THE COLLEGES OF MEDICINE OF SOUTH AFRICA

 

DCH

Aug/Sep 2004

Paper II

 

 

 

Answers Paper II

 

 

Question 1

 

Sipho, a 6-week-old infant, is brought to the clinic for a routine visit. He is well. His 19-year old mother, Joyce, received antenatal voluntary counselling and testing and was told that she was HIV positive. Both Joyce and Sipho received nevirapine at the time of Sipho’s birth. Joyce is unmarried, unemployed and Sipho is her only child. She lives with her sister and her two children. Jabu, Sipho’s father, provides no financial support. Joyce is currently breastfeeding Sipho.

 

a)     What is the chance that Sipho is HIV-infected, and what would his risk be is nevirapine was not offered at birth?                                                       (2)

With nevirapine- 8-12%

Without nevirapine- 15-30%

 

b)     List THREE interventions that have been shown to reduce mother-to-child transmission of HIV, in addition to nevirapine.                                                (3)

Caesarean section

Delayed rupture of membranes

Avoiding traumatic delivery

Other antiretroviral regimens during pregnancy- e.g. AZT, 3TC

Highly Active Antiretroviral Therapy (HAART) during pregnancy

Formula feeding (or exclusive breast feeding)

 

c)     List THREE maternal factors that increase the possibility of mother-to-child transmission of HIV?                                                                         (3)

High Viral load (plasma HIV-1 RNA level)

Mother has AIDS

Low CD4 count

 

d)     Would you confirm Sipho’s HIV status at this stage? Justify your answer.    (3)

Both a Yes or a No answer was acceptable as long as the response could be justified.

Factors to consider:

Would require a Polymerase Chain Reaction (PCR) test (which identifies the antigen) to diagnose HIV-infection. However, it’s expensive. Advantage is that if positive, could advice mother on appropriate steps (e.g. continue exclusive breast feeding). If negative, would advice mother to consider stopping breastfeeding. Would also not need to provide prophylaxis. However, test would have to be repeated later, as Sipho might still seroconvert (still breastfeeding).  

HIV Elisa can be done, but only indicates maternal status (know Joyce is positive) and does not help establish Sipho’s status. Therefore, useless presently.

 

e)     Would the vaccinations you offer Sipho be affected by his mother’s HIV status? Substantiate your answer.                                                               (2)

No. Sipho is well and not at risk of any adverse effects from vaccination.

 

f)       Discuss any prophylaxis you may offer to Sipho to prevent opportunistic infections.                                                                                                               (6)

Cotrimoxazole prophylaxis

Cotrimoxazole syrup should be administered once daily, on every day of the week

The recommended dose is 5 mg/kg trimethoprim and sulphamethoxazole 20 mg/kg per day. (0.625ml/kg)

For infants and children less than 15 months of age, prophylaxis should continue until HIV infection has been ruled out (e.g. a negative HIV Elisa) and the risk of exposure has ceased, e.g. breast feeding stopped.

Prophylaxis should be continued for life if a HIV infected child has:

had an episode of Pneumocystis carinii  pneumonia

had three or more pneumonia episodes

symptomatic HIV disease or an AIDS-defining illness

Some evidence that INH prophylaxis may prevent TB in children, but not routine practice yet.

 

g)     What advice would you offer to Joyce about feeding Sipho?                     (3)

Exclusive breastfeeding for 6 months

Preventing and promptly treating oral lesions and breast problems.

Shortened duration of breastfeeding when replacements are safe and feasible

 

h)     What advice would you offer to Joyce about making a safe transition to replacement feeding when she decides to stop breast feeding?                                        (3)

 

Prepare for Transition:

  • Mum to discuss weaning with family
  • Express milk to practice cup feeding
  • Find a regular supply of formula or other milk e.g. full cream milk
  • Learn to prepare and store milk safely

Make the Transition

  • Teach mum to cup feed
  • Clean all utensils with soap and water
  • Express and discard some breast milk to keep mum comfortable until lactation stops
  • Give complementary feeds from 6 months

 

i)        Briefly discuss any social security/support measures which Sipho might be eligible for including eligibility criteria, requirements and the procedure for obtaining these. (8)

 

Child support grant

·         A grant of R170 payable to a primary caregiver for any child under the age of 11 years.

·         A primary caregiver is any person who takes primary responsibility for the daily care needs of the child and need not be a relative of the child.

 

Qualifying requirements:

·         Parent/s and child/ren must be resident in South Africa AND South Africa citizens

·         The primary care-giver and the child/ren must comply with the financial criteria in the means test (income of primary care-giver and spouse) below:

  • R15 200 per year and live in rural area;
  • R13 200 per year and live in urban area informal dwelling;
  • R 9 600 per year and live in urban area formal dwelling
  • The child must not be receiving any other grant
  • Payable for a maximum of 6 children (for one primary care-giver)

 

Various documents (e.g. baby’s birth certificate, caregiver’s ID) are required and special forms have to be completed.

As requirements change with time, the local Social Worker should be consulted, who will assist the process.

 

j)       What financial support can Joyce legally expect from Jabu? What procedure needs to be followed to obtain this support?                                                       (7) 

 

Maintenance Order can be issued against Jabu. Both parents have a legal duty to support their children. Joyce can apply to the Maintenance Court for the Jabu to pay support for Sipho.

This is a long and complicated process and may take some time. To apply for a maintenance order against the father of a child, Joyce needs to go to the Maintenance Office at the Maintenance Court in area to apply for the court order. There are special Maintenance Courts at every Magistrate's Court. Maintenance officers work in these courts and help people who want to apply for maintenance. They also deal with applications to get more or to pay less maintenance.

  1. Joyce will need:
    • The name and address of the child's father, and the details of where he works
    • A photograph of the father (if available)
    • Identity document
    • Sipho’s birth certificate
    • Proof of income (like a salary or slip)
    • Papers, receipts and accounts, showing all the things you must pay every month
  2. The maintenance officer will send a summons to the father asking him to come to the maintenance office on a certain date.
  3. On the date, Joyce and Jabu must go to the office to determine how much Jabu must pay for Sipho’s maintenance.
  4. The maintenance officer will help work out all the things Joyce must pay for every month, how much money Joyce earns and how much money the father earns.
  5. If Jabu says that he is not the father of the child, Joyce needs to ask the court to order a paternity test.
  6. If Joyce agrees how much Jabu must pay for Sipho, the maintenance officer will get both to sign a paper called an order of court. This says that the father must pay the agreed amount of money every week or every month.
  7. If Joyce does not agree, or if the father does not come to the office on that date, then the officer will say Joyce case must go to the Maintenance Court. The court sends notices to Joyce and the father telling them both to come to the Maintenance Court on a certain date.
  8. The magistrate will listen to both the parents' stories. They will ask the mother and father to show how much they earn and how much they pay every month for things like rent, electricity and food.
  9. The magistrate then decides how much the father must pay for his children. The magistrate will make this amount an order of court, in writing.

The father must pay the maintenance amount every week or month to the maintenance office. The mother must collect the money from the maintenance office. The father can also pay his maintenance into the mother's bank account. This will save the mother from having to collect the money from the office. Once there is a court order instructing a parent to pay child support, it is a criminal offence not to pay.

 

 

Question 2

 

a)     Identify FOUR major causes of deaths under the age of 5 years in
South Africa.                                                                                 (4)

b)     Tabulate what measures could be implemented at national, district/regional and hospital level to reduce deaths from each of these causes                                                     (36)

 

a)    The 4 MAIN causes of childhood deaths between the ages 1 month and 5 years in South Africa.

 

Pneumonia, Diarrhoea, Malnutrition, AIDS

 

b)    Strategies needing to be implemented to reduce these deaths

 

The most important interventions to reduce childhood mortality:

 

Prevent malnutrition

 

Literacy of the mother

 

Other interventions:

 

Local Hospital/Clinic

 

  1. Weigh every patient at every visit and plot weight on RTHC.
  2. Investigate all patients with weights below the 3rd centile or with failure to thrive

 

  1. Start all patients below 3rd centile or with failure to thrive on food supplementation programs. Food supplements must be available.

 

  1. Promote exclusive breastfeeding for the first 6 months

 

  1. Implement WHO’s ten steps of management of severe malnutrition at local hospital.

 

  1. Give vit. A according to national guidelines

 

  1. Teach families to produce their own vegetables

 

  1. Check every child’s immunisation status and bring immunisations up to date

 

  1. Teach hygiene to caregivers eg. Handwashing and clean water

 

  1. Teach communities how to manage children with diarrhoea and recognising signs of dehydration

 

  1. ORT corners in every clinic

 

  1. Implement correct rehydration guidelines at clinics and hospitals

 

  1. Effective family planning service at local clinic. Teach mothers to space children at least 2 years apart

 

  1. Teach IMCI’s community component to waiting caregivers at clinics and in the community.

 

  1. Establish regular meetings with community leaders to promote health

 

  1. Train community on prevention of transmission of HIV

 

  1. Effective VCT service

 

  1. Effective PMTCT program

 

  1. Introduce ART as soon as trained healthworkers available

 

  1. TB contact tracing

 

  1. Effective TB treatment programs

 

  1. Implement IMCI strategy at all primary health care clinics. Train healthworkers to use IMCI strategy.

 

  1. Availabilty of oxygen at or in all clinics, ambulances and hospitals.

 

  1. Availabilty of essential drugs especially antibiotics.

 

  1. Availability of essential equipment to give and monitor oxygen delivery, fluid and drug administration.

 

  1. Regular audits  by supervisor to check quality of care

 

  1. Collect accurate statistics on morbidity and mortality with weekly reports to management.

 

  1. Access to social grants for patients that qualify.

 

  1. Zinc supplementation may be beneficial in children with malnutrition and diarrhoea.

 

 

District/Provincial

 

An effective MCWH (Maternal, Child and Women Health) and Nutrition directorates responsible for the following:

 

  1. Training staff
    1. IMCI
    2. Nutrition
    3. PMTCT
    4. HIV management

 

  1. Supervision of quality of care at health care facilities using
    1. Statistics
    2. Visits
    3. Audit tools

 

The department of health at provincial level should take responsibility for the following:

 

  1. Liason with other departments concerning the following:

 

    1. Safe water supply
    2. Poverty Alleviation Programs
    3. Grants
    4. Adult Education Programs

 

  1. Ensuring enough staff to manage health

 

  1. Adequate budget for child health

 

  1. Effective transport of emergencies and elective cases for higher levels of care.

 

National

 

  1. Ensuring political commitment to child health in the country

 

  1. Developing guidelines, essential drug lists and audit tools.

 

  1. Collecting provincial reports and producing national report on the status of child health.

 

  1. Organising national immunisation campaigns.

 

 

Question 3

 

A mother presents with a 12-month old boy with a tender, swollen forearm. She explains that he fell from his bed the night before. On examination you notice that the child has several bruises.

a)     What other clinical signs would you specifically look for when examining this
child?                                                                                                (10)

b)     What are your differential diagnoses?                                                      (6)  

c)     What special investigations would you undertake?                                     (10)

d)     How would you preferably manage this child?                                            (14)

 

a) What other clinical signs would you specifically look for when examining this child?

 

 i.          Frozen watchfulness – interaction with mother and other people

ii.          Weight, length, head circumference and plot on percentile charts – check RTHC

iii.          Developmental milestones reached

iv.          Bruises – position of bruises (back of legs, buttocks, back, face, ears)

 v.       Aging of bruises – are they of different ages according to colour

vi.       Finger marks (grip marks) or other identifiable bruises

vii.       Any other sign of physical abuse e.g. cigarette burns, bite marks

viii.       Any internal injury, also check fontanel

ix.       Further fractures - old or new

 x.       Check for signs of sexual abuse e.g. anal injury

xi.       Level of consciousness, and if abnormal, retinal bleeds

xii.       Check for alternative underlying diseases that could be responsible for pathological fracture e.g. tumour, osteoarticular TB, osteogenesis imperfecta

 

b)  What are your differential diagnoses?


Accidental fracture with normal bruising in a one-year-old starting to walk

Non-accidental injury or physical abuse

Pathological fracture because of e.g. tumour (lymphoma, leukaemia), osteoarticular TB, osteogenesis imperfecta

c)     What special investigations would you undertake?

 

This will depend largely on the outcome of the history and clinical examination and the extent of injury found in the child as well as the probability of NAI

FBC including platelet count and smear

Clotting profile

X-ray of forearms to evaluate fracture (could also give indication of type of injury)

Skeletal survey X-ray or, alternatively, radio-isotope scan to check for old fractures

Depending on nutritional status, also LFT’s, especially globulin and albumin

Head abnormality – consider CT scan

 

d)    How would you preferably manage this child?

 

NAI most likely with given history and clinical findings

Take a complete history – including previous admissions, trauma, etc

Thorough clinical examination

Exclude other possible causes for presenting problems

Special investigations as required

Suspicion of child abuse should be notified to Director of Social Services

Clinically manage the child (fracture and any other problem)

Refer appropriately for further clinical management when indicated

Mobilise Child abuse management team, especially social worker

Involve police/CPU if indicated and in such a case, complete J88 form

Write clear notes, body sketches important

Photographs may add value if appropriately identified

Ensure safety of the child – not primarily the doctor’s responsibility, but to notify SW or police if doctor’s assessment is that the child will be unsafe if sent home. SW or police to arrange placement/safety

Prepare medico-legal evidence and be prepared to give evidence

Follow-up of the child, even if the child is placed in other care, is extremely important

 

 

 

Question 4

 

A professional nurse at a nearby clinic refers Linda, an 8-month old girl, to your hospital. The nurse’s diagnosis is “Severe Pneumonia” according to the Integrated Management of Childhood Illness (IMCI) guidelines. Linda’s mother tells you that Linda was well until last night when she developed a cough and a noisy chest. Since the morning she has not been feeding and feels hot.

Examination reveals a normally grown girl with an axillary temperature of 38oC, a respiratory rate of 60 breaths per minute, a pulse rate of 130 beats per minute, chest in-drawing, a 4 cm soft liver (displaced downwards), loss of cardiac dullness on percussion, and crackles and wheezes over most of the chest. Linda appears lethargic and grunts with expiration. She is neither pale nor cyanosed. Other findings are normal.

a)     How severe is the respiratory condition in this child on the basis of the findings? Motivate your answer.                                                                                                   (6)

 

b)     Based on the above clinical findings, what is the most likely patho-physiological  diagnosis, and the most likely aetiological agent(s)?                                                              (5)

 

c)     Indicate TWO differential diagnoses that you would consider, but exclude, and indicate for each why you have not made it the most likely diagnosis.                                          (6)

 

d)     What special investigations would you carry out and describe the value of each investigation.          (6)

 

e)     Provide a patho-physiological explanation for the “chest in-drawing” and explain what information it gives concerning this child’s condition.                                                       (4)

 

f)       Explain the mechanism for “grunting” in children with respiratory disease and its significance in this child.                                                                                                  (3)

 

g)     How would you treat this child and explain each therapy’s mechanism/mode of action. (10)

 

 

A             How severe is the respiratory condition in this child on the basis of the findings.? Motivate your answer.                                                                      6


This is a severe respiratory condition which would warrant inpatient care and respiratory support.                                                              þþ

 

2 The indications of severity are:

§         Tachypnoea                                    - 60 breaths per minute – severe tachypnoeaþ

§         Grunting                                          - indicates need to increase oxygenation. ie relative hypoxaemia. þ

§         Chest indrawing (subcostal recession)  - indicates increased diaphragmatic activity, decreased diaphragmatic efficiency (flattening).– all worrying in especially in the face of the other findingsþ

§         Lethargy                                         - may indicate either hypoxia, hypercapnoea, tiredness or “toxaemia (septicaemia) or other sites of diseaseþ

 

 

B         Based on the above clinical findings, what is the most likely patho-physiological diagnosis, and the most likely aetiological agent(s)?     5

 

1 Bronchiolitis (infective lower airways obstruction) þþ

 

2 The most likely aetiological agent is:

         Respiratory Syncitial Virus              þ

Alternatives causes include:

                             Adenovirus                        þ

                             Mycoplasma

Alternative differential diagnosis include:

                   Pneumonias of various causes       

(þ for combinations of the other significant agents even if not noted above)

 

 

C         Indicate TWO differential diagnoses that you would consider, but exclude, and indicate for each why you have not made it the most likely diagnosis.                                                                                                    6

 

Bronchopneumoniaþ – this is a likely differential diagnosis which would fit with the respiratory distress, pyrexiaþ. It fits less well with the lower airways obstruction (wheeze, hyperinflation) þ but may be compatible and difficult to exclude if chest xray were to show infiltrates which may appear very similar to atelectasis.

 

Infantile asthmaþ - this diagnosis is a less likely on the basis of uncommon presentation at this ageþ. Other wise the findings (including radiological) would be very similarþ. Presentation in the first year of life is quite uncommon.

 

Congenital airways diseases (eg cystic fibrosis, abnormal airways, vascular rings)

Foreign Body

Recurrent aspiration

Cardiac Conditions

 

(The above 4 would be less frequent differential diagnoses but may be considered – should be only presented after the first 2 above).

 

D         What special investigations would you carry out and describe the value of each investigation.                                                                                                6

 

(Any combination of 3 of the following with higher marks if prioritized and logically presented – my priority as follows)

 

Oxygen saturation monitoring or arterial blood gasesþ

-          To confirm inspired oxygen requirements to maintain O2 >90%

-          Would preferentially do blood gases in lethargy or severe illness such as this child to exclude hypercapnoea (but would monitor on sats oximeter) þ

 

Full blood count or haemoglobinþ

-          To confirm adequate haemoglobin to maintain optimum oxygen carriage in the face of respiratory compromise. (Optimum Hb around 12 g%)þ

 

Chest X rayþ

-          To support diagnosis, exclude other severe respiratory conditions including specific chronic lung eg TB, pneumocystes jevocci or acute lung infection eg staphylococcus, klebsiella etc  pictures, or intervenable conditions eg pneumothorax, lung collapse. þ

 

CRP or ESR or WBC (Acute Phase Reactants)

-          To support or mitigate against the causative organism being bacterial vs viral

 

Respiratory Syncitial Virus immunofluorescence

-          In the developed world this would be a significant test and decide on the appropriateness of antibiotics were it to be positive, and not negated by other signs of “toxicity – bacterial infection” eg very severe disease, circulatory changes, high pyrexia etc

 

 

E          Provide a patho-physiological explanation for the “chest in-drawing” and explain what informationit gives concerning the child’ condition.                  4

 

3 different mechanism account for chest indrawing:

 

§         Decrease efficiency of contraction where the diaphragm is already flattened at onset of contraction due to hyperinflation of the lungs and thus leads to pulling in of the chest wall to which it is attached. (it cannot further flatten the diaphragm as the normal dome shape has gone). þ

 

§         Increase activity (strength of contraction) of the diaphragmatic muscle. þ

 

§         Increase flexibility (compliance) of the chest wall due to: þ

1.      physiological causes (young age, increased cartilage not yet ossified, thin ribs / costal cartilages)

2.      pathological causes of increase rib/cartilage compliance eg ricket, osteogenesis etc

 

In this child the first mechanism would be the major cause but both of the other tow mechanism probably also play a part. þ

 

F          Explain the mechanism for “grunting” in children with respiratory disease and its significance in this child.                                                                               3

 

Grunting is the sound of prolonging inspiration by closing the glottis as a means of obstructing expiration. þ

This maintains the alveoli and terminal bronchioles more inflated for longer, increases the partial pressure of oxygen in the respiratory airways and alveoli for longer (greater percentage of the respiratory cycle) and leads to an increase in oxygenation. It may also decrease carbon dioxide levels modestly. þ

 

It is thus a compensatory response (and clinical indicator of) to relative hypoxaemia. þ

 

 

G         How would you treat this child and explain each therapy’s mechanism / mode of action                                                                                                                        10

 

(1 mark for logical prioritization / presentation þ)

 

1 Oxygenþ þ– starting with 40% either by nasal prongs (2+ li / min) or nasal cannulae (2 li/min) or face mask (less effective) or head box with either formal blender or venture blender.

 

         This would be to counteract the anticipated hypoxaemia.

 

2 Check Blood Gasesþ in 40% oxygen – to exclude respiratory failure (or acidosis)

   And monitor O2 saturation with a transcutaneous oximeter

 

         In the event of significantly raised CO2, or mixed acidosis, or unresponsive hypoxaemia in 40-60% oxygen consider need for active respiratory support (CPAP, IMV) in an ICU / High Care Setting.

 

3  Check Hbþ for adequacy for O2 carriage

 

         Correct if critical / significant

 

4  Ensure adequate fluid / nutrition balanceþ with naso / oro gastric or IV Fluids bearing in mind the dangers of aspiration of gastric contents, and the effects of upper airways obstruction by placement of nasal tubes and the dangers of excessive fluid administration.Feeding children orally in such a distressed child is fraught with dangers and will in a significant proportion of children lead to increase hypoxia, aspiration and even death. þ

 

5  Consider use of antibiotics þas appropriate in pneumonia in this age group where pneumonia cannot be confidently excluded.

         Eg       Penicillin G/ Ampicillin + Gentamycin

                             Or 3rd generation cephalosporin

                             Or amoxy clavulanic acid      etc

 

         A positive Respiratory syncitial virus test, lack of infiltrates on CXR, negative acute phase reactants and absence of “toxicity” would be most supportive of not using antibiotics.

 

6  Consider anticholinergic agentsþ eg ipratropium or β adrenergic agents eg salbutamol by nebulization or MDI with appropriate spacing device

         Opinion is divided on the use of this agent with poor evidence in various anayses. In severe disease many child health carers would use the agent but observe for a clinical response which would indicate the effectiveness in a particular patient.

This is not analogous to the use of B2 stimulants in asthma where the effect is obvious and well documented.

 

7                    The place of inhaled steroids remains controversial in practical terms

 

8                    Exclude other serious respiratory diseases þwhich might mimic the condition :

 

Bronchopneumonia, TB with lymph node compression of airways, HIV and its opportunistic infections, foreign bodies, aspiration syndromes etc.

 

As with all examination situations not every possible permutation can be taken into account – common sense must prevail in assessing the answers which in addition to noting the essential points must show a sense of priority and logic (understanding) in their presentation. The marks shown thus are intended as an indication of a marking framework – however even if an item is mentioned no mark will be given unless it is done so in an appropriate and contextualized fashion. Chaotic scribbling of words without format is not an indication of knowledge. At times marks may be given for items not indicated if they are presented in an appropriate and correct context.

 

 

Question 5

 

Thandi, an 18-month-old child, is brought by her mother to the local clinic. Thandi has had diarrhoea and vomiting for the past three days. She is restless and irritable, has sunken eyes and a slow skin pinch. Thandi weighs 6.4 kg (59% of median weight-for age; <-3SD weight-for-age), has a length of 71 cm (88% of median length-for age; < -2SD length-for-age) and her weight-for-length is 75% of median (<-2SD weight-for-length). She is visibly severely wasted. Thandi’s Road-to-Health chart shows that she was breastfed up to 13 months of age, and while she followed the 3rd centile for most of the first year of life, her weight gain has been unsatisfactory for the past two months. The nurse at the clinic notes that Thandi is pyrexial (38.2°C). The nurse offers Thandi some oral rehydration solution, which she eagerly drinks. She decides to refer Thandi to the district hospital where you work as the paediatric medical officer.  

 

a)    How would you classify Thandi’s diarrhoea using IMCI classification criteria?      (1)

“Some dehydration”

 

b) List THREE pathophysiological mechanisms for Thandi’s diarrhoea.                  (3)

·         Secretory diarrhoea

- Toxogenic diarrhoea

·         Osmotic diarrhoea

·         Enteropathogenic diarrhoea

                                                                                                                  

c)    Describe how you would make a clinical assessment of a “slow skin pinch.”              (2)

For this procedure the child must be lying flat on his back, either on the mother’s lap or on an examination couch, with the arms at his side and not above his head. Locate a point midway between the umbilicus and the side of the abdomen.

Lift a skin-fold with the underlying fatty tissue between the thumb and the index finger for one second.

Note that the skin-fold should be in the longitudinal and not the transverse plane of the body.

Closely observe how long it takes for the fold to return. It may return very slowly, taking 2 seconds or more. It may return slowly (< 2 seconds) and remain visible with slight tenting for a short time. On the other hand it may return immediately.

 

d) Explain the mechanism by which oral rehydration solution (ORS) corrects dehydration.      (3)

ORS contains glucose and sodium

Glucose molecules are absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - and in conjunction sodium is carried through by a co-transport coupling mechanism.

This occurs in a 1:1 ratio, one molecule of glucose co-transporting one sodium ion (Na+).
Glucose does not co-transport water - rather it is the increased relative concentration of Na+ across the intestinal wall which pulls water through after it.

e) How would you classify Thandi’s nutritional status?                                      (3)

Wellcome classification – depends if she has oedema or not.

If no oedema- marasmus; if oedema- marasmic-kwashiorkor.

WHO classification- severe malnutrition on basis of visible wasting.

Moderate stunting (< -2SD LA) and moderate wasting (<-2sd WL)

 

 

f)   Offer an explanation for why Thandi might have been referred to the hospital, based on IMCI guidelines.                                                      (1)

For her visible severe wasting (severe malnutrition)

(Incorrect responses- rehydration, failure to thrive)

 

g)  List FIVE priority interventions that should be instituted once Thandi is admitted to the ward and briefly explain why each is important.                                                            (10)

·         Treat/prevent hypoglycemia

Low glycogen and fat stores and decreased gluconeogenesis. Blood glucose monitoring (e.g. with dextrostix) at the time of admission and during the first few days should be routine. Feeds should be provided at frequent intervals, at least 2-3 hourly, day and night, to prevent hypoglycaemia.

 

·         Treat/prevent hypothermia

Low energy reserves. Also, hypoglycaemia and hypothermia are both signs of severe infection. Keep in warm environment.

 

·         Treat dehydration

Can develop hypovolaemic shock, particularly if diarrhoea worsens. However, judicious fluid replacement as can also develop cardiac failure from fluid overload.

 

·         Correct imbalance of electrolytes

Severely malnourished children have deficiencies of potassium and magnesium which may take two weeks or more to resolve. Hypokalaemia is potentially lethal.

Total body sodium is increased although the plasma sodium may be low. Giving high sodium loads to the child is dangerous.

 

·         Treat infections

Bacterial infections, often with gram-negative organisms, are common and difficult to detect in children with malnutrition.  Routine administration of broad-spectrum antibiotics to children with severe malnutrition, irrespective of clinical signs of infection, is most probably the single most effective measure to reduce the high case-fatality rate due to malnutrition in developing countries.

 

·         Correct deficiencies of micronutrients (vitamins and minerals)

Stores of Vitamin A, folate, zinc, magnesium and other micronutrients are depleted and require correction to allow recovery.

 

·         Start cautious feeding

Needs energy supplementation. Feeding should be commenced as early as possible after admission. The only reasons for delaying the introduction of feeds might be in a severely toxic or shocked child. Low solute load (low sodium) feeds best, e.g. F-75, Nan.

 

Thandi is rehydrated, her fever resolves and she tolerates feeds. However, while her vomiting settles, she continues to have watery diarrhoea, which requires her to be actively rehydrated on two further occasions. Two weeks after admission, Thandi’s diarrhoea has still not resolved. 

 

h)  Offer TWO explanations for Thandi’s ongoing diarrhoea?                                (4)

 

1. Secondary disaccharidase deficiency

The brush border of the epithelial cells lining the small intestine produce disaccharidases that are responsible for the digestion of disaccharides such as sucrose and lactose. In malnourished children and those who have persistent diarrhoea, the brush border is lost, and thus, the ability to digest disaccharides is also lost. Ingesting food containing disaccharides, such as milk for example, causes the persistence of diarrhoea because the undigested disaccharides increase osmotic pressure in the GI tract. 

 

2. Combination of infection and mucosal injury

In the malnourished child with poor healing, a combination of infection and mucosal injury result in persistent diarrhoea. Infection could be systemic, e.g. UTI or local, e.g. cryptosporidium, Giardia.

 

3. Poor host immunity

Factors leading to poor immunity include:

- protein energy malnutrition

- micronutrient deficiencies of vitamin A and zinc, and

- immunodeficiency such as AIDS

All of these can result in poor healing and persistent diarrhoea. 

 

i)  List THREE investigations that you would consider doing to identify a possible

    cause for the persistent diarrhoea.                                                            (3)

Stool- lactose test

Stool- microscopy (and culture occasionally)

Urine – Combur 9 (dipstix) followed by MCS

HIV test- if not done earlier

Skin test for TB (Mantoux) and CXR, if TB suspected

 

j)  How will you manage Thandi’s persistent diarrhoea?                                    (10)

 

Therapy must include correcting dehydration, improving nutrition status and using antibiotics if warranted. 

 

Diagnostic tests as above.

Consider non-intestinal infections.

Must rule out HIV

 

Oral rehydration solution to rehydrate when and as needed.

 

Careful attention to feeding essential

Continue breastfeeding (not relevant here)

Feed six times a day

At least 110 calories/kg/day

 

Recommended diets

  1. Starch based, reduced milk concentration
  2. No milk (lactose-free) diet with reduced cereal

Candidate required to discuss this further

 

If resources available:

- Lactose free milk, e.g soya- formula (Isomil, Infasoy)

- Sucrose free milk, e.g. AL 110

- Semi-elemental feed e.g. Alfare

- Parenteral nutrition

 

Multivitamins and minerals

Daily supplements for two weeks

Folate, zinc, vitamins, iron, copper, magnesium and others

 

Antibiotics

Treat bloody diarrhoea with an oral antibiotic effective against Shigella

Treat for amebiasis (if appropriate)

Treat for Giardia (if appropriate)

The role of bowel cocktail (cholestyramine, gentamicin) is controversial 

Anti-motility agents are dangerous in infants and young children and should not be used.

 

Ongoing monitoring

Weight

Hydration

Infection

Electrolytes