmilk, especially with mixed feeding. However, rates are lower if the mother chooses to exclusively breastfeed or exclusively formula feed (study in Durban showed rates of 15% and 19% at 3 months, respectively).

According to the National Breastfeeding Guidelines, mothers should be given a choice and should be supported to either exclusively breastfeed or formula feed.

Mothers who choose to formula feed are given free acidified milk (Pelargon) until their infants at 9-months old. Mothers who choose to breastfeed are encouraged to do so for 4-6 months, after which there is an abrupt cessation in breastfeeding.

Follow-up:

Infants are followed up weekly for first month, then monthly until 12 months and then 3 monthly until 2 years of age. They are given co-timoxazole to prevent pneumocystis pneumonia from 6 weeks. The HIV test is done on the infant at 12 months and if negative, co-trimoxazole is stopped.

Problems in implementation:

- Lack of human resources at sites

- Increase in staff work load

- Counselling focuses on getting agreement from women to be tested rather than empowering them to deal with their HIV status

- Lack of couple counselling

- Lack of privacy

- Variability in remuneration of lay counsellors

- No adequate evaluation of the implementation of the programme

- Poor PHC infrastructure to implement programme

Question 5

a) Ntombi, a 11-month-old girl is brought in by her mother for irritability and fever. She has had rhinorrhoea and a cough for two days. She developed fever and irritability last night. Ntombi is refusing to eat and only drinks from her bottle. Her mother says she had an ear infection four months ago and is concerned that she has one again.

i) List your differential diagnosis other than an ear infection? (4)

Upper respiratory tract infection (e.g. pharyngitis)

Lower respiratory tract infection (e.g. bronchopneumonia)

Meningitis

Urinary tract infection

Septicaemia

ii) What findings on examination of the ear will confirm the diagnosis of an ear infection? (4)

1. The tympanic membrane might be erythemaous, opacified, or bulging.

2. Disrupted light reflex

3. Immobile drum

4. Perforation of tympanic membrane or discharge from ear (otorrhoea)

5. Visible fluid, pus or air bubble/s behind tympanic membrane

Your examination confirms an otitis media.

iii) List two factors that may have contributed to the pathogenesis of Ntombi’s otitis? (2)

Immune response – age, genetic predisposition, atopy, HIV

Eustachian-tube dysfunction or anatomic defect (e.g. cleft palate)

Environment - breastfeeding for less than 3 months, pacifier use, parental smoking, positive family history, day care outside the home, siblings, season,

iv) Name three likely aetiological agents responsible for Ntombi’s ear infection? (3)

Streptococcus pneumoniae, Moraxella catarrhalis, and nontypeable

Haemophilus influenzae are the predominant bacterial pathogens.

Viral OM is most frequently caused by respiratory syncytial virus or rhinovirus.

v) How will you treat Ntombi? (6)

1. All children should receive adequate analgesics (paracetamol or ibuprofen), especially for the first 24 hours after diagnosis. Give every 6 hours until pain is gone.
2. Observation (without prescribing an antibiotic) is advised when appropriate follow-up and communication can be assured (less likely to do this in younger child like Ntombi).
3. Children who are initially observed should receive prompt antibiotics if symptoms worsen or do not improve within 48–72 h.
4. Antibiotic - Amoxicillin 50mg/kg/day q8hrly for 5 days.

5. If ear discharge - teach mother to clean ear by dry wicking.

6. Follow-up in 5 days if pain or discharge persists and again after 14 days (IMCI guideline).
7. Antihistamines and decongestants offer no benefits.

8. List two potential complications of an acute otitis media? (2)

Perforation of the tympanic membrane, mastoiditis, facial paralysis, labyrinthitis, external otitis, cholesteatoma, ossicular necrosis, pseudotunour cerebri, and cerebral thrombophlebitis.

Disturbance in vestibular, balance, and gross motor function can also occur.

May have developmental consequences, because of long-term or frequent episodes of hearing loss

9. If Ntombi had been treated for an otitis media with amoxicillin within the past month, how would this change your management? (3)

Most likely due to a resistant organism.

Provide high dose (90mg/kg/day) amoxicillin for 10 days, to cover resistant pneumococcal strains.

Third-generation cephalosporins, amoxicillin plus clavulanate, and erythromycin plus sulfamethozaxole offer no advantage in terms of coverage of resistant organisms.

Myringotomy or tympanocentesis should be performed if OM still persists after a second course of antibiotics.

b) You are uncertain about the benefits of an antibiotic in children with acute otitis media and risk factors for a poor outcome. You perform a Medline search and find the following abstract. Read the abstract below and answer the questions that follow:

i) What study design was used? (1)

Randomised controlled trial

ii) What intervention/s were the children randomised to? (1)

Immediate or delayed (taken after 72 hours if necessary) antibiotics.

iii) Explain what the odds ratio of 4.5 means in the statement “Distress by day three was more likely in children with high temperature (adjusted odds ratio 4.5, 95% confidence interval 2.3 to 9.0)… on day one.” (2)

The odds ratio (OR) represents the proportion of patients with the target event divided by the proportion without the target event. Thus, distress on day three was 4.5 times more likely in children with a high temperature on day one compared to those who did not have a high temperature on day one.

iv) Explain the significance of the 95% confidence interval of 2.3 to 9.0 in the above statement. (2)

Investigators often tell us the neighbourhood within which the true effect likely lies by the statistical strategy of calculating confidence intervals within which one can be confident that that a population parameter is estimated to lie. You can consider the 95% confidence interval as defining the range that includes the true relative risk reduction 95% of the time. Thus, the authors were confident that if they repeated their study a 100 times, in 95 instances their odds ratio would be somewhere between 2.3 and 9.0. In other words, distress by day three would be somewhere between 2.3 and 9 times more likely in children with a high temperature on day one compared to those who did not have a high temperature on day one, in 95% of instances.

v) Is the p-value statistically significant in the statement “Among the children with high temperature or vomiting, distress by day three was less likely with immediate antibiotics (32% for immediate v 53% for delayed, chi²=4.0; P=0.045, number needed to treat=5).” Explain your answer. (2)

Yes, p value less than 0.05

vi) What statistical test was used to calculate the p value in the above statement? (2)

Chi-square test

vii) Explain what the ‘number needed to treat = 5’ in the previous statement means. (2)

Number needed to treat (NNT) is the number of patients that need to be treated to prevent one target event, i.e. 5 children with high temperature or vomiting would have to be treated with immediate antibiotics to prevent one child still being distressed by day three.

viii) Summarise the likely conclusion of this study in one or two sentences.(4)

Children with a high temperature, vomiting or cough on day one were at a higher risk of distress or night discomfort on day three.

Immediate antibiotic use was associated with less distress or night discomfort on day 3 in children with a high temperature or vomiting on day one.

Useful review article: Lancet 2004; 363: 465–73. Available at www.lancet. com/