DCH – Sept 2005
Paper I Question 2
a)
Describe the diagnosis and management of gastroesophageal
reflux disease in children (GERD)
Symptoms and signs of GERD
Typical
Atypical
Investigation of GERD
Primary care management
includes parent education regarding dietary modifications, avoidance of smoke
exposure and of unnecessary seated and supine positioning. It may be useful to
observe a feeding of an infant in order to offer focused assistance with
feeding and/or positioning. If symptoms are not relieved consider a 2-week
trial of and elemental formula to assess possible cow milk intolerance.
Breastfeeding mothers may try eliminating cow milk protein from her diet for a
similar period.
Infants with GERD benefit
from prone and left lateral positions for the postural management. Cautions
about avoiding soft bedding materials must be given with any recommendations
for prone positioning.
Feeding suggestions:
Medical treatment of GERD
includes: antacids, thickeners, H2 blockers, prokinetics. Confirm GERD and to rule out obstruction
before initiating motility agents.
Consider
consultation/referral for further evaluation if:
Surgical treatment: fundoplication, pyloroplasty, gastrostomy.
·
Fever
lasting at least 5 days
·
Presence
of 4 out of the following 5 clinical signs not explained by other known disease
process.
1. Swelling and erythema
of hands and feet (acute phase) or
periungual desquamation (convalesent phase)
2.
Mucosal
changes of the oropharynx (injected pharynx, red or
dry fissured
lips, strawberry tongue)
3. Cervical lymphadenopathy:
anterior cervical lymph note at least 1.5
cm in diameter
4.
Bilateral
non-purulent conjunctivitis
5.
Diffuse
polymorphous rash, primarily truncal, nonvesicular
These
criteria may not all occur simultaneously.
TA is the third most common
form of childhood vasculitis. The cause of TA remains
unknown, although histopathology and immunohistochemistry
of biopsy samples suggest a primarily T-cell-mediated mechanism. Pathologically
TA lesions consist of granulomatous changes
progressing from the vascular adventia to the media.
The diagnosis of TA is based
on the distribution of involvement-primarily the aorta and its branches-and the
young age of patients, typically under 40 years. Onset
of TA is most commonly during the third decade of life, but childhood disease
has been reported as early as the first year of life. There is significant
preponderance of female patients.
Signs and symptoms:
hypertension, cardiomegaly, fever, fatigue,
palpitations, nodules, abdominal pain, arthralgia, claudication, weight loss, and chest pain.
Delayed diagnosis is the
cause of high mortality in children.
Diagnostic methods: agniography, and less invasive - CT / MRI angiography are
the standard methods.
Laboratory tests: WBC, ESR,
CRP can be normal despite ongoing inflammation.
Early diagnosis and
aggressive therapy are important to prevent irreversible vessel damage. Steroid
and the immunosuppressive agents (cycophosphamide, methotrexate, azathiprine)
have shown variable efficacy. Before starting such treatment it is important to
test patients for tuberculosis because aortitis can
be associated with mycobacterial infection.
c) Discuss the causes, pathophysiology
and management of hypocalcaemia in children
Extracellural calcium levels are maintained at 2.2 – 2,6 mmol/l.
Ionized Ca is a better
measure then total Ca. Consider values <1.1 mmol
as low.
For total Ca low values <2,2 mmol in children and <2.0 mmol
in term infants.
Calcium regulation is
maintained by parathyroid hormone (PTH), vitamin D, and calcitonin
through complex feedback loops. These compounds act primarily at bone, renal
and GI sites. Calcium also is affected by magnesium and phosphorus.
Deficiency or impairment function of one of the
three main determinants of circulating calcium can lead to hypocalcaemia.
The main causes of
hypocalcaemia include:
·
Vitamin
D deficiency, resistance/impaired metabolism
·
Dietary
calcium deficiency
·
Malabsorption states
·
Hypomagnesaemia,
hyperphosphataemia, hypoalbuminaemia
·
PTH
deficiency or resistance
·
Renal/hepatic
failure
·
Acute
pancreatitis, sepsis, malignancy.
·
Blood
transfusion
·
Prematurity, asphyxia, neonate of diabetic mother
·
Drug
therapy (anticonvulsants)
Management:
d) Describe your
approach to a previously well 2-year-old child who presents with vomiting for
two days.
Nausea
and vomiting are common sequelae of a multitude of
disorders that can range from mild, self-limited illnesses to severe,
life-threatening conditions.
A
standardized approach to children with nausea and vomiting cannot be
recommended since many pathologic states involving several systems (including
gastrointestinal, respiratory, neurologic, renal) may
be responsible. Younger children may not be able to describe nausea, which may
further complicate diagnosis. The best course of action should be dictated by
the medical history, taking into consideration clinical features of specific
disorders and their relative frequency among children in different age groups.
The most important consideration during the initial encounter is recognition of
serious conditions (such as intestinal obstruction and increased intracranial
pressure) for which immediate intervention is required.
Evaluate
the child with a careful history and physical examination. The goals are to
identify any acute needs the child may have: to quantify the degree of
dehydration and to assess the need for further testing. There is limited value
in screening laboratory tests, as the majority of children with vomiting have
uncomplicated GE or URI. Although some well-defined clinical pictures demand
urgent radiologic/laboratory workup (e.g. bilious
vomiting, suspected intussusception or menitngitis)
The
differential diagnosis for vomiting is influenced by the age of the patient.
Common
causes of vomiting in a 2-year old child are: gastroenteritis, pneumonia, URI,
Clinical
clues can be obtained from the appearance of the vomitus.
Appearance
– Source/Cause:
·
Undigested food – Reflux
·
Digested food – Stomach, proximal to pylorus
·
Yellow-gree, bilious –
Obstruction distal to ampulla of Vater
or retrograde peristalsis
·
Feculent – Distal obstruction, colonic stasis
·
Blood, bright red – Esophagus
or stomach above the cardia with minimal contact of
blood with gastric secretion. Blood, brown, “coffee grounds” – Gastric
bleeding
Management
·
Treat dehydration or maintain adequate hydration
·
Provide treatment for specific cause of vomiting
·
Antiemetics are not advised
Treatment for vomiting includes: drinking gradually larger
amounts of clear liquids; avoiding solid food until the vomiting episode has
passed; resting; and temporarily discontinuing all oral medications, which can
irritate the stomach and make vomiting worse. If vomiting last more than 24
hours, an oral rehydrating solution should be used to
prevent and treat dehydration.
Paper 1 Question 4
a)
Describe how you would manage a known asthmatic who presents with an acute
severe exacerbation.
b)
Describe your approach to the management and subsequent follow up of a 6 week
old boy with a proven urinary tract infection
c)
Describe the criteria for diagnosing a simple febrile seizure, the acute
management, and the advice you would give the parents of a 2 year old child
with a recent simple febrile seizure including advice regarding prognosis.
d)
Discuss your approach to a well 6 week old child that presents with a
persistent conjugated hyperbilirubinaemia
a)Initial assessment and treatment:
Clinical assessment:look for danger signs/severe episode:
THEN:
Ř
continuous inhaled Beta-2 agonists
Ř
Ivi
corticosteroid: dexamethasone
Ř
Stat
dose ivi B2 agonists(ventolin)
Ř
Adrenaline
subcut if moribund
Ř
Hydrate
if dehydrated
REASSESS:
·
Good
response: continue inhaled B2 agonists/maintenance Rx, complete course of oral
steroids, follow up plan
·
Incomplete
response: admit to ward, hourly B2 agonist+inhaled ipratropium, oxygen, oral steroid
·
Poor
response with ongoing severe retraction/silent chest/altered
LOC/hypoxia/PEFR<30%: refer/admit ICU
ON DISCHARGE:
b)
c)
Diagnosis
Management
Advice/Prognosis
d)Need to define whether there is complete obstruction/extrahepatic obstruction
·
Further
investigation/management depending on cause
·
Complete
obstruction/cannot define/metabolic: refer (for cholangiogram
etc)
·
Rx
congenital syphilis etc
Management of Attention Deficit and Hyperactivity
Disorder
1. Evaluate children/adolescents suspected of having ADHD based on
DSM-IV diagnostic criteria using consistent and appropriate diagnostic tools.
·
Although
the core symptoms of inattention, impulsivity and hyperactivity are
characteristic, their severity and pattern are highly variable across
individuals.
·
The
evaluation of primary symptoms should include information from multiple sources
such as parents, the child, and school personnel.
·
There
is no single evaluation tool available to make a definitive diagnosis of ADHD.
·
Screen
all patients for other primary conditions or comorbidities
and appropriately refer to subspecialty consultation for further evaluation.
·
Many
children can exhibit symptoms of ADHD at some point in their development, but
it is important to note that common symptoms (inattention, hyperactivity,
disruptive behavior, academic difficulty), can be caused by a number of other
difficulties. At this stage of the process, the clinician must consider
diagnoses other than ADHD.
2. Coordinate a simultaneous multimodal management plan that
involves parent, child, and school-focused interventions.
3. Establish communication
and intervention linkages with
related systems (e.g. schools, mental health, etc
4. Establish appropriate use
of psychostimulants
in both initial and ongoing management of patients with ADHD.
Psychostimulant medications are considered first-line therapy in
children with ADHD: these include psychostimulant
medications such as methylphenidate.
5. Provide consistent and
comprehensive monitoring and care
coordination for all patients with ADHD including pharmacologic and
non-pharmacologic interventions, identification and management of emerging comorbidities, and the impact of ADHD condition on
patients, their families, and schools.
Congenital Hip Dislocation
Epidemiology
·
Congenital
hip dislocation (CHD) occurs more commonly in girls than in boys.
·
The
left hip is twice as often involved
as the right and bilateral dislocation occurs in more than 25 percent of
affected children.
·
Congenital
hip dislocation is more frequently encountered in Whites than in Blacks
Clinical Presentation:
In the neonate the diagnosis may be made clinically because the femoral heads
are not ossified yet. The Ortolani/Barlow manoeuvre is used in which you attempt dislocation of the
flexed hip by abduction of the proximal femur producing a click on posterior
dislocation and another as the femoral head slides back into the acetabulum with adduction.
Etiology/Pathophysiology:
In utero dislocation of hip is unusual. Most
dislocations occur after birth and
are related to unstable or dislocatable hips.
Imaging Findings:
Ultrasound of the hips is very
useful in making the diagnosis in the newborn.
Femoral head ossification
centers appear at 3-6 months so radiographs
are not useful in the newborn. By 2-4 months old you begin to see lateral
displacement of the femur and an increased acetabular
angle.
Treatment
Ninety percent
of dislocatable hips will stabilize in first 2 months of life if not treated, but the ones
which will stabilize cannot be predicted so all patients are treated with a
flexion-abduction-external rotation device.
The principal treatment for
CHD is conservative, especially if diagnosed early. The most common technique
is to reduce the dislocation of the femoral head by means of a
flexion/abduction maneuver, for a sufficient period of time to permit proper
growth of the head and acetabulum, which in turn
assures a congruent and stable hip joint. This technique is usually performed
on children in the very early stages of CHD and in infants under two years of
age; which include splinting, with a
Frejka splint or Pavlik
harness.
If the conservative approach
fails, or the child is too old, or the deformities are too advanced, surgical management is indicated.
The key to preventing
significant deformities and future arthrosis of the
hip is to diagnose CHD early, before
the child begins to walk, when conservative care is most effective, and before
the femoral head has completely ossified.
Safety advice to parents,
older children or local authorities to prevent children getting involved in
road traffic accidents.
Parents/older children
Bicycle helmets
Car safety seats
Seat belts
Visibility – reflective
material
Advice on crossing roads
Dangers of drunk
driving (adoslescents)
Local Council
Pedestrian crossings
Scholar patrols
Street lighting
Pavements
Play areas (parks) – not
streets
Speed humps – traffic calming
Education – by parents, schools
and authorities
Legislation – fines
SIDS counselling
Most parents who have
lost an infant to SIDS are grief-stricken and unprepared for the tragedy. They
usually feel guilty. They may be further traumatized by investigations
conducted by police, social workers, or others.
Counselling and
support from specially trained doctors and nurses and other parents who have
lost an infant to SIDS are critical to helping parents cope with the tragedy.
Specialists can recommend reading materials, web sites, and support groups to
assist parents.
At the time, parents need empathy and support, e.g. in
some cultures it may be appropriate to hold their baby one last time before the
body is sent to the mortuary.
Delay
discussion of SIDS avoidance measures to a subsequent visit (in 4-6 weeks time
when the autopsy results are available) as it is inappropriate to do this now.
An autopsy is needed.
Autopsies indicate a definite explanation in about 20% of cases of sudden
infant death. In addition, an autopsy can often put to rest any doubts the
parents may have
Mpho, a
12 week old female infant, is brought to the well baby clinic. She was born at 34 weeks gestation. Her mother is HIV positive, but Mpho is clinically well and thriving. Mpho received all
her vaccines at birth, but none since. Her mother was advised by a nurse to
delay immunisation until Mpho
reached 6 weeks corrected age. The
clinic sister is unsure whether to immunise Mpho as she has a runny nose, cough and a temperature of
38.1oC. The sister is also concerned about giving oral polio drops
to Mpho because of her mother’s HIV status.
a) Explain whether each of the following are valid
contraindications to immunisation: (3)
No.
A common infection that does not intefere
with immune response.
No.
Only a fever >38.5° would be a relative contra-indication
No.
Antibiotics do not interfere with the immune response.
b) Was the nurse’s advice to
postpone immunisation to six week’s corrected age
appropriate? (1)
No. Pre-term infants should
be immunized at the appropriate chronological age with the full dose of
vaccine.
c) What are current
recommendations about immunising HIV-exposed and -infected
children? (3)
WHO guidelines for immunizing
children with HIV infection and infants born to HIV-infected women differ only
slightly from the general guidelines.
HIV-infected children should receive all EPI vaccines,
including live vaccines
BCG and yellow fever vaccines should be withheld from
symptomatic HIV-infected children.
The benefits of measles and poliovirus vaccines far
outweigh the potential risks in HIV-infected children.
Only one serious complication (fatal pneumonia) has been
attributed to measles vaccine administered to a severely immunocompromised
adult. An extra dose of measles vaccine is recommended at 6 months of age in
order to provide protection at a younger age than for non-HIV-infected infants
and to improve protection against measles.
Although two HIV-infected infants have developed
vaccine-associated paralytic poliomyelitis, several million infected children
have been vaccinated and the evidence does not suggest that there is an
increased risk.
d) Comment on the efficacy of
vaccines offered to HIV infected children. (3)
Response to most EPI vaccines
is adequate (though may be less efficacious than in immunocompromised
children)
HIV-infected children and adults develop lower
geometric mean antitoxin titres and are more likely
than uninfected persons to lose antibody within a few years after vaccination.
Some studies have correlated antibody titres with
CD4+ T-lymphocyte counts
Efficacy of congugated vaccines is reduced (by about half)
e) List two common adverse reactions
that occur after DTP immunisation? (2)
Many children experience
adverse reactions within 48 hours after the DTP immunisation,
including pyrexia (>38.5oC), local induration
and tenderness. This may manifest as screaming.
f) How may a caregiver prevent
or reduce these adverse events? (1)
By giving paracetamol
˝ hour before and regularly (3-4 hourly) after the vaccination
g) List two absolute
contraindications to continuing DTP immunisation. (2)
Convulsions, encephalitis,
focal neurological signs and collapse with shock, anaphylactic reaction.
Mpho’s mother is concerned about the possible adverse events
related to DPT vaccine. She asks you about the possible benefits of using
another vaccine type. She read in the “Mother and Baby” magazine about an acellular pertussis vaccine, and
asks whether this vaccine may not be preferable. You agree to investigate this
option. You find the following abstract on a Medline search
A trial of three-component, and five-component acellular
pertussis vaccines compared with whole-cell pertussis vaccine.
BACKGROUND: Trials in
METHODS: We enrolled 62 195 babies aged 2-3 months. Babies
were vaccinated at age 3 months, 5 months and 12 months. They were randomly
assigned a three-component acellular DTP vaccine (n =
20,728), a five-component acellular DTP vaccine (n =
20,747), or a whole-cell DTP vaccine (n = 20,720).
We collected data for all reported cases of culture-confirmed pertussis during 3 years of follow-up. Analyses were by
intention to treat.
FINDINGS: For culture-confirmed pertussis,
there were 19 cases in the whole-cell group (relative risk 1.00), compared with
27 in the five-component group (relative risk 1.40 [0.78-2.52]), and 49 in the
three-component group (relative risk 2.55 [1.50-4.33]). Hypotonic hyporesponsiveness occurred
significantly more frequently in the whole-cell group (p < 0.05) and was
more frequent in the acellular groups than previously
reported. High fever and seizures occurred more frequently after whole-cell
vaccine than after any of the acellular vaccines (p
< 0.001).
h)
What study design was used in this trial? (1)
Randomised controlled trial
i)
What was the primary study outcome?
(1)
Cases of culture-confirmed pertussis
j)
What is meant by an intention to treat analysis? (1)
Study
participants are analysed at the end of a trial in
the group they were initially assigned to, rather than on what treatment they
actually received.
k) Was there a
significant difference in the number of culture confirmed pertussis
cases between those who were given whole cell vaccine and:
i.
those given 5-component acellular vaccine? Explain (1)
No,
relative risk was 1.40 [0.78-2.52]. The
95% confidence interval includes 1.
ii. those given three
component acellular vaccine? Explain (1)
Yes,
relative risk was 2.55 [1.50-4.33]. The
95% confidence interval exceeds 1. (At higher risk)
l)
What will you advice Mpho’s mother based on this
trial? Explain your choice (2)
She should use the
5-component acellular pertussis
vaccine (if available), because it is as efficacious as the whole cell vaccine
in preventing culture-proven pertussis, and has fewer
adverse effects.
m) Explain what is meant by a
“conjugated” vaccine and why they are more immunogenic than “ordinary” vaccines ? (2)
Combining a polysaccharide (bacterial
Ag) to a protein carrier increases the antigenicity
of a vaccine. Because many purified polysaccharides are T-independent antigens,
vaccines composed of these antigens are often ineffective in infants and young
children younger than 2 years of age. However, by conjugation to a protein carrier, a polysaccharide can acquire the
antigenic properties of the protein and resulting characteristics of a
T-dependent antigen, including immunogenicity in
infants. This phenomenon is the basis of the development of the new Hib and pneumococcal conjugate
vaccines.
n) Explain the difference
between passive and active immunisation? (2)
Active- depends on an
individual to mount an immune response
Passive- depends on
antibodies (or immunity) produced by another individual, including an infant’s
mother.
p) Briefly discuss the
benefits (if any) of passive vaccination in the following situations (8)
i) A 12 year old boy with
tetanus
Tetanus immunoglobulin (TIG)
should be used for passive protection of individuals who have sustained a
tetanus-prone wound, where the person has not received three or more doses of a
tetanus toxoid-containing vaccine or where there is
doubt about their tetanus vaccination status. It should be given as soon as
practicable after the injury.
ii) A neonate born to a mother with chicken pox
High-titre varicella-zoster immunoglobulin (ZIG) is available on a
restricted basis for the prevention of varicella in
high-risk subjects. ZIG must be given early in
the incubation period (within 96 hours of exposure).
Normal immunoglobulin (human) can be used for the prevention of varicella if ZIG is unavailable.
iii) A child attending a creche
where another child has been diagnosed as having hepatits
A
A single case of hepatitis A probably does not justify
the mass
use of normal human immunoglobulin (NIGH). Two or more
cases (associated with a day-care or pre-school facility) that occur in
different households is strongly suggestive that
transmission of hepatitis A is occurring within the facility. NIGH should then
be offered to all staff and attendee children at the facility.
iv) An child with leukemia residing in a ward with a
suspected case of measles
Measles immune globulin (MIG) or normal immunoglobulin
(human) should be considered for immunocompromised
contacts of patients with confirmed or suspected measles. If immunoglobulin is
administered within 7 days of exposure, it can prevent or modify measles in
non-immune persons.
q) What advice would you
provide to a parent who refuses immunisation because:
(6)
i) She
believes in homeopathy
Homeopathy is not a contra-indication
Homeopathy cannot protect from infections
Important
bodies, such as London School of Hemeopathy,
recommend vaccination
ii)
She is concerned about the association of the measles vaccine with autism
First
proposed by
Various
studies (involving many thousands of children) have since examined the
association, and none have established any association.
Paper 2; Question 2
A
24 year unbooked mother has just delivered a 33 week
premature baby at the hospital where you are the medical officer on call. Birth weight is 1.2 kg. The baby has Apgar
scores of 8 and 10, looks pink in room air and has a respiratory rate of 60
breaths per minute.
a) Initial Management
§
Keep
warm – incubator or overhead heater.
§
Examination.
§
Give
oxygen.
§
IVI
fluids 60 ml/kg.
§
Oral
feeding if remains stable after 24-48 hours.
§
Monitor
dextrostix.
§
Theophylline for apnoea
prophylaxis.
§
±Antibiotics-gram
+ and – cover.
§
Check
maternal blood group, WR, VCT
b) Repeated
Apnoeanic Attacks – most likely causes
§
Apnoea of prematurity infections – septicaemia, meningitis, NEC, aspiration pneumonia.
§
Metabolic/endocrine
abnormalities – Na, calcium glucose.
§
Anaemia/Polycythamia
§
Congenital
heart dx – PDA
§
Temperature
control ↑ or ↓. Hypoxia. IVH
Investigations:
Septic screen
§
FBC,
U&E, calcium, blood and urine cultures, LP, CXR + Abdominal X-ray, head
sonar
Management
§
Antibiotics,
feeding if no features of NEC, theophylline, ±blood
transfusion
§
Apnoea monitor, ventilation of apnoea persists.
c) Supportive treatment and Supplements in Ward
§
Feeding
– gradual ↑ oral feeds. 1st
NG feeding, volume 60ml/kg – 150ml/kg
§
Cup
feeding if on formula or breast feeding
§
Temperature
control – incubator then KMC
§
Theophylline for apnoea of prematurity prophylaxis
§
Supplements
– vitamin K on day 1, vidyalin or MVT or vitamin B
co-syrup, vitamin D, sunflower oil or polycose, iron
after 3 weeks.
d) Discharge
criteria and arrangements for follow-up
§
Full
oral feeding – breast feeding or formula
§
Adequate
weight gain (1.7 – 2.0kg)
§
Thermally
stable – can be send home on KMC position.
Can use KMC score sheet.
§
Vaccination
– BCG + OPV
Follow-up
six weeks or earlier – check weight gain, neurological function, cardiac
defects, eye examination.
Advise
to go for six weeks vaccines.
Paper 2;Question 3:
A 4-year old girl presents to
you with a vaginal discharge for 2 days. The mother says that the discharge is
greenish and quite copious. Just before this started, she noticed a spot of dry
blood on the child’s panty, but she did not really take notice because she was
on her way to work. Since then the child did not want her to wash her genital
area and she complained about when she had to urinate. When the discharge
started, the mother became concerned, but because she works night shifts, this
was her first opportunity to bring the child to the doctor.
a)
What
is the differential diagnosis for a 4-year old child with a vaginal discharge?
(5)
Worm infestation – Enterobius vermicularis;
Bubble baths and nylon/synthetic panties; Sexually transmitted infections due
to CSA; Local infection due to injury – also CSA; Foreign object in vagina;
Poor hygiene with secondary infection, (and some other RARE conditions for half
the mark).
b)
You
suspect from the history that the child has been sexually abused. Briefly
describe all the responsibilities of the doctor in the management of child
sexual abuse. (10)
Take a full history (if possible, no
detail about CSA)
Full examination of the child (growth parameters, sexual development -Tanner
scale, etc.)
Collect medico-legal evidence
Further investigations as indicated: for physical abuse, pregnancy test,
syphilis & HIV tests
Explain findings to parent (&child)
Team – approach
Write notes, reports, J88 forms
Safety of the child – ensure but not arrange
Treatment where indicated
Referral & follow-up
c)
What
special investigations would you do in this case (5)
Vaginal MCS swab, wet smear, chlamydiae test; HIV,
RPR, urine MCS, forensic swabs and tests if <72 hours.
d)
If
the child had presented 3 days before, when the mother noticed the blood on the
panty, and on examination CSA was suspected, would HIV post-exposure
prophylaxis been indicated? What is the rationale behind HIV PEP for child
sexual abuse cases and describe the process you would follow when providing
PEP.(10)
(This is the complete answer, but for points, the basics)
All parents/guardians of children under the age of 14 years, presenting
to a health facility after being sexually abused should be counselled by the
examining health worker about the potential risk of HIV transmission.
If the child presents within 72 hours of being
sexually abused, antiretroviral drugs [AZT (zidovudine)
and 3TC (lamivudine), or Combivir
(AZT/3TC combination) plus Kaletra (lopinavir/ritonavir combination] should be offered to
prevent HIV transmission.
The following points should be covered in the counselling:
o
The
risk of transmission is not known.
o
There
is strong evidence to support the use of a combination of antiretroviral drugs
in preventing HIV transmission although its effectiveness in sexual abuse cases
is not known.
o
The
common side effects of the drugs should be explained (tiredness, nausea, diarrhoea and flu-like symptoms). These are temporary, vary in intensity and do
not cause long-term harm.
o
The
side effects of antiretroviral drugs may be aggravated when taken with other
medication such as antibiotics.
o
The
importance of compliance should be emphasised.
Parents/guardians of children presenting after 72
hours should be counselled about the possible risk of
transmission and be given a follow-up appointment date for 6 weeks and 3 months
for HIV testing and counselling. If parents/guardians request antiretroviral
prophylaxis, it should be explained that there is good evidence that the use of
prophylactic drugs more than 72 hours following sexual abuse will have NO
impact on preventing HIV transmission.
2.1.
Informed consent should
always be obtained before HIV testing is done. Rapid testing should be made
available where feasible and offered to patients when parents/guardians request
it. Where not feasible, blood should be
drawn for routine laboratory HIV testing and a date given to the
parent/guardian for follow-up.
2.2.
If the parent/guardian
does not want immediate HIV testing of the child (either rapid or routine
testing), this issue can be re-addressed at the first follow-up visit (within
one week).
2.3.
If a child is already
HIV-infected at the time of presentation, the child should be appropriately
referred for long-term management.
2.4.
Post-exposure prophylaxis
should start immediately. Do not wait for HIV test results unless immediately
available.
3.
ANTIRETROVIRAL PROPHYLAXIS:
3.1.
Antiretroviral dosages:
3-drug prophylaxis is now the rule rather than the exception. AZT (zidovudine), 3TC (lamivudine) and
Kaletra (a combination of 2 protease inhibitors – lopinavir/ritonavir) is recommended. In low-risk cases AZT
and 3TC should be sufficient.
3.1.1 The
dose for AZT (zidovudine) in children is 180 mg per
meter square of body surface area 12 hourly for a period of 28 days.
A nomogram is attached to determine body surface
area. Draw a straight line between the weight of the child marked on the weight
scale and the child’s length/height on the height scale. Where the line crosses
the surface area scale is the BSA of that child. To determine the dose,
multiply the dose per meter square with the BSA.
Body surface area can be calculated as follows: Square root (child’s weight
(kg) X length/height (cm) divided by 3600) = BSA
AZT is
available in 100mg capsules and 10mg/ml suspension.
3.1.2 The
dose of 3TC (lamivudine) is 4 mg/kg/dose 12 hourly. Lamivudine is available in 150 mg tablets, which can be
broken, and a syrup containing 10mg/ml.
3.1.3 In
older children with a weight of more than 35 kg, Combivir
tablets (300 mg AZT + 150 mg 3TC) a combination of AZT and 3TC may be used.
These tablets should not be broken in half, as the drugs are not evenly spread
throughout the tablet.
3.1.4 The
dose of Kaletra is calculated by child’s body weight
according to the lopinavir dose as follows:
7-15 kg = 12 mg/kg 12-hourly
15-40 kg = 10 mg/kg 12-hourly
>40 kg = 400 mg 12-hourly with food (3 capsules)
Kaletra solution contains 80 mg/ml of lopinavir and capsules contain 133 mg lopinavir
each.
3.2.
The following should be
taken into consideration:
o Children covered by a Medical Aid should be given a 3-day supply of the
drugs and a prescription for the remaining 25 days.
o Children who are not covered by a Medical Aid should be given a one-week
supply of AZT, 3TC and Kaletra, and a date to return
for reassessment within one week.
3.3.
All children should be
seen after one week for follow-up assessment to obtain results of all
tests. The remainder of the
antiretroviral drugs should be given at this visit (that is a 3-week supply).
3.4.
Subsequent follow-up
visits should be at 6 weeks, 3 months and 6 months respectively for HIV and
other relevant tests.
3.5.
Children who are known to
be HIV-infected should not be offered antiretroviral prophylaxis. They should be counselled and referred to an
appropriate health facility for long-term management of their HIV status.
3.6.
Routine full blood count
and liver enzymes for patients on antiretroviral prophylaxis only is not
recommended. Any blood tests should be
performed according to the child’s symptoms and only if indicated by the
clinical condition of the patient.
3.7.
Relative contra-indicators
to the use of AZT include significant renal or liver impairment. Where in doubt about the use of
antiretroviral drugs in individual patients, contact your local physician or
referral centre for advice.
e) How would you further follow-up this
child? (5)
First visit – one week: Results of special investigations, any development of
further symptoms or improvement
Correct/adjust treatment according to results
Is the child safe – no further incidents (even if the child is removed from
parents’ care)
Follow-up HIV/RPR tests (6weeks/3 months at least)
If psychosomatic type symptoms, evaluate for referral to mental health team
See that team is in place (Social worker etc)
f)
You
are subpoenaed to appear in court regarding this case two years later. How
would you prepare yourself for such a court appearance? (5)
Contact the state prosecutor and make necessary arrangements about time and
place or where you could be contacted to appear on that specific day
Find and read your notes/J88 form/affidavit
Make sure that you have all the results available (special investigations) and
notes on follow-up of the patient
Consult with expert if you are unsure how you should interpret certain findings
and be sure of your facts
Dress conservatively, be on time
Paper 2 Question 4:
A 14 month old baby boy is brought into the
hospital by his mother. He is usually looked after by his grandmother in the
a) What is the diagnosis? (2)
b) Describe your initial
management of the child, indicating what specific complications you are looking
for (12)
c) There is a high incidence
of associated infections with this condition. What type of infections would you
expect and what investigations would you do to try to diagnose them (minimum 4
infections and 4 investigations) (8)
d) Describe your subsequent
approach to management once the patient has been stabilised (12)
e) If this child’s mother
decides to keep the child in
Answers:
1.
a) Kwashiorkor
b)
·
Resuscitate(
Ringers/normal saline)
c) Infections (4) Investigations
(4)
Septicaemia esp
gram - Blood culture
UTI urine
MC&S
Diarrhoea stool
MC&S
Giardiasis stool
MC&S
TB Mantoux
Gastric
washings
CXR
HIV HIV
ELISA with appropriate councelling
Measles
Worm
infestation
d)
e)
Paper 2; Question 5:
a. What do you understand by
the terms:
i)
Dependency
ratio?
Ratio of dependent
population (those under 15 and over 64
years of age) to the working aged population (aged 15 – 64).
ii)
Perinatal
mortality rate?
Annual number of
deaths from 28 weeks gestation to 7 days of
life per thousand total
births.
iii)
Infant
mortality rate?
Annual number of
deaths of children under one year of age per
thousand live births.
iv)
Under
5 mortality rate?
Annual number of
deaths of children under five years of age per
thousand live births.
b. In this district what, if
any, factors could contribute to the above mortality rates?
Poor services
Overcrowding
Poverty
HIV
Unemployment
Inadequate health facilities
c. What are the five most
likely diseases contributing towards the U5MR?
GE
ARI
Malnutrition
HIV
Septicaemia
d. What steps would you take
to reduce the PNMR?
Antenatal
Spacing
Booking
Screening
Supplements
PEP training
Facilities
Referral systems &
transport
Intrapartum
Monitoring
Resuscitation
Postnatal
Facilities
Protocols To provide oxygen, warmth &
energy
e. What would you do to reduce
the U5MR?
Infrastructural development
(WHS – water, housing & sanitation)
Job creation
Facts for life
Effective case management
IMCI
Vit A supplements
Clinical guidelines &
protocols
pMTCT
ART
Integrated Nutrition Programme
f. What is a baby friendly
hospital and what steps do you need to introduce to be accredited as such?
A hospital that is accredited by UNICEF as meeting
best practice standards to support & promote breastfeeding.
Standards are:
g.
What is IMCI and provide a brief outline of its components?
A strategy developed by the
World Health Organization to reduce morbidity & mortality from the 5 most
common conditions in infancy as well as HIV.
IMCI
consists of three components:
Standard
treatment guidelines (STGs)
i.
First
step is a triage process i.e.
o
looking
for General Danger Signs
o
Common
approach – Ask, Check, Classify
o
Check
for malnutrition & anaemia
o
Check
immunization status
ii.
Treatment
based on classification rather than diagnoses
o
Colour-coded algorithms
o
Follow
up
iii.
Counsel
mother
o
When
to return
o
About
food, feeding & fluids
o
About
her own health
iv.
Training
followed by supervision on site
Household
and Community Component
i.
Aims
to establish 15 key family practices
ii.
These
cover issues such as breastfeeding, immunizations, disease prevention, early
and appropriate treatment of common conditions e.g. use of ORS, improved
health-care seeking practices
iii.
Also
aims to improve the relationship and communication between primary health care
facilities and local community
iv.
No
single approach but includes identifying local resources and potential
community partners
v.
Multisectoral approach – should include participation of other
non-health sectors e.g. water and sanitation, social welfare, transport – to
increase feasibility of achieving key family practices
Health
Systems Review
i.
Aims
to improve the infrastructure of health systems so as to enable primary care
practitioners to effectively conduct their work
ii.
Includes
national, provincial and local activities
iii.
Links
with Essential Drugs List re. availability and dispensing of drugs
h. How would you monitor and
evaluate the impact of the above actions?
Monitor basic health indicators – attendance, admissions, outcome –
mortality rates (PNMR, IMR, U5MR), immunization rates etc
Quality assurance programmes – clinical audits, mortality reviews