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THE COLLEGES
OF MEDICINE OF |
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DCH |
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Aug/Sep 2004 |
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Paper 1 |
Answers Paper I
Question 1
a) Describe
breath holding spells and temper tantrums and how you would manage them.
b)
How
would you manage a 7-year old boy who wets his bed at night?
c)
What
would be your approach to a baby who at his routine 6-week check-up is noted to
have a big head?
d)
How
would you manage a toddler who was seen eating his grandmother’s “heart” pills
2 hours previously?
b) Enuresis
Differentiate between 1o and 2 o
enuresis.
Causes:
1o delayed maturation – 5% of 10 years have
enuresis.
Family
pattern
Underlying
anatomical abnormality – ectopic urethra, obstruction with overflow
incontinence
Underlying
neurological abnormality – neural tube, diastematomyelia.
2o causes of polyuria – diabetes mellitus or
insipidus, renal failure
cystitis
psychological
trauma
Management:
Establish whether enuresis is 1o
and 2 o
Exclude underlying organic
problem
History
of polyuria, frequency or dysuria
Examination
especially CNS and urogenital
Investigations
– routine urine dipstix & MC&S and as indicated
by history
and examination.
Treat any organic pathology.
No organic pathology consider
developmental or psychological problem.
Family history
Social history
Past medical and surgical history
Avoid
punitive approach and provide parental education and reassurance
Home
programme -
to increase bladder capacity
self training to recognise a full
bladder
Restrict
evening fluid intake
Reward system
Imipramine 25
mg nocte
DDAVP for
special occasions
c) Big head at 6 weeks
Confirm that the head is big by measuring the head
circumference and plotting on growth chart.
Possible causes:
Soft tissue
swelling – cephalhaematoma
Thickening of
skull
Subdural fluid
collections
Hydranencephaly
Big brain -
megalencephaly
Intraventricular
fluid - hydrocephalus
Examination to
Assess most
likely possible cause
Establish
neurodevelopmental status
Exclude associated abnormalities
– neural tube, cardiac etc
Investigations
Transillumination
SXR
Ultrasound
Possible CT
scan
Management
Confirm
problem
Establish cause
Treat cause
Cephalhaematoma
– reassurance and no drainage
Thickening
of skull – exclude anaemia - unlikely at this age
Subdural
fluid collection – no treatment unless pressure effects
Hydranencephaly
– education, counselling and support
Megalencephaly
– education, counselling and support
Hydrocephalus
– consider shunting
Education , counselling and
support
Ongoing monitoring -
megalencephaly
e)
How would you manage a toddler who was
seen eating his grandmother’s “heart” pills 2 hours previously?
d) Tablet ingestion
Assess child’s clinical state:
Level of consciousness
Vital signs – BP, pulse, resp
Resuscitation if required:
Circulation
Respiration
Try to identify type of drug and quantity ingested.
Decontamination:
Consider inducing emesis up to
12 hours after ingestion as long as toddler is conscious.
Ipecacuanha syrup - 10 ml
followed by drink of warm water.
Repeat if no effect after 20
minutes.
Delay absorption with activated
charcoal - 15 g in 50 ml water via NGT
Repeat 6
hourly
Hasten excretion of toxin with
cathartic – MgSO4, lactulose or Golytely
Consider antidote if available.
Admit for overnight observation of vital signs, cardiac &
renal function.
Educate parents and family about safety and prevention
strategies.
Question 2
a)
Discuss
the link between measles immunization and egg allergy and describe other valid
contraindications to measles immunisation
b)
Discuss
how you would deal with a mother who refuses immunizations for her child.
c)
Describe
the management of post-streptococcal glomerulonephritis.
d)
Describe
the management of a newborn with congenital syphilis.
a) Measles
vaccine
Anaphylaxis and
allergy to egg:
i.)
Health care professionals reluctant to immunize
infants or children with measles or MMR vaccine if there is a history of
allergy to egg, whether it be a skin rash or anaphylactic response, or even if
they have not yet had egg before.
ii.)
The majority of life threatening (cardio
respiratory) allergic reactions to measles or MMR vaccine have been reported in
children who were not allergic to
egg.
iii.)
The amount of ovalbumin, derived from the
chicken egg embryo tissue in which the vaccine is produced, is probably
insufficient to cause an allergic response. The allergic response is more due to
gelatin or neomycin present in greater quantities than the albumin.
iv.)
Allergy to egg should therefore not delay
measles vaccination. Any vaccine can cause anaphylactic reactions and
adrenaline (epinephrine) should always be available where vaccines are administered.
v.)
Skin testing for reactions and desensitization
are both associated with a risk of allergic reaction and should not be done.
vi.)
Children with milder forms of allergy to egg,
even urticarial skin reaction, can be safely vaccinated without additional
precautions.
vii.)
The only children that need to be vaccinated
under conditions where they could be observed for about two hours and be
effectively resuscitated are those with an allergy to egg in whom previous
exposure led to cardio respiratory reactions and those with egg allergy and
coexisting asthma (mainly older children).
Other
contraindications:
viii.)
Immunosuppression. Children with congenital immunodeficiencies, malignant disease, or those
receiving cytotoxic drugs, high-dose, prolonged steroid treatment or radiation
therapy should not be given live vaccines, i.e. measles, MMR. Defer
immunizations with these vaccines for at least 3 months after cessation of
immunosuppressive therapy.
ix.)
Administration of plasma
or immunoglobulin. Defer immunization for three months.
x.)
Immunosuppression
because of HIV infection: measles is contraindicated if the child is already
severely symptomatic (CD4 percentage <15%).
xi.)
Immunosuppression due to
kwashiorkor is not a contraindication for routine immunization.
xii.)
Severe acute illness;
postpone immunization to recuperation phase.
b) Anti-vaccination
movements
i.) Try to
determine where the parents’ resistance comes from. (They have different
reasons) Parents may question the need for or the safety of immunizations and
some may even refuse certain or all immunizations for their child. These
concerns could be based on religious or philosophical objections, incorrect
information or deliberate one-sided information about possible problems that
vaccines may cause. The latter is often found on anti-vaccine websites.
ii) No
immunization is currently mandatory in
iii) The
benefit of the EPI vaccines outweighs the risks in by far the majority of
children, with a few exceptions. Know your facts
iv) The
response to parents who resist immunization should not be aggressive.
v) Health care
professionals should aim to effectively and empathetically communicate the true
benefits, safety and possible risks of vaccine(s) to them, as well as the risks
encountered by unimmunized children. Communicate risk and probability
adequately
vi) Promote,
not just give neutral information on, immunisation
vii) Educate on
association and causality, and the difference between the two
viii) Counter
irrationalism and the dangers of “alternative” medicine
ix) Many
vaccine-preventable conditions are more severe in adults and parents who have
withheld immunization from their children are obligated to inform them once
they reach adulthood.
x) If, after
discussion, parents still refuse immunization for their child, this should be
documented in the patient’s record to reduce any future liability should a
vaccine-preventable disease occur in the unimmunized child.
c) Describe the management of post-streptococcal
glomerulonephritis.
i) Confirm
diagnosis – haematuria/oedema/hypertension/skin lesions of impetigo. Special
investigations such as complement (C3 decreased)/Streptococcal antibodies/U +
electrolytes + albumin – potassium/CXR and ?ECG if K+ not available/skin/throat
cultures?)
ii) Assess
severity: hypertension, heart failure, oliguria, severe oedema – hospital
admission
iii) Fluid
balance: Strict intake and output monitoring.
iv) Fluid
restriction/requirements:
Nothing if in heart failure due
to fluid overload
Insensible losses only - while child
is still oedematous and has oliguria
Oliguria (<300ml/m2/d) –
insensible losses + previous day’s urinary output
v) Fluid/food: high colories, low protein
vi) Regular
monitoring: Blood pressure, urine appearance/albuminuria)
vii)
Stimulate/increase urinary function/output
– Diuretics (Furosemide)
viii) Control
of blood pressure
ix) Manage
hyperkalaemia if present
x) Bedrest,
sports and activity?
d) Describe the management of a newborn with congenital syphilis.
i)
Confirmation
of diagnosis - Special investigations:
Serological tests should be done on the mother’s blood. (RPR/VDRL and FTA/TPHA)
Cord blood and even the neonate’s blood can give false negative results. If CSF
is obtained, a RPR or VDRL titre should be obtained to aid in the follow-up of
these patients.
X-rays of the long bones may aid the diagnosis and 12% of asymptomatic infants
will have radiographic changes of the long bones. C-reactive protein may be
positive.
If wet skin lesions are present, smears can be obtained for dark field
microscopy which will confirm the presence of spirochetes.
ii)
Management
of congenital syphilis:
Symptomatic infants of an untreated or partially treated (ie.
treated with erythromycin only, benzathine penicillin in last month of
pregnancy or only 1-2 doses of benzathine pencillin), serologically positive
mother should receive full treatment as if they had neurosyphilis.
This treatment consists of crystalline penicillin 100 000-200 000 u/kg/day IV
in 2-3 divided doses or procaine penicillin 50 000 u/kg/day IMI for 10-14 days.
Penetration of the crystalline penicillin into the CSF is better than that of
procaine penicillin and therefore it is advisable to use the first in infants
with severe disease.
Asymptomatic infants of untreated seropositive mothers can either be treated in
full as above or receive a stat dose of benzathine penicillin 50 000 u/kg IMI
stat. The latter has been shown to be sufficient in most of these infants but
serological follow-up is necessary to verify cure. Asymptomatic infants of
partially treated mothers can also receive a stat dose of benzathine penicillin
only.
iii)
Follow-up:
This is important to verify cure. RPR or VDRL titres are necessary for
follow-up since once the specific treponemal tests are positive they stay
positive for life.
Follow-up should be done at 1 month, 3 months, 6 months and 12 months until the
infants titre becomes negative. A rising titre or stable titre indicates
disease and the infant should be retreated.
iv)
Notifiable
disease. Symptomatic congenital syphilis is a notifiable
disease.
Question 3
a)
Describe your advice to a mother and the treatment of an 18-month-old
child diagnosed with a haemoglobin of 9 g/dL (with haematological indices
suggestive of iron deficiency).
b)
What are the possible causes of a fever during the last 48 hours in a
4-year child undergoing chemotherapy for a malignancy and its management?
c)
Describe your advice to a mother on how best to feed her newborn baby
during the first year of life.
d) What are the indications
for referring a well child aged 3-5 years with a cardiac murmur to a paediatric
cardiologist?
a)
Iron deficiency anaemia
Most probable cause is dietary. Must
discuss: Changes in feeds, milk amount, use of cows milk, solids, type of
solids.
Drug treatment: 5-6mg elemental iron per kg per day until the Hb is normal and
then ½ dose for a further two months to replenish stores. Try not to give with
tea etc. Can add Vit C.
Do FBC during and after treatment is finished to document response. If no
response or reoccurs then need to look for other causes.
Note that the causes are not required in the answer.
b)
Causes of fever in child on chemotherapy
Infection, drugs, antibiotics, tumour it
self, chemotherapy drugs, blood products, environmental
Finds cause, do relevant investigations (not need to list them), remove
clothing bedding, use fan, tepid sponging, give panado or equivalent at the
correct dose. Start on antibiotics unless other cause obvious
c) Advice to a mother on how
best to feed her newborn baby
Breast is best, preferably for 24 months. Exclusive breast for 4 to 6 months then starts to wean. If not breast then artificial milks (how to mix and prepare). Weaning: Cereals and then soft foods one at a time, different types so that colour, texture and taste varies. Slowly increase amounts and decrease the milk. Additive such as iron, multi-vitamins. Mention the difference between HIV negative and positive mothers re the feeding.
d)
Indications for referring a well child aged 3-5 years
with a cardiac murmur to a paediatric cardiologist
Exercise intolerance, clinical signs symptoms of early cardiac failure, any systolic murmur >3/6, ejection systolic murmur, any diastolic murmur, any murmur that is in strange position radiates widely or sounds different, any abnormality in pulse or BP, any abnormal heart sounds, growth failure, dysmorphic features, recurrent infections and murmur, previous history of rheumatic fever, any cyanosis or clubbing previous cardiac surgery. Note that the question does not need a list of characteristics of an innocent murmur.
Question 4
a)
Discuss
the achievement of child rights in SA.
b)
Outline
the main components of health services for school children in
c)
How
would you developmentally assess an 18-month old toddler in terms of gross
motor, fine motor and vision, language and social skills?
d)
Describe
the Integrated Nutrition Programme.
a) The
achievement of child rights in SA
UN
Convention on the Rights of the Child was developed to ensure the survival and
protection of children in 1989
These
rights include:
The Right to Survival (the right to life, access to health care, an
adequate standard of living and a name and nationality)
The Right to Development (education,
leisure and play, and freedom of expression)
The Right to Protection (from violence,
abuse and neglect, mental and physical disability; protection of refugees and
children separated from their parents)
The Right to a Safe
Environment
The
Right to Participation in all matters affecting the child
Government’s response to implementing these rights:
In
order to achieve these rights the SA Government has developed several policies
including:
- Right to survival:
-
Social Assistance Act (through which the Child Support Grant, Child
Disability Grant and the Foster Care Grant are made available)
-
Health Care Policies
-
Integrated Management of Childhood Illness, Integrated Nutrition
Programme, PMTCT Programme, Free Health Care (under-sixes and pregnant mothers)
and Youth and Adolescent Health Policies
- Right to Development:
-
To ensure education to all children, the SA Schools Act (1996) was
developed, which provides compulsory schooling to all children between 7-15
years.
-
The School Health Policy was recently developed to ensure optimal
health and development of school children.
- The Right to Protection:
-
Child Care Act
-
The Children’s Bill is being reviewed and redrafted and will ensure
that children’s right to health and nutrition is met and afford support and
protection especially to children from abuse and neglect
-
The Domestic Violence Act indirectly protects children from physical
abuse through a protection order
-
SA Schools Act outlaws corporal punishment
- Right to a Safe Environment
-
Through legislation on control of smoking in public places (Tobacco
Products Amendment Act)
-
Main constraints to implementation of these policies:
-
Lack of implementation of a number of policies and programmes
-
Poverty (including poor housing, unsafe environments and food
insecurity)
-
Lack of sufficient social assistance
-
Increasing violence and injury
-
Lack of access to and ineffective health services
-
Insufficient resources
-
Growing epidemic of HIV/AIDS
b) Main components of health
services for school children in South Africa
The components
of a school health service are outlined in the School Health Policy (2003),
which was recently drawn up by the National Department of Health.
These services
cover children from grade R-12 and are centred in the Health promoting Schools
Initiative.
The school health
service package includes:
Assessments for
hearing/ vision and speech impairment
Mental health
assessments
Assessments for
motor dysfunction
Oral health
assessments
Nutrition/
anthropometry assessments
Identification and
treatment of injuries and child abuse
Disease control:
parasites, disease outbreaks (e.g. cholera and measles)
Health promotion
on a number of issues that affect children: life skills, child abuse, risk-taking
behaviour, safety, sexuality and healthy lifestyle
Contribute to
Health Promoting Schools Initiative including:
-
Establishing a healthy
environment
-
Supporting School
Programmes
-
Supporting
identification and management of children with HIV and chronic conditions
It is important
that the services provide for referral, follow-up, and monitoring and
evaluation.
c) How to developmentally
assess an 18-month old toddler
Ensure
privacy
Ensure that the caregiver and child are
comfortable and explain the procedure to the caregiver
Will need: tape measure, building blocks, small
objects e.g. raisins/ crumpled piece of paper
History:
-
Examine RTHC for birth history, birth
weight, apgar, previous developmental screen, diseases
-
Ask about previous illnesses
-
Developmental milestones: age at which the
child smiled, sat, was able to stand, said first words
-
Current development:
o
Gross & fine motor: does the child walk, grasp a bean sized
object, drink from a cup
o
Language:
§
Does the child respond to simple commands
§
Does the child use 3 recognisable words
§
Does the child respond to his/ her name
o
Vision:
§
Does the child watch a moving object
o
Social:
§
Does the child attempt to feed him-/ her-self
Examination:
General:
-
Check percentiles for weight, height and head circumference
-
Check for dysmorphism e.g. Fetal Alcohol or Down’s Syndrome
Check Motor Function: Posture, tone,
reflexes
Development:
Gross motor:
-
Assess if child can walk. If the child is unable to walk he/ she may
need an assessment by a developmental paediatrician
Fine motor:
-
Should be able to build a tower of 3 cubes
-
Should be able to drink from a cup
-
Should demonstrate pincer grasp i.e. thumb finger apposition with
small objects e.g. raisin/ crumpled piece of paper
Language and hearing
-
Ask child to show you his/ her foot/ nose
-
The child should know 3 recognisable words (ask caregiver). If not,
there may be a hearing problem
-
Child should turn when his/her name is called
Vision/ hearing
-
Check eyes for squint/
cataracts
-
Check if follows a
moving object
Social:
-
May indicate wet/ dirty
nappy
-
Child may play alone
-
Assess interaction with
caregiver
d)
The Integrated Nutrition Programme
Comprehensive nutrition strategy, which was
developed nationally in 1994 and is implemented through health facilities and
community-based programmes
Aimed at addressing all the causes of
malnutrition and is based in the UNICEF conceptual framework
Aims:
-
Enable women to
breastfeed (Baby-Friendly Hospital Initiative)
-
Promote optimal growth
of infants
-
Promote health of
pregnant and lactating women
-
Prevent mortality from
diseases of lifestyle
-
Improve capacity of
communities to solve nutrition problems
-
Intersectoral
collaboration
Target groups of the INP:
-
Children < 6 years
-
At risk pregnant and
lactating women
-
Those with chronic
diseases of lifestyle
-
At-risk elderly
Community-based Nutrition Programme:
-
Improving household food
security
-
Improving knowledge/
changing behaviour
-
Promoting a healthy
environment
Health Facility-based Programme:
-
Growth monitoring and
promotion
-
Counselling (through
IMCI)
-
Micronutrient/ food
supplementation (Vitmain A and iron)
-
Treatment of undernutrition (PEM Scheme)
-
Treatment of underlying disease (TB, HIV,
Parasites)
Nutrition Promotion:
-
Breastfeeding
-
Food fortification
Question 5
- How would you manage a prolonged
(>30 minutes) seizure in a 5-year old child?
- What are the medical complications
of cerebral palsy in a child?
- Describe the differential diagnosis
and management of a toddler with recurrent wheezing.
- How would you manage a 3-year-old
child with recurrent ear infections?
a) Management of a prolonged Seizure in a
5 year old
Secure the child’s airway, breathing, and
circulation ( ABCD) …give Oxygen,
Monitor saturation, pulse and BP, glucose
PR diazepam (0.5mg/kg)----------à IV access IV diazepam(0.3mg/kg)…….take blood
For glucose, gas, electrolytes, FBC &
blood culture , ?toxins if history suggestive)---à
Access failure /delay- gain intra osseous
access / intranasal Midazolam 200mcg/kg--à
No response in 10 minutes---à IV Phenobarbitone (20mg/kg)------àRepeat
Phenobarbitone (10mg/kg) ---àRepeat Phenobarbitone (10mg/kg)----à Refer to a
Secondary/ Tertiary ICU for intubation and
Sodium Pentothal infusion.
Alternatives:
i.
Lorazepam (0.1mg/kg) faster acting
alternative to diazepam for bolus IV intervention.
ii.
Midazolam intranasally (200mcg/kg) or
sublingually(500mcg/kg) if no venous access
iii.
Midazolam infusion / Clonazepam
infusion…if seizure control is not gained by first Phenobarb infusion.
iv.
Phenytoin (20mg/kg over 20 minutes) if
known adverse reaction to Phenobarb ( monitor for cardiac arrhythmias.
v.
Watch carefully for drug related
respiratory depression.
ADMIT
NB. History …1st fit/ Recurrent
…Pyrexial/ Apyrexial
...If pyrexial…focal/ , or focal pathology,
GCS < 8/15…….Septic screen
Rx as
Meningitis/ Encephalitis
…If apyrexial…>
recurrent focal Sz…> Neuroimaging/focal signs – Ref
…>normal
imaging/ no focal signs
start Carbamazepine
…If apyrexial recurrent
Gen Seizure Type .....>EEG, ref Neurology
b. Medical Complications of Cerebral Palsy
Definition: an umbrella term covering a group of
non progressive but often changing motor impairment syndromes secondary to
lesions or anomalies of the brain arising in the early stages of development.
Complications
relate to problems with:
i.GIT&Feeding-
poor oromotor tone, difficulty with co ordination of chewing and
swallowing,pseudobulbar palsy drooling
- dental caries,
thrush and other oral sepsis
- gastro-oesophageal
refux,gastritis, delayed gastric emptying,
-
Aspiration….pneumonias
- constipation
- Failure to
thrive/Malnutrition
- Anaemia
- Other micronutrient
deficiency
ii.Related
to impaired Mobility
-deformities
-pressure
sores
-contractures, fixed flexion deformities
-dislocated hips
-scoliosis leading to chest deformities…..risk
of recurrent chest infections
-pain associated
with dystonia or spasticity
-osteoporosis and fractures
iii.Seizures
….as well as status epilepticus which may worsen the brain insult (occur in 30%
of CP children)
iv.High Risk of
Infections/Sepsis
-
Chest- due to weak cough, swallowing of
secretions, colonisation with atypical organisms
-
Oral Sepsis
-
Skin Sepsis
v. NB* Other
Neglect
Abuse
Depression
c. Differential Diagnosis and Management of Recurrent Wheezing in
a toddler.
Definition: a soft, high pitched sound made by obstruction to
smaller peripheral bronchi and bronchioles. It is louder at the chest than at
the mouth , and more marked on expiration (which is prolonged). Recurrent
wheezing refers to 3/ more episodes in a toddler.
Differential
Diagnosis:
NB. Not all wheezing implies Asthma
- Infections:
- Viral Bronchiolitis RSV, adeno, influenza, parainfluenza,
-
Bacterialeg. Pertussis, poor socio economic conditions, smoking increase
the risk of
recurrent infections.
- TB especially with lymph node compression
- Worms …Loefflers
2.The allergic
profile and Asthma
eg. Recurrent
‘Wheezy Bronhitis’ or the happy Wheezer: typically children with a family
history of atopy, parental smoking, exposure to environmental allergens. The
majority of these children do not develop Childhood Asthma, and Brochodilator
response is variable.
Asthma =characterised by episodic reversible airway obstruction causing a
recurrent wheeze, cough (often at night) and dyspnoea.
3.Other Causes:
- gasro oesophageal reflux
-Congenital lung
anomalies
-Broncopulmonary
dysplasia
-Tracheal bronchomalacia
-Vascular rings
-Bronchial compression
eg. lymph node
-Foreign body inhalation
-Cardiac anomalies/
cardiac failure
- as a feature of Chronic
lung disease ie.
-
Bronchiectasis
-Cystic Fibrosis
-
Lymphocytic interstitial pneumonitis
-
impaired ciliary motility
Management :
NB* Take a good history:
-Is the Whheze transient, persistant/
recurrent?
-Was the Child born prematurely?
-Was the wheeze of sudden onset?
-Is there a history of Gastro-oesophageal
reflux?
- Is there a strong family history of
atopy.
- does the child have other features of
allergy eg. eczema, hay fever
-Is the wheezing associated with exposure
to pets, pollens, smoke etc.
Examination
-Signs of infection
-other signs of atopy…eczema, allergic
shiners, salute etc.
-Lymphadenopathy
-failure to thrive
-Chest deformities
-Clubbing
-Signs of immunosuppression
Chest examination:
-severity of hyperinflation
-other sounds-focal clinical signs
-level of distress
Investigations…many children need none
-Broncodilator responsiveness…very impt
to demonstrate reversibility.
-Chest XRay
- Nasopharyngeal aspirate for RSV
- Milk Scan/ Barium/ pH monitoring for
GOR
- Cannot really do Pulmonary function
tests in a toddler
- Skin tests/RAST for allergy
Treatment- depends on cause
-
Reversible ie. Asthma- assess Severity….Mild –
trial of Bronchodilator via Spacer device
-
Add Inhaled Corticosteroid in Mod / Severe
-
Treat worms and infections
-
Avoidance of triggers
-
Chest physio Plus short term oral
corticosteroids in Chronic Lung disease.
d) Management of a 3 year old with recurrent Ear Infections
Ear infections are more common in children 3yrs and under because of
the Immature Eustachian Tube making it easier for bacteria to migrate from the
nose and throat to the middle ear
Pathophysiology: With Viral upper respiratory infections
(Colds) the nasal passages get swollen and mucus collects at the back of the
nose, allowing overgrowth of bacteria which then migrate via the Eustachian
Tube to the Middle Ear. Overgrowth of bacteria, pus and mucus cause the
Tympanic Membrane to bulge and appear red, and prevents the TM from vibrating
properly.
Risk factors for recurrent infections in
Toddlers include:
-
Bottle feeding (feeding lying down….milk may
irritate Eustachian tube)
-
Smoking
-
Day Care Centres….cross infection and frequent
colds
-
Chronic nasal Congestion
-
Allergies…causing Eustachian tube
dysfunction/obstruction
Management:
Take a detailed history:
- isolate risk factors in the child and
ways to prevent them eg.feed upright, keep nose clear, treat allergies, avoid
exposure to cigarette smoke.
- need to distinguish Recurrent
infections from Persistant infections with Cronic Otitis Media and Middle Ear
Effusions.
- Check which antibiotic what was used to
treat previous infections ( first line is Amoxil) ..was the course completed,
is the infection resistant to the antibiotic?, was the child examined after the
treatment to see if the infection was cleared.
- NB* Recurrent Ear infections/ Chronic
Ear infections cause prolonged middle ear effusions , if the fluid stays for
more than 3 months it can cause Glue ear.
During the period when the is fluid in the Middle ear ….hearing is
impaired/muffled.
If this is chronic it can cause Speech Delay.
Examination
- look for signs of allergy/ chronic nasal
congestion.
- Diagnosis of Acute Otitis Media = Red,
bulging Tympanic Membranes
- Exclude Chronic Infections especially
‘Glue Ear’
-Look for signs of a ruptured TM
If the Child is toxic exclude signs of
Meningitis/mastoiditis
Treatment
First line antibiotic is Amoxil…..must
treat for 7 days
NB*..pain relief ..paracetamol/Brufen
Ruptured TM may need Topical antibiotic +
steroid
Persistant symptoms of fever/ pain >
72 hours…..may need another antibiotic
Chronic infections may also imply
bacterial resistance.
Fluid that persists in the middle ear for
more than 3 months may need Surgical drainage
Recurrent Middle Ear Effusions hinder
normal hearing….Manage by referral to an ENT for insertion of Grommets.
Patients at high risk of recurrent
infections may need prophylactic antibiotics(once aday Amoxil) taken for 10 –
14 days at the first sign of a cold.
High index of suspicion for Speech delay ( especially if
asymptomatic middle ear effusions)…refer for an Audiogram before Grommet insertion….if Conductive
Hearing impairment….repeat Audio after insertion of Grommets
Refer to Speech Therapy.