DCH: P1; Q1

1a) The characteristics of an innocent murmur (10)

· Common

· Asymptomatic

· Normal pulses and normal heart sounds

· Short ejection systolic

· Never diastolic

· Usually at the left sternal border

· May change with posture

· Soft (not more than 3/ 6)

· Normal ECG

· Normal CXR

· Not associated with cyanosis

· Not associated with heart failure

· Accentuated by fever and exercise

· No chest pain

· Not associated with clubbing

· Examples: Still’s vibratory murmur, venous hum, pulmonary flow murmur, functional murmur

· No other syndromic features which may be associated with cardiac abnormalities

1 b) Clinical features of poliomyelitis and polio eradication strategies Poliomyelitis (10)

· An enteroviral infection serotypes 1, 2, and 3. Fecorally spread. Human reservoir

· Viral infection that multiplies in the GIT and Peyer’s patches leading to a viraemia. There are 4 clinical manifestations:

· Inapparent disease: > 95% of individuals infected remain asymptomatic or have-

· Abortive disease: Initially fever, headache and vomiting and get minor non CNS illness- sore throat, nausea, vomiting, diarrhoea, constipation, non specific abdominal pain lasting 5-7 days.

· Non-paralytic disease: <5% develop aseptic meningitis. Can also get neck stiffness and myalgias, backache. Meningitis with lymphocytic pleocytosis. This phase lasts 1-2 weeks.

· Paralytic disease: <1% get asymmetrical flaccid paralysis. Can invade the CNS along nerve routes with destruction of the motor neurons in the anterior horn and brainstem

· Localised or widespread muscle pain, spasms leading to weakness. Asymmetric loss of muscle function. Lower limbs more than upper limbs.

· There may be complete, partial or no recovery in this phase

· Death occurs by respiratory muscle paralysis, bulbar involvement, vasomotor instability and rarely an encephalitic illness.

· virus is shed in the stool for several weeks

Eradication Strategies

Specific measures:

· Diagnosis is made by having a high index of suspicion especially when dealing with a patient with acute flaccid paralysis who particularly is not / or incompletely vaccinated. Travel history is also important. The virus can be isolated from stool, (as well as throat swabs). Treatment is mainly supportive with full infection control measures

· Urgent telephonic notification to the provincial EPI coordinator for the Department of Health should occur.

· Containment of cases and spread

· Immunisation of contacts should be effected.

· Avoidance of unnecessary visiting areas reporting outbreaks

General Measures:

· WHO global initiative to eradicate and eliminate polio

· Prevention is by vaccination: EPI-SA as part of the immunisation programme live oral polio drops(OPV) given at birth; 6, 10, 14 weeks; 18 months and 5 years.

· Inactivated polio vaccine (IPV) can also be used for selected cases

· National Coverage Immunisation campaigns to mop up and increase herd immunity

· Public awareness campaigns

· Health Education, Promotion and Training at community and health facility levels

· Political Commitment and Department of Health guidelines, updates and surveillance programmes

· Provision of safe water and sanitation to all

1c) List the features that would lead you to refer a child with a ventricular septal defect for early evaluation by a Cardiologist. (10)

Clinical:

· Persistent tachypnoea and dyspnoea

· Poor feeding

· Growth restriction and failure

· Recurrent pneumonias

· CCF

· Pulmonary hypertension

· Left praecordial bulge

· Cyanosis

· Suspected endocarditis

Investigation:

· Abnormal ECG

· Abnormal CXR

Other:

· Suspected complex lesion

· Syndromic e.g. Down Syndrome

1d) Causes and clinical features of erythema nodosum (10)

Discreet painful nodules on the shins, calves, thighs, buttocks and upper extremities representing a form of delayed hypersensitivity to variety of stimuli. Often felt better than seen; may be associated with fever and arthralgia. Usually self limiting. Resolution in a few weeks. Progression through the colour changes of a bruise. Should look for a cause because it is not the erythema nodosum itself that is the important illness. In many cases, there is an underlying illness, often an infection that is thought to trigger this inflammatory reaction.

· Infections:

- streptococcal infection

- primary tuberculosis

-

· Drugs -any

- sulphonamides

- penicillins

- phenytoin

- barbiturates

· Other

- inflammatory bowel disease

- sarcoidosis

- lymphoproliferative disorders

- Idiopathic

DCH: P1; Q2

1) Causes of apnoea in the first week of life.

Standard Treatment Guidelines and Essential Drug List for South Africa Hospital Level Paediatrics 2006 p. 325

2) Pharmacological management of neonatal convulsions.

Standard Treatment Guidelines and Essential Drug List for South Africa Hospital Level Paediatrics 2006 p. 362-3

Note that intravenous Phenobarbitone is available again and is regarded as first line drug of choice with loading dose of 20 mg/kg which can be repeated if no response. Diazepam is not recommended for neonates.

3) Principles of management of hypovolaemiac shock in a child.

Standard Treatment Guidelines and Essential Drug List for South Africa Hospital Level Paediatrics 2006 p. 8-11

APLS or PALS guidelines

4) Notifiable diseases affecting children.

Standard Treatment Guidelines and Essential Drug List for South Africa Hospital Level Paediatrics 2006 p. 385

Standard Treatment Guidelines and Essential Drug List for South Africa Hospital Level Paediatrics 2006 will be available in January 2007

DCH: P1; Q3

A. Vaccine schedule, adverse effects and contra-indication

Use Coovadia textbook for answers.

Tabulate which vaccines are given, their adverse effects and contra-indications if any.

B. A 2 year old who presents with a wheeze for the first time

• History
• Perinatal factors
• Allergy
• Onset
• Acute/gradual
• Precipitating factors
• Choking (?foreign body)
• Progression
• Severity
• Ill-looking or not

• Examination
• Signs of respiratory distress
• Movement of the chest
• General signs- e.g clubbing
• Signs of heart disease
• Investigation
• CXR
• Infection screen
• Peak flow
• ABG depending on severity
• Treatment

C. Child headed households

Problems that these children face can be psychological and socio-economic. The majority of them have been orphaned by HIV/AIDS. They have problems with the following issues:

1. Death and dying- probably saw parents suffering from a chronic illness and dying. Some probably had to nurse their parents.
2. Finance
1. Lack of schooling
2. Child labour
3. Poor nutrition
4. Criminal activities

i. Stealing

ii. prostitution

3. Lack of supervision by an adult
4. Child may be infected with HIV/AIDS themselves or looking after a sibling who is infected
5. Lack of shelter

Possible Interventions

1. Early identification of such households
2. Placement
1. Find relatives first
2. Fostering
3. Adoption
4. Children’s homes (avoid placing them in these if possible)
3. Social grants
4. Make sure that they attend school
5. Psychological support/counselling
6. Anti-retrovirals

D. Thirteen year old with PV bleeding

• History
• Onset, duration
• Associated symptoms
• ? menarche
• trauma
• assault/abuse
• medication- overdose
• foreign body
• Examination
• General health
• Tanners staging
• Signs to try to exclude the above
• May need examination under anaesthesia (depends on other findings)
• Management
• Depends on the findings

DCH: P1; Q4

Advice to parents who complain that “My 3-year old child won’t eat.”

· This pattern is quite common: Children can start refusing food at any age but it tends to start between the ages of one and two years.

· Typically, a child will take well to solid food, even eating a wide variety of foods but the novelty of this can wear off, often around the time she becomes more active.

· Food refusal can have different implications depending on the extent: many children, for instance, point-blank refuse to eat anything green, having tried and disliked strong-tasting vegetables such as broccoli or cabbage.

· The only situation which gives rise to real concern is when there is evidence of failure to thrive (on a Road to Health Card), which is rarely the case.

· There is no link between refusing food as a toddler and eating disorders later in life. Eating disorders are more to do with emotional problems and less to do with food.

· Parents who have or in the past had an eating disorder are more likely to be anxious about food refusal in their children.

· Parents should try not to give children lots of attention when they refuse to eat, as they are more likely to continue with any behaviour that gets attention. Instead, try praising them when they do show interest in food, but making no comment otherwise.

· As well as being common, food refusal often just goes away by itself.

Tips to encourage eating

· Sit and eat with your child – even if you are only having a sliced-up apple. She will enjoy the company.

· Introduce a few action rhymes and songs which are just for mealtimes.

· Keep choices few and simple as too much variety can be confusing

· Serve small portions, so she doesn't feel over-faced with food: she can always request a second helping.

· If your child is a poor eater, offer her foods that are high in calories and nutritious, such as cheese and full-fat milk, to make up any shortfall.

· Avoid letting your child eat whatever she chooses, on the grounds that at least he's eating something, as this will perpetuate the problem. Cut down gradually on her favourites, introducing some variety.

· The occasional packet of sweets or plate of biscuits will do no harm once your child has established better eating habits. However, you could make a rule that they are limited to weekends or after meals.

· Don't put too much emphasis on eating only 'healthy' foods. Fats and sugar are important sources of energy at this age.

· Avoid distractions such as TV or toys at mealtimes.

· If she is hungry, encourage her to eat freely from whatever foods you have prepared. If not, don't force her but be clear there will be nothing else until her next snack or mealtime, and stick to your guns.

· You're more likely to tempt your child to eat something new when she is at her hungriest: offer her child-friendly portions of healthy snack foods.

· Don't allow her to fill up on juice and squash; instead, offer her a small cup of water at mealtimes, and limit her fluid intake in the run-up to each meal.

· Children are influenced by their peer group and will often start to eat new foods when visiting their friends for meals.

A comparison of major causes of under 5 mortality globally, in Africa and in South Africa

Infectious and parasitic diseases remain the major killers of children globally, accounting for more than half of all deaths in children younger than five years of age (Figure 1). The toll is even higher in sub-Saharan Africa where infections are responsible for more than two-thirds of young child (<5 years) deaths (Figure 2). The single greatest contributor is lower respiratory infections.

In high-income countries, perinatal causes have replaced infectious diseases as the leading cause of death and are now responsible for up a third of deaths. Such a shift in the cause of death pattern has not occurred in Sub-Saharan Africa, where malaria, lower respiratory infections and diarrhoeal diseases, in that order, are the leading causes of death.

In South Africa in 2000, HIV/AIDS accounted for at least 40% of under-5 deaths and was easily the leading cause of death in this age category. Low birth weight (mainly preterm birth), diarrhoeal disease, respiratory infections and severe malnutrition accounted for a further 30% of childhood deaths. Congenital defects, particularly of the heart and neural tubes also ranked highly. There was little gender difference in young child mortality.

Figure 1 Main causes of death among children under-5 years, worldwide, 2001

Source: Global Burden of Disease and Risk Factors, 2006.

Figure 2 Main causes of death among children under-5 years, sub-Saharan Africa, 2001

Source: Global Burden of Disease and Risk Factors, 2006.

Figure 3 Main causes of death among children under-5 years, South Africa, 2000

Source: SA MRC Burden of Disease study

Risk factors for, and the prevention of, dental caries

Risk factors:

Preventative Measures

Fluoride
Foods, toothpastes, mouthwashes, and even tap water are fluoridated. Water fluoridation is particularly important in dental prevention because it is an effective, safe, and low-cost way to prevent and protect against the occurrence of tooth decay. Using topical fluoride applications, such as fluoride toothpastes, fluoride varnishes, or fluoride rinses, can also aid in remineralization.

Dental Sealants
The chewing surfaces at the back of the teeth, the molars, are where decay often occurs. A dental sealant or a pit and fissure sealant is a professionally-applied, safe plastic material that is placed on the chewing surfaces of back teeth to protect and prevent against caries.

Behavioral Component

Dietary Practices
Unquestionably, sugar plays a huge role in the development and progression of caries. Feeding children sweetened beverages coupled with poor hygiene habits are detrimental to the health of children’s teeth. Discontinuing the use of baby bottles, replacing sugary liquids, and using fluoride gels all assist in reducing risk.

Parental Education and Dental Knowledge
Both education and knowledge of dental caries are vital in prevention of caries. Whether a parent or caretaker has the ability to read and thus, understand and learn about the dangers of sugar intake, general facts about ECC and its prevention methods can affect what practices a parent implements on the dental health of her children. Training parents and caretakers to determine decay or decalcification in children’s teeth can be important in secondary prevention.

Access to Dental Care
Dental care is the most prevalent unmet health need in children.

The role of the various team members in the management of a child with a cleft lip and palate

A collection of medical and social service providers speak to the needs of the child born with a cleft and that child's family. The following persons may or may not be on the team.

SURGEON
The Surgeon is often considered the "Captain" of the team. He/she provides the plastic, reconstructive surgery on the cleft. This person will close the lip and the palate and provide for any scar revision and rhinoplasty. The plastic surgery to repair and reconstruct the cleft is often done by a Plastic Surgeon. Other persons who may do the plastic surgery include Oral Maxillofacial surgeons, Otolaryngologists, etc. PAEDIATRICIAN
The pediatrician looks at the overall well-being of the child. The pediatrician checks the normal growth and development of the child and makes certain that the child is physically fit for upcoming surgical procedures.

PAEDIATRIC DENTIST
The role of the pediatric dentist is to ensure that the child's teeth are healthy and strong. Many times children with clefts have teeth in unlikely positions in the mouth. It is sometimes very difficult to keep those teeth clean and therefore healthy. The pediatric dentist helps to maintain a healthy and cavity-free mouth.

ORTHODONTIST
The orthodontist, on the other hand, helps to establish a good shape to the dental arches. A child with cleft may need the services of an orthodontist even before she has teeth! The orthodontist will work to achieve a normal dental arch prior to bone graft surgery, and then follow-up to maintain the integrity of that arch once achieved.

PROSTHODONTIST
There are times when a child with a cleft needs a prosthetic device to meet her specific needs. Such prosthetic devices may be an obturator, a bridge, a retainer, an implant, or any one of a number of other devices. The prosthodontist works very closely with the orthodontist and the surgeon to provide the cleft-affected child with necessary appliances.

OTOLARYNGOLOGIST
Children with clefts typically suffer from poorly functioning Eustachian Tubes and therefore experience a larger than normal number of ear infections. The Otolaryngologist serves to keep those infections at a minimum, and to minimize any damage done subsequent to such infections.

AUDIOLOGIST
The audiologist checks the child's hearing regularly. Recurring ear infections, waxy build-up and fluid behind the ear drum (all common among children with clefts) can rob a child of the ability to hear effectively. The Audiologist measures how well a child is hearing and makes recommendations if a child's hearing is compromised.

SPEECH AND LANGUAGE THERAPIST
The Speech and Language Therapist assists the child in producing intelligible language. The Speech and Language Therapist will provide therapy in areas of articulation and language development, depending upon the child's unique need. It may be likely, due to the nature of speech therapy, that the child may see more of the Speech and Language Therapist, and on a more regular basis, than any other member of the team.

COMMUNITY HEALTH NURSE
The Community Health Nurse assesses the health needs of the entire family and makes recommendations concerning resources that might aid in maintaining the overall health of the household. The Community Health Nurse may also help by instructing the parents on how to feed and otherwise care for the child.

GENETICIST
The Geneticist studies various aspects of the family, the family history, etc. and assists the family in determining a recurrence risk when choosing whether or not to have more children. The Geneticist helps the family gain an understanding concerning the factors that contribute to clefting conditions. The geneticist will also help persons of child-bearing age who were born with clefts to determine the probability of producing a cleft child themselves.

SOCIAL WORKER
The Social Worker helps the family to deal with all the issues that touch them concerning the cleft. Issues of grief, finance, emotional and moral support, feelings of anger and guilt, and so forth, are non-medical topics that affect the over-all treatment of the child and the family. The Social Worker will help the family to access appropriate resources and to network for support.

PSYCHOLOGIST
The Psychologist works with the child alone, the parents alone, or the family as a group to ensure normal functioning. Many times parents find a child's disability or deformity difficult to adjust to. Often, a child with a cleft has self-esteem issues that limit his/her potential. The Psychologist will provide intervention that speaks directly to those needs.

DCH: P1; Q5

a. Treatment of a child with severe anaphylactic shock.

Initial assessment with particular attention to shock & bronchospasm

Lie patient down

IVI with Ringers Lactate / Normal Saline / Haemacel

with 20 ml/kg bolus if shocked

Adrenaline

1:1 000 0,3ml IM stat

1: 10 000 0,1 ml/kg IV stat

Repeat in 20 minutes if needed

Oxygen

Antihistamine Promethazine

Hydrocortisone stat & 4 – 6 hourly

Salbutamol : saline (1ml each) nebs if bronchospasm present

Try to identify allergen

Counsel and educate child and caretaker

Arrange for medic alert bracelet

Make a note of sensitivity in patient’s medical record and RTHC

b. Intraosseous infusion

Aseptic technique

Select needle – intraosseous / short yellow spinal needle

Prepare equipment

Set up infusion – fluid, buretrol, giving set

Identify infusion site - 2 – 3 cm below tibial tuberosity on flat antero-medial surface

Clean site

Push with screwing motion till needle “gives” as it enters marrow cavity

Assess patency of needle

Connect infusion

Secure and protect needle and infusion site

c. Causes for and immediate treatment of fractured femur in 6 year old

Causes:

Normal bone accidental trauma

Non accidental injury

Abnormal bone rickets

Malignancies

Osteopaenia – variable causes

Osteogenesis imperfecta

Immediate treatment:

Assess fracture - clinically & with X-rays of both limbs including hips & knees

open / closed

Isolated or multiple

Associated problems – dislocations

Assess haemodynamic status

Treat shock

Analgesia

Immobilisation – skin traction (too old for Gallows, too young for Thomas splint)

d. What is a clinical audit?

Quality assurance activity that compares routine standards of care for a clinical condition with a recognised gold standard for care for that condition.

Select topic for audit based on the burden of that condition on the health services

Very common

High morbidity or mortality

Expensive management

Identify gold standard for comparison: International, national or local guidelines

Establish indicators for comparison

12 – 15 in total

Include history, examination, investigations, treatment

Identify clinical records

Collect and review records

Analyse performance against the ideal management

Identify strengths and weaknesses / gaps in management

Plan corrective measures to improve standard of care

Implement corrective measures

Review effect of corrective measures

DCH: P2; Q1

Paper 2 Question 1

Thabo, a four-year old boy, is brought to the paediatric casualty at the hospital by his mother, Letitia. She says that he suffered a generalised tonic-clonic seizure lasting 35 minutes about one hour ago. He is on phenobarbitone, but has not been given his medication for the past 6 weeks as his mother “did not have transport money” to get to the clinic. He has had frequent seizures since stopping the medications, but this episode was particularly long.

Thabo was born at term at the local midwife obstetric unit. He weighed 4.3kg at birth. He did not cry well at birth and was referred to the district hospital, where he stayed for three weeks. Letitia remembers that Thabo was very floppy in the first week of life and was fed via a nasogastric tube for about two weeks. He also had seizures after birth that persisted after discharge.

Letitia says that Thabo has Cerebral Palsy (CP). He is still unable to sit, crawl or walk. He is unable to talk and only makes sounds. He is attending CP Clinic for physiotherapy and occupational therapy.

Thabo is microcephalic. Both his weight and height are below the 3^rd centiles for age. He has contractures in his elbows and Achilles tendons. He has increased muscle tone with his arms more affected than his legs. There are no signs of meningitis. Thabo does not respond to auditory or visual stimuli.

1. Define cerebral palsy. (2)

Cerebral palsy is a disability of motor (1/2) function due to a non-progressive (1/2) insult or damage (1/2) to a developing brain (1/2)

2. What is the most likely cause for Thabo’s cerebral palsy? Provide at least 4 facts that support your conclusion. (4)

Had hypoxic ischaemic encephalopathy after birth (accept perinatal asphyxia) (1 mark)

Did not cry at birth, big baby, floppy, nasogastric feeds, seizures (1 mark each)

3. How would you classify Thabo’s cerebral palsy? (3)

Spastic (1) quadriplegic (1).

- with possible sensory deficits (vision, hearing)- 1 mark

4. Provide a brief (one line) pathophysiological explanation for each of the following signs: (8)

a) Clonus

Increased reflexes (1/2) are a sign of a upper motor neuron lesion (1/2)

b) Seizures

Indicates damage to some part of the brain

c) Poor response to visual stimuli

Accept either that:

i) May be blind- because of damage to the optic cortex or some part of the vision pathway

ii) Post-ictal and therefore non-responsive to stimuli

d) Contractures

Related to increased muscle tone with inadequate movement of relevant muscles and joints

5. Thabo has another generalised (tonic-clonic) fit soon after arriving at the hospital. List the critical steps in your management of the seizure. (5)

Secure airway

Turn to side

Administer oxygen

Monitor vital signs

Perform appropriate investigations, e.g. Glucose

Manage underlying problems, e.g. fever if present (no history of fever in this case)

Rectal diazepam or buccal midazolam

Still convulsing after 10 minutes- IV/IM Lorazepam (Rivotril) or IV Clonazepam

Still convulsing after 10 minutes- IV Phenytoin over 30 minutes

6. What grant is Thabo eligible for that could help provide the “transport money” to allow him to attend the clinic regularly? Why does Thabo qualify for this grant (3)

Child dependency grant (1 mark). No marks for disability grant

Qualifies because he has a disability (1) that requires full-time care (1)

7. List TWO primary and TWO secondary prevention measures that could have prevented Thabo from developing cerebral palsy. (4)

Primary:- Achieving highest possible standard of maternal and child health.

Early antenatal booking ( pick up high risk mothers ie. diabetic /mutiparous)

High risk deliveries done in specialised centres.

Earlier recognition and referral for Caesarean section for large baby.

Intrapartum monitoring, CTG, Foetal scalp electrode etc.

Secondary:- Good resuscitation at birth

Hypothermia

? high dose phenobarbitone

8. How would you optimise Thabo’s anti-convulsant therapy to ensure adequate control of his seizures? (5)

Monotherapy is preferred to combination therapy. Combination therapy should be specialist initiated

Drugs levels are not indicated as there is a clear history of non-compliance.

Preferred drug would be sodium valproate (rather than phenobarbitone).

2^nd line – carbamazepine

3^rd line- refer to specialist decision about need for lamotrigine

Counsel parents on need for compliance

9. Thabo continues to fit at the hospital despite appropriate anti-convulsant treatment. He requires admission to the regional hospital’s ICU for a thiopentone infusion (general anaesthesia) to control his seizures but is refused admission on the grounds that he has cerebral palsy and is mentally retarded. Is this ethically justifiable? Briefly discuss the principles involved. (6)

Need to provide key principles, either for or against this

DCH: P2; Q2

a. Key components of care over next 24 hours

Premature

Routine observation

Maintain

Warmth

Blood sugar with feeds and fluids

Oxygenation

HIV exposed no history of maternal nevirapine

Baby requires nevirapine asap

b. Feeding choices.

Exclusive breast milk

Formula feeds

Pasteurised expressed breast milk

Pasteurised pooled breast milk

HIV+ mother with suspicion of progression to AIDS - risk of HIV infection from breast milk

Premature baby with risk of NEC and other complications from formula feeds

Presumably poor socio-economic circumstances with risk of increased infant mortality from GE and ARI associated with formula feeding

The choice should be made by the mother with support of health care workers

Ideally this baby should have pasteurised EBM whilst in hospital with the definitive choice being made prior to discharge, recognising the specific circumstances of this family

c. Criteria for discharge.

Well baby

Well mother

Decision re infant feeding

Established source of infant feed

Baby feeding well

Baby gaining weight

Maintaining temperature

Vaccinated – BCG & Polio 0

Follow up details arranged

d. Long term care

Family care – adoption

Foster care

Institutional care – children’s home

		Pros	Cons
Family	Physical care	Secure
		Basic needs provided
	Emotional	One-on-one care
		Supportive
	Social	Part of a family	No contact with biological family
		Permanent - adoption	Temporary – foster care
			Risk of abuse/exploitation
	Intellectual	Stimulating
Institutional	Physical care	Secure
		Basic needs address
	Emotional		No intimacy/family
			Temporary placement
	Social	Company	Lack of permanence
			Behavioural problems
			Risk of abuse/exploitation
	Intellectual	Good - fair

e. Legal processes.

All placements into surrogate in this sort of circumstance require the same legal process.

Children’s court enquiry:

Social worker to:

present case to court

satisfy the court that adequate attempts have been made to trace the family

recommend option for surrogate care

Presiding officer to:

declare baby a child in need and a ward of the state

authorise surrogate care placement

Surrogate parents to fulfil necessary criteria as adoption or foster parents

f. Medical assessment.

Full physical assessment

Full neurodevelopment assessment

Basic screening tests – WR, HBV, Thyroid functions, urine

HIV specific blood tests – ideally p24 Ag or more realistically PCR at 6 weeks

g. Management of HIV status.

Confirm diagnosis

with PCR at 6 weeks, if available

or Eliza test at 15 – 18 months if no PCR available

Monitor growth, development and wellbeing at routine IMCI visits

Early treatment of intercurrent illnesses

Nutritional support

Support for infant feeding choice

Micro-nutrient supplements especially Vit A from 6 months

Immunizations – routine EPI schedule

Cotrimoxazole prophylaxis from 6 weeks

h. Long-term health risks.

Related to Surrogate care Malnutrition

Abuse or exploitation

Behavioural problems

Poor immunisation status

Increased general morbidity & mortality

Related to HIV status Growth failure

Development delay

Increased frequency of infections

Opportunistic infections

Related to prematurity Development delay

Interventions:

Supervised placement

Active monitoring of health status in line with IMCI protocols

Active management of HIV status

DCH: P2; Q3

Colette, a previously healthy three-year- old girl presents at the hospital casualty with a four day history of coughing and fever. On examination you note a respiratory rate of 53 breaths/min and chest wall indrawing (retraction). The left side of the chest is dull to percussion with bronchial breathing heard posteriorly.

a. What is the most likely diagnosis using the IMCI classification. (1)

Severe pneumonia

b. List THREE organisms that commonly cause this presentation. (3)

Most likely bacterial or mixed cause. S. pneumonia, H influenzae.

Less likely in previously healthy child of this age: S. aureus, M pneumoniae

c. List FOUR investigations that you think are necessary. Motivate the need for each. (8)

CXR – to confirm diagnosis, may help to establish etiology (S aureus), look for complications like effusion/empyema

Blood culture -5% chance of culturing responsible organism

ESR. CRP – May support diagnosis of bacterial cause

WBC and differential count - May support diagnosis of bacterial cause

NPA for viruses. – unnecessary

Induced sputum – not helpful in this case

Mantoux – no supporting facts

Gastric aspirates for acid-fast bacilli no supporting facts

Student may motivate to do no special investigations – give marks if adequately motivated

d. Describe the rational empirical use of antibiotics in community acquired pneumonia in South-African children. (12)

	Ambulant	Hospitalised
0-2mo	Hospitalise all children < 2 mo	Ampicillin/Penicillin + AG iv or Ceftriaxone/Cefotaxime iv
3mo-5yr	Amoxicillin po high dose	Ampicillin iv/ Amoxicillin po high dose or Cefuroxime iv/Amoxi-Clav po/iv Ceftriaxone/Cefotaxime iv Add Cloxa if S. aureus suspected
>5yr	Amoxicillin po high dose Or Macrolide po – if suspected M. pneumoniae or Chlamydia spp.	Ampicillin iv/ Amoxicillin po high dose or Cefuroxime iv/Amoxi-Clav po/iv Ceftriaxone/Cefotaxime iv Add: Cloxa if S. aureus suspected Add: Macrolide po – if syuspected M. pneumoniae or Chalmydia spp

If description of reasons given:

Marks given for:

· Epidemiology of infecting organisms

· Prevalence of drug resistance

· HIV prevalence

· Available resources

· Aetiology in age groups

· Aetiology in HIV

· Specific organisms – treatment (more than 1 mark)

· Route of antibiotic administration

· Duration of treatment

e. Discuss the prevention of childhood community acquired pneumonia under the headings:

i. General preventative strategies (8)

ii. Specific preventative strategies (8)

i. General preventative strategies

a. Nutrition

1. Malnutrition predisposes to pneumonia

2. Breastfeeding decrease incidence of pneumonia up to 32%

3. Encourage breastfeeding up to 6 months

b. Micronutrient supplementation

4. As routine care in HIV or malnourished

5. Vit A

a. Measles

6. Zinc

a. Particularly NB in malnourished children

c. Reduction in

7. Passive smoke

8. Indoor fuel exposure

ii. Specific preventative strategies

i. Immunisation

1. Routine

a. Measles

b. BCG

c. Pertussis

d. Hib

2. Pneumococcal

3. Influenza

4. Varicella

ii. Prophylaxis

1. Pneumocystis jiroveci prevention

2. TB prophylaxis where household contact

3. Palivizumab

4. HAART

Complete memo: SAMJ Dec 2005. Diagnosis and Management of Community-Acquired Pneumonia in Childhood – SATS Guidelines

DCH: P2; Q4

Johnny is 15 months old and his weight of 12 kilograms places him on the 75^th percentile) He is brought to the outpatient clinic because has been playing less and tiring easily. His mother thinks he is pale. You do a full blood count. The results are: Hb 4g%, MCV 54fl, MCH 16pg. White cell and platelet counts are normal

1. Interpret the full blood count? 2

Hypochromic microcytic anaemia

2. What is the likeliest explanation for this abnormality? 1

Iron deficiency, probably dietary

3. List THREE other possible causes for the low haemoglobin 3

Sideroblastic, chronic disease, thalassaemia, blood loss, marrow diseases etc

4. What else would you like to know from Johnny’s mother (history) to identify a possible cause for his problem? 6

Diet, promotors and inhibitors of iron absorption, milk intake, vegetables, pica, family history, ethnicity, other symptoms, medical history

On examination, Johnny has a tachycardia and a gallop rhythm.

5. Explain the significance of these two signs (2)

Incipient failure

6. Would you transfuse Johnny? Justify your response. (1)

Yes, he is symptomatic and in incipient failure

7. You decide to offer a blood transfusion, Write out the orders for this procedure? 5

10 to 15 ml/kg/transfusion = 120 ml over 4 to 6 hours (30 to 20ml/hr)

Lasix 0,5mg IVI at end of or half way through the blood to prevent further cardiac failure.

Observe for any reactions to the blood, ie monitor pulse, RR, BP, and temp as well as skin rashes.

Stop infusion is any reaction and notify doctor on call

Compat to be done, forms filled in correctly and checked before blood given

8. What other drugs would / may you prescribe? 2

Lasix ,digoxin ( want what other drugs during transfusion not what others on discharge)

Johnny is stabilised and ready for discharge in three days.

9. What medication will you offer Johnny on discharge (provide dose and duration)? Explain your follow up plan. 6

Ferrous sulfate 6mg of elemental iron per kg per day

ie 72 mg elemental iron per day 2 or 3 divided doses until the Hb is normal and then half the dose for another 2 to 3 months to replenish the stores.

May give Vit C and folic acid

Do FBC after 3 to 4 weeks to check response, the 4 to 6 weekly until normal. Repeat 2 to 3 months after all treatment completed to check that he is not anaemic again and that you did not miss diagnose the child

10. What other advice would you give Johnny’s mother? 4

Make sure diet is adjusted, decrease cows milk intake, make sure of meat and green leafy vegetables. Check for pica, de worm

11. What are possible long-term consequences if Johnny’s condition recurs and is left untreated? 3

Poor neurodevelopment, poor growth, poor school performance, immune abnormalities

12. Johnny has a one-month old sister. What advice would you give Johnny’s mother about preventing her from developing the same problem? 5

Breast feed, supplement with iron at 3 to 4 months.

Formulae, are all fortified, should be enough iron

Use iron fortified cereals

De worm when appropriate

Mixed diet when able

Careful of amount of cow’s milk ingested

DCH: P2; Q5

Busisiwe, a 5-year-old female presents to the local clinic with a six-week history of abdominal pain. The pain is not associated with other symptoms. She is growing and gaining weight appropriately

a) What questions on history –taking may assist in establishing the significance of the abdominal pain.

Questions related to:

Location, intensity, character and duration of pain, time of day or night that pain occurs
Appetite, diet, satiety, nausea, reflux, emesis
Stool pattern, consistency, completeness of evacuation
Review of systems: weight loss, growth or pubertal delay, fever, rash B
Medications and nutritional interventions
Family history, travel
Interference with school, play

b) Provide TWO likely differential diagnoses for the abdominal pain

Constipation, Functional pain, Giardiasis, Parasites, Peptic ulcer disease,

Tumour/masses

Busisiwe’s blood pressure is 140/100 mmHg. She has a smooth, firm, 8 cm by 7 cm mass palpated in the right upper quadrant of her abdomen that does not cross the midline. The right side of her body appears large than the left.

c) Provide FOUR differential diagnoses for the abdominal mass.

Gastrointestinal - fecal mass, duplication, Meckel’s diverticulum

Liver – hepatomegly, hepatic cyst (hydatid) hydrops of gall bladder.

Renal - hydronephrosis, megaureter, polycystic kidney disease.

Tumors - neuroblastoma, Wilms’ tumour, lymphoma, hepatoblastoma, rhabdomyosarcoma, ovarian cyst, teratomas.

d) What is the most likely diagnosis?

Nephroblastoma (Wilms’ tumour)

e) Provide a pathophysiological explanation for Busisiwe’s

i) Blood pressure

Up to a third of patients with Wilms’ tumour can present with hypertension secondary to rennin-secreting tumour or production of renin in response to renovascular insufficiency casued by tumour mass.

ii) Body asymmetry

Wilms’ Tumour may arise in 3 clinical settings: (1) sporadic, (2) in association with genetic syndromes, (3) familial. Genetic syndromes that predispose to Wilms’ tumour include Hemihyperthrophy.

f) List the investigations you would undertake, and suggest a likely positive findings(s)

for each test: at a

i) district hospital

FBC – anemia, neutropaenia, low platelet count – suggest bone marrow infiltrate

U&E: High urea, creatinine – kidney involvement or tumour lysis,

High LDH, high uric acid – suggests rapid cell turnover in malignancy

IINR high, PTT prolonged – coagulation problem

Urinalysis – haematuria, proteinuria – lesions involving urinary system

CXR – lung metastases

Plain abdominal radiograph – intestinal obstruction, calcifications.

Ultrasound – renal mass

ii) regional or tertiary hospital

• Ultrasound

• Initial diagnosis of a renal or abdominal mass, possible renal vein or inferior vena cava (IVC) thrombus

• Information regarding liver and other kidney

• Computed tomography scan of the chest and abdomen

• Differential diagnosis of a kidney tumor versus adrenal tumor (neuroblastoma)

• Liver metastases

• Status of opposite kidney

• Lymph node assessment

• Status of chest with respect to metastases

• Magnetic resonance imaging

• Typically, these tumors appear inhomogeneous when using gadolinium-enhanced MRI
• This type of imaging also is useful for magnetic resonance venography to aid in the diagnosis of thrombus of the renal vein of the IVC.

• Chromosomal analysis and gene mapping
• Histopathologic confirmation of disease

g) How would you manage Busisiwe at a:

i) district hospital

Reduce high blood pressure, improve renal function, give fluids and electrolytes , treat infection, transfuse if severe anemia and/or thrombocythopaenia. Refer the patient as soon as possible to the regional/tertiary hospital.

ii) regional or tertiary hospital

Multimodality treatment: chemotherapy, radiotherapy and surgery. The goal of current clinical trials is to reduce therapy for children with low-risk tumours, thereby avoiding acute and long-term toxicities.

Medical/Surgical therapy: The main agents include vincristine, dactinomycin, and doxorubicin. Chemotherapy is administered up front to reduce tumor volume, thereby decreasing the risk of surgical spillage of tumor. Radiation therapy is restricted for treatment of higher-stage (III and IV) disease.

The aim of long follow up is to:

· Monitor renal function

· Evaluation of Anthcycline related cardiotoxicity

· Assessment of growth and sexual development

· Assessment of musculo-skeletal development in irradiated patients

· Assessment of fertility

· Watch out for second malignant neoplasia

Support & Education Programs
When a child is diagnosed with cancer, it has a significant impact not only on the child, but parents, siblings and extended family as well.

Psychological support

Cancer support group

Social worker involvement

Genetic counseling if required