DCH P2; Q1:
Impact of Millenium Developmental Goals (MDGs)
on Child Health
8 MDGs for 2015 part
of Millenium Declaration accepted by United Nations
September 2000.
•
1. Eradicate extreme poverty and
hunger
•
2. Achieve universal primary
education
•
3. Promote gender equality and
empower women
•
4. Reduce child mortality by 2/3
•
5. Reduce maternal deaths by 3/4
•
6. Combat HIV/AIDS, malaria and
other diseases
•
7. Ensure environmental
sustainability
•
8. Develop a global partnership for
development
All 8 MDGs will have a positive impact on
child health either directly or indirectly.
MDGs have put child health on the
political agenda at a global level.
It created targets and comparisons between different countries and
continents that will benefit child health.
MDG1
Decrease in poverty will decrease malnutrition in children, a major
contributor to childhood mortality.
MDG2+3
Improved education and empowerment of women will led to improved
outcomes for child health
MDG4
Under 5 and Infant mortality rate will be
used as indicators. Mortality have to be decreased by
2/3 at 2015 using 1990 as base.
Measles immunization at 1 year will be the third indicator for this
goal.
MDG5
Improved survival of mothers will improve outcome for their children.
MDG 6
Decrease in HIV, malaria and Tuberculosis will decrease mortality and
morbidity for children.
b) Approach
pedal oedema (bilateral) 1 year for 1 day
Diff Dx
Kwashiorkor
Protein losing enteropathy
Heart failure (cor pulmonale,
cadiomyopathy)
Nephrosis
Nephritis (rare in 1 year old)
Portal hypertension
Increased intra-abdominal pressure
Lymphoedema
Angiooedema
Approach
History:
diarrhoea
cough
nutrition
urine output and appearance
snoring
allergies
RTHC
weight loss
TB contact
Examination:
General
plot
centiles and determine antropometric
status
jaundice,
anaemia, lymphadenopathy
distibution oedema
features
of malnutrition
skin
Cardiovascular
BP, circulation
signs
of failure
Respiratory
upper
airway obstruction
distress
plearal effusion
Abdomen
organomegaly
ascites
Special investigations:
Urine test for protein,
haematuria
CXR
FBC
U+E
LFT
Mantoux
If indicated:
O2 sat during sleep
Echo
Abdominal sonar
c) Stunted
Note: Not wasted or underweight
Reasons:
Endocrine
hypothyroidism, growth, cushing, hypopitiurism
Ex low birth weight
Familial
Constitutional
Rickets
Renal
Achondroplasia
Chomosomal/syndromes
(Down, Noonan)
Steroids
Investigations:
Mid parental height
Bone age
Thyroidfunction
FBC
U+E
Urine test
If indicated:
Chromosomal studies
Ca, Phosphate, Alkaline
Phosphatase
Growthhormone stimulation
test (if height more than 3 standard deviations below)
Cortisol
d) Five main
causes U5 Mortality
Neonatal (low birthweight, asphyxia,
infections)
Lower respiratoty infection
Diarrhoea
AIDS
Malnutrition
Strategies to reduce mortality:
See Saving Babies and Saving Childrens Report
P2; Q2
The care
dependency grant (10)
What are the
qualifying criteria?
The applicant,
spouse and child must meet the requirements of the means test. A means test is the test used to measure the financial
status of the family. The means test for the care dependency grant depends on
the income of the entire family. Can
get the grant if the joint income of the applicant (you), spouse and child is
less than R48 000 a year or
R4 000 a month. The income of the child, must not
be more than R19 680 per year.
You cannot get
the grant if the child is in a psychiatric
The
amount of the grant changes every year. In 2008 the grant amount is R940 per month
You
will also need to show certain documents
and provide some information, including:
·
Your South African
identity document (ID), which must
be bar-coded.
·
The child's birth certificate, which must have an
ID number.
·
A medical report for the child, which must say what the child is able
to do. This is known as a functional assessment.
·
If you are the foster
parent of the child, the court order making you the foster parent.
·
Proof of your marital
status, such as a marriage certificate, divorce papers, or a death certificate
of your spouse, or a sworn statement (affidavit) if you have never married.
·
Proof of the income for
you and your spouse, such as UIF card ('blue card'), wage certificate, or
pension details.
·
Proof of the income of the
child.
The diagnosis and management of
congenital hypothyroidism (10)
·
The goal of treatment of CH is to avoid disturbed mental development, and
initial treatment can be adjusted to physiological conditions. To match the
higher thyroid hormone concentrations in the first weeks of life, substitution
with l-thyroxine should aim to achieve serum T4/free
T4 levels in the upper half of the normal age-related reference range.
Indications
for a tonsillectomy and/or adenoidectomy in children (10)
INDICATIONS FOR TONSILLECTOMY AND ADENOIDECTOMY
|
Recurrent Throat Infections |
Patients with 3 or more
infections of tonsils and/or adenoids per year despite adequate medical
therapy |
|
Obstructive Sleep Apnea |
|
|
Adenotonsillar
Hypertrophy with Upper Airway Obstruction |
|
|
Suspicion of Malignancy |
Unilateral tonsil hypertrophy presumed
euplastic. Although without other indications (abnormal appearance,
physical examination, symptoms or history) most asymmetries can be followed
conservatively. |
|
Speech Abnormalities |
|
|
Eating and Swallowing Disorders |
severe dysphagia,
sleep disorders, or cardiopulmonary complications. |
|
Orofacial Growth
Abnormalities and Dental Malocclusion |
Hypertrophy causing dental malocclusion or adversely affecting oral-facial
(mouth-face) growth documented by orthodontist. |
|
Failure to Thrive |
|
|
Streptococcus Carriers |
Chronic or recurrent
tonsillitis associated with the streptococcal carrier state and not
responding to beta-lactamase-resistant
antibiotics. |
|
Persistent foul taste
or breath due to chronic tonsillitis not responsive to medical therapy. |
|
INDICATIONS
FOR TONSILLECTOMY (WITHOUT ADENOIDECTOMY)
·
Hemorrhagic Tonsillitis
·
Peritonsillar
Abscess- unresponsive
to medical management and drainage documented by surgeon, unless surgery
performed during acute stage.
Public
health actions required to prevent smoking in teenagers. (10)
·
Forbid advertisements for tobacco
·
Make cigarettes more expensive
·
Prevent sale of cigarettes to children
·
School programme combined with community
and media-based activity
·
Encourage youth participation in sport (provide
alternatives)
School
programme
·
All schools should develop and enforce a
school policy on tobacco use. Policies should prohibit tobacco use
by all students, and visitors during school-related activity.
·
All schools should provide tobacco prevention education
in grades 1 to 12. The instruction should be especially intensive in
junior high school and reinforced in high school.
·
Schools should provide instructions about
immediate and long-term consequences of tobacco use and the reasons
why adolescents say they smoke, and about social influences that
promote tobacco use. Schools should provide behavioural skills for
resisting social influences that promote tobacco use.
·
Improve curriculum implementation and
overall programme effectiveness
P2; Q3:
Write
short notes on:
a)
Immunisation recommendations for a South African
HIV-infected infant. (10)
·
The Revised SA EPI schedule should
in general be followed + at least
REGIME:
Notes:
[] = Incurred at own expense.
The 2008 schedule has Td at 6yrs and
12yrs instead of DT at 5yrs.
·
(The previous 2007 schedule is acceptable
as the revised schedule only came into effect in Feb 2008.)
·
A symptomatic HIV infected neonate
should not be given BCG – it should be deferred. (Nor yellow fever vaccine if
applicable.)
·
Live vaccines must be given with
care.
·
An extra dose of measles at 6 months
may be required, especially if admitted frequently to
·
TIPV instead of TOPV should be
considered
·
Other vaccines that should be given
are:
(HIV uninfected siblings to be fully immunized.)
b)
The causes of macrocephaly
in a 14 month-old child. (10)
1. Increased intracranial pressure:
dilated ventricles, subdural fluid collections, intracranial tumours, benign increased intracranial pressure (pseudotumour cerebri) etc.
2. Thickened calvarium:
Cranioskeletal dysplasias
(e.g. osteopetrosis), anaemias.
3. Megalencephally/Increased
brain substance: familial, syndromic e.g. Sotos syndrome, storage disorders,
leukodystrophies, neurocutaneous
disorders, e.g. Neurofibromatosis.
c)
Typical features of Attention Deficit Hyperactivity
Syndrome in a 7-year-old boy, and the
management thereof. (10)
Features: (DSM IV)
1. Inattention & distractibility features: Fails
to pay close attention to detail, makes careless mistakes, does not finish
tasks, loses or forgets things needed for tasks or homework etc.
2. Hyperactivity features: Squirms, fidgets in seat,
always on the go as if driven by a motor etc.
3. Impulsivity features: Shouts out answers, can’t
wait turn, interrupts etc.
Features should be present in more than 1 setting.
Management:
1.
Non-pharmacological:
·
Obtain collateral information:
Teachers, parents etc.
·
Exclude other mimickers of ADHD.
·
Use DSM IV criteria to Diagnose.
·
Behavioural counselling & educational
interventions.
·
Provide resources & information to parents.
2. Medication – when symptoms impair function:
·
Stimulants: Methylphenidate, (Dextroamphetamine)
are first line treatment. Dose variations may be required to optimise therapy.
Use Teachers & Parents Rating Scales to determine response to medication.
·
Tricyclic antidepressants, Bupoprion, Pemoline, Clonidine etc. second line agents.
·
Follow-Up: Assess relationships, school performance,
check for medication side effects.
d)
Underlying reasons why a child with severe
malnutrition may not respond to treatment. (10)
1.
Decreased intake:
Social, psychological (maternal) reasons – alcohol/drug
abuse/depression, incorrectly mixed formula, poor feeding techniques, child
neglect/abuse/poor parent-child interaction, cerebral Palsy/neurological
problems.
2.
Excessive losses: Chronic/intermittent diarrhoeal
disease, vomiting, GORD.
3.
Excessive requirements: Chronic disease or illness
e.g. Malabsorption, cystic fibrosis, thyroid disease,
adrenal disease, pituitary disease, TB, RVD, chronic lung/cardiac disease,
syndromes e.g. FAS, Genetic diseases,
P2: Q4
Write
short notes on
a.
The management of a teenager who presents with a
depressed level of consciousness and history of alcohol ingestion.
Teenage – age of risk taking
behaviour.
Causes for depressed level of
consciousness related to behaviour
Alcohol
Other
substance abuse
Trauma
Unrelated medical causes for
depressed level of consciousness
History – look for behavioural risk
factors 7 medical conditions
Examination – exclude trauma,
substance abuse & other “medical” causes.
Management:
Resuscitate &
stabilize according to clinical condition
Baseline investigations
according to history & examination
Basic observations
Monitor glucose
IVI dextrose infusion
Further management in
line with clinical findings & investigations
NB once over acute state refer to social worker or psychologist.
b.
Discuss the implications of the Children’s Act (Act
38 of 2005) on ages of capacity and consent.
Capacity: Age of majority reduced from 21 to 18
Implications
for all common law contracts
Working age redeuced to
<15 for certain work within specific restrictions – adverts, sport, artistic
& cultural activities.
Consent: Medical treatment 12 years with sufficient maturity
& mental capacity
Surgical
treatment 12 years with
sufficient maturity & mental capacity
With
assistance of parent / guardian
Contraception 12 years with appropriate medical advice
Condoms 12 years
HIV
test & disclosure 12 years &
< 12 years if mature enough
Adoption 10 years
c.
“Poverty has the single greatest negative influence
on child health.”
Associated with Lack of income
Lack
of access to resources
Lack of opportunities
Social
exclusion
Powerlessness
Lack
of security
Vulnerability
Associated with increased
demands on individual, household & community with reduced coping capacity.
Leads to poor social
circumstance, poor education, poor health care & failure to achieve full
human development potential.
d.
The indications for, and delivery of, oxygen therapy
in children.
Indications: clinical Cyanosis
Grunting
Severe respiratory distress
Feeding difficulties
Unable to talk
SpO2 < 90%
ABG – PaO2 < 10
Delivery: Nasal
prong / canulae O2 0,5 – 2 l/min
Head
box
Face
mask
Nasal
CPAP
IPV
Must
monitor delivery - clinically, SpO2 and ABG
P2;
Q5:
a) There is an outbreak of diarrhoea in the paediatric ward of your
b) Discuss the aetiology and management of infantile colic. (10)
c) Discuss
your approach to a 6-year-old presenting with recurrent vulvovaginitis
(10)
d) Outline your approach to an 8-year-old girl who has failed Grade 1 for a
second time. (10)
Answers:
a)
§
Notify infection control and/or superintendent and/or
senior doctor(1)
§
Try to identify source case: 1st affected(1)
§
Send cultures of stool of source and other cases:
bacterial and viral(1)
§
Try to isolate infected and non-infected children in
separate wards/parts of the ward(1)
§
Re
§
Look into other potential sources of infection e.g.
milk from milk kitchen and storage, shared utensils etc(1)
§
Manage individual cases of diarrhoea: hydration
checks/extra fluid, zinc, antibiotics if necessary etc(2)
§
Notify if necessary(1)
b) Aetiology(5)
Management
c)
Possible causes(3, ˝ each cause):
Approach:
d) Possible causes(often multifactorial):Triad: school system, parents and home
circumstances and the child
1.
The school system(2)
a.
Poor school attendance e.g. recurrent
b.
Poor physical conditions e.g. overcrowding
c.
The teachers e.g. large student allocations, poor
teaching methods, poor pupil teacher relationships, absent teachers
2.
Parents and Home(1)
a.
Inappropriate expectations
b.
Poor home circumstances e.g. substance abuse, marital
conflict, inappropriate discipline, absent parents
3.
The child(3)
a.
Physical wellbeing e.g. epilepsy, vision, hearing,
chronic illness
b.
Psychosocial wellbeing e.g. affective disorder, ADHD,
school phobia/refusal, hungry, deprived, not school ready
c.
Intellectual and educational development e.g. low
intelligence, FAS, gifted(boredom), specific learning disability(reading,
dyslexia, mathematical)
Therefore
Approach:
P3; Q1:
An infant weighing 1.3 kg is born
vaginally with Apgar scores of 8 and 9 at 1 and 5
minutes respectively. The infant is noted to have “respiratory distress”. His respiratory
rate is 70/min and he is grunting. His
mother had an uneventful pregnancy but did not “book” at a clinic.
a)
How would you assess the infant’s gestational
age? (1)
b)
List THREE physical (external) criteria used to
evaluate an infant’s gestational age. (3)
c)
List THREE differential diagnoses for the
“respiratory distress” other than hyaline membrane disease.
(3)
The infant’s gestational age is
estimated to be 30 weeks. She is thought to have hyaline membrane disease.
d)
Describe the natural history of hyaline membrane
disease. (3)
Tends to worsen over 72hrs with increasing oxygen
requirements before slowly improving over several days. Untreated, hypoxia
worsens with increased work of breathing being demonstrated with recession and
grunting, apnoea from exhaustion and possible death. Gradual resolution occurs over several days
but chronic lung disease may result with prolonged oxygen therapy required.
e)
Describe the pathophysiology
of hyaline membrane disease.
(4)
Type
2 pneumocytes affected – decreased Surfactant
production – lamellar bodies - increased surface tension in alveoli - more atelactasis/hyperinflated alveoli – hyaline membrane
(debris of proteinaceous material etc.) decreased
compliance etc. – hypoxia and hypercarbia due to poor
gas exchange.
f)
List THREE likely findings on the chest X-ray of this
baby. (3)
1. Small lung fields.
2. White-out” of lung fields.
Symmetrical “ground glass appearance”.
3. Air-bronchograms
that extend beyond the heart borders.
g)
Describe SEVEN key principles in the management of
this infant. (7)
The infant is noted to be jaundiced
on day 2 of life; the total serum bilirubin is 183 µmol/l (conjugated fraction 5 µmol/l).
h)
What are the possible causes of the jaundice and
outline your management?
This is unconjugated hyperbilirubinaemia and needs investigation and management
as it significantly elevated within 24hrs of birth.
Causes:
(5)
On day 5 the infant is noted to have
bounding pulses, a gallop rhythm, a loud systolic murmur and an enlarged liver.
i)
What is the likely problem? (2)
PDA and cardiac failure.
j)
How would you manage this new problem in the
infant? (3)
The mother’s blood results come back
as RPR positive.
k)
How would you manage the mother and the infant in
this regard? (3)
Mother: Needs Bicillin X 3
doses. (Partner needs treatment as well.) Exclude other STI’s
(HIV VCT).
Infant:
1. If the infant is asymptomatic and the mother
“fully treated” (3 doses of Bicillin, with last dose
> 1 month before delivery), then no specific treatment is required.
2. If the infant is asymptomatic and the mother is
not fully treated (3 doses of Bicillin with last dose
> 1 month before delivery), then the infant should receive a single dose of Bicillin 50000 iu
IM.
3. If the infant is symptomatic for congenital
syphilis, then the infant should receive 10 days of Penicillin treatment:
Procaine or Soluble (esp. if meningeal signs). NOTIFY
infant.
(A titre could be done: A four-fold increase over
mother’s titre is a strong sign of congenital syphilis and requires full
treatment.)
The infant is discharged 33 days
after birth.
l)
What follow-up arrangements should be made for this
infant at discharge?
(3)
·
A discharge letter must be provided.
·
Regular clinic follow-up to ensure weight-gain, baby
well, continuation of vitamins and vitamin D, deal with any maternal
issues/concerns, vaccinations etc.
·
Neurodevelopmental follow-up due to
prematurity at ~ 18 weeks.
·
Cardiology review to ensure PDA is closed or closing
if on therapy or if needs further intervention eg.
Surgery to close PDA. etc.
·
Audiology for neonatal hearing screening test: (At
risk: Diuretics, prematurity, jaundice etc.)
·
Ophthalmology: At risk of ROP due to prematurity and
oxygen therapy.
[40 Marks]
P3; Q3:
You are the new
medical officer at a
a)
List SIX possible underlying reasons for the high
incidence of diarrhoeal disease in this community. (3)
Low Breast feeding
No/limited potable
water supply
Poor sanitation
Flies
Waste disposal poor
Poor personal hygiene
(hand washing)
Malnutrition
HIV
Accept others
b)
What would be the THREE main underlying medical
reasons for diarrhoeal deaths in this area? (3)
Dehydration- acute
diarrhoea
Dysentery – bloody
diarrhoea (shigella infection)
Persistent diarrhoea –
associated with malnutrition
c)
As a doctor, describe TEN things that you could do to
reduce the morbidity and mortality associated with diarrhoeal disease in the
area. (10)
Promote breastfeeding
– exclusive for 6 months
Health education –
safe water, hand washing, hygiene, fly control
Promote use of ORS
–e.g. ors corner at clinic
Management of
dehydration, early recognition of danger signs
Antibiotics for bloody
diarrhoea
Persistent diarrhoea
management
Immunisation – to
prevent measles or rotavirus
Ensure safe storage of
food and adequate reheating
Micronutrient
supplementation - promote prophylactic vitamin A, zinc
Advice community on
projects, motivate for better water/sanitation/garbage disposal
d)
List SIX likely explanations for the high prevalence
of childhood malnutrition.
(3)
Breast feeding –poor
exclusive feeding, duration
Early change to
formula/ cereals/ mixed feeding
Poverty/unemployment - food
insecurity
Complementary feeding
(frequency/variety/quality/volume)
High infection rates –
diarrhoea, pneumonia, otitis, HIV/TB
High number of LBW or
IUGR babies
Poor parental
education
High number of orphans
(parental death)
Family disruption-
substance abuse, HIV, migrant labour,
Accept others
e) Describe FIVE interventions (each) that could
be instituted in the context of the Integrated Nutrition Programme to reduce
the high malnutrition rate in this community at the:
i)
Community, and (5)
ii) Clinic level (5)
Community
Promote breastfeeding
Health education -
weaning diets,
Personal hygiene and
food preparation
Child support grant
Water and sanitation
Economic aid
Food fortification
Employment
Communal gardens/
farming
Female empowerment
School feeding
Get help of
traditional healers 1/2
Clinic
Growth monitoring
Food supplementation
Treat infections
Deworming
Immunisation
Better clinical
management of severe malnutrition (referral)
Prevent MTCT of HIV
Nutrition centres
Nutrition
counselling and micronutrient supplementation.
M J Manary1, M J Ndkeha2, P Ashorn3, K Maleta2, A Briend4
Background: The standard treatment of severe
malnutrition in
Aims: To test the hypothesis that the recovery rate,
defined as catch-up growth such that weight-for-height z score >0
(WHZ, based on initial height) for ready-to-use food (RTUF) is
greater than two other home based dietary regimens in the treatment
of malnutrition.
Methods: HIV negative children >1 year old discharged from
the nutrition unit in
Results: A total of 282 children were enrolled. Children receiving RTUF were more likely to reach WHZ >0
than those receiving RTUF supplement or maize/soy flour (95% v
78%, RR 1.2, 95% CI 1.1 to 1.3). Intention
to treat analyses also showed that more children receiving RTUF reached
graduation weight than those receiving RTUF supplement or maize/soy (86% v 66%,
20% difference, 95% CI 8% to 33%). The average weight gain was 5.2 g/kg/day in the
RTUF group compared to 3.1 g/kg/day for the maize/soy and RTUF supplement
groups. Six months later, 96% of all children who
reached graduation weight and returned for follow up, had normal anthropometric
indices
Abbreviations: MUAC,
mid-upper arm circumference; NRU, nutritional rehabilitation unit; RTUF,
ready-to-use food; WHZ, weight-for-height z score.
f)
What
type of study design was used? (1)
Randomised controlled trial
g)
What
was the main study outcome? (1)
Recovery rate, defined
as catch-up growth such that weight-for-height z score >0 (WHZ,
based on initial height)
h)
How
would you interpret a weight-for-height z-score of 0 and -1? (2)
A z-score of 0= the mean
for the sample
A z-score of -1= -1
standard deviation from the mean
i)
How
would you interpret the relative risk of 1.2 in the statement “Children
receiving RTUF were more likely to reach WHZ >0 than those
receiving RTUF supplement or maize/soy flour (95% v 78%, RR
1.2, 95% CI 1.1 to 1.3).”? (1)
Children receiving RTUF
were 1.2 times more likely to reach WHZ>0
j)
How
would you interpret the 95% confidence interval of 1.1 to 1.3 in the same
sentence? (1)
If the study were repeated
a 100 times, in 95% of instances the relative risk would lie between 1.1 and
1.3
k)
Was
this difference statistically significant? Explain. (1)
Yes, 95%CI does not include
1
l)
What
statistical test would you use to decide if the average weight gain in the RTUF
group was significantly different to the maize/soy and RTUF supplement
groups? (1)
Student t-test
m)
What
would your conclusion be about managing children with severe malnutrition at
home, based on this study? (3)
HIV negative children >1
year old discharged from a nutrition
unit benefit from the use of RTUF more than other supplements, and can be
expected to maintain normal anthropometric indices six months after discharge
if maintained on RTUF.
[40 Marks]
P3: Q4:
A
21 year old HIV +ve woman, who has attended antenatal
clinic four times, presents to your
General care of LBW baby – warmth, oxygen, fluids
(preferably oral feeds), routine observations
Management of HIV exposure NVP & AZT
Implement
preferred feeding choice
Informed choice by mother
Based on AFASS – acceptability, feasibility,
affordability, safe, sustainable
Breast Own normal
Own
pasturised
Pooled
(bank)
Formula
Healthy mom & social circumstances
Well infant – no problems, immunizations completed
etc
Feeding established and baby gaining weight
PMTCT treatment prescribed & dispensed
Follow up arrangements completed
After
delivery the mother is transferred to the medical wards but dies two days after
her baby is born. The social worker is unable to trace any family members.
Adoption: permanent
Holistic
care
Family setting – addresses physical,
social & emotional needs
Foster care: Holistic care
Family setting – addresses physical,
social & emotional needs
Temporary
Risk of neglect, exploitation, abuse
Institutional care addresses physical & possibly
social needs
Emotional
& behavioural problems
Risk of
neglect, exploitation & abuse
Require children’s court enquiry
Facilitated
by social worker
Declare
baby as child-in-need
Report
of investigations into circumstance – social worker & SAPS
Recommendation
re placement
Monitor
placement
Comprehensive medical examination
Basic screening HIV,
WR, Hepatitis B,
Thyroid
function tests
Urinanalysis
Exposed baby
PMTCT NVP &
AZT
Formula
feeds
Confirm diagnosis PCR at 6 weeks
HIV- not infected, no further follow up re HIV
status
HIV+ infected – comprehensive care plan
Normal
care of infants – ie growth monitoring, immunization
etc
Cotrimoxazole prophylaxis
Nutritional
supplements
Follow
up:
clinical monitoring of growth,
development and well being
immune status CD4 count
LBW infant Growth
developmental problems
Monitoring
& supplements
HIV exposed Progression
to AIDS with all the associated complications
Comprehensive
care plan
Monitoring
– clinical, immunological & virological status
Prophylaxis
Supplements
Early
management of inter-current problems
Early
initiation of ART
Surrogate care emotional
& behavioural problems
neglect, exploitation &
abuse
Monitor placement
P3; Q5
Sipho is a 9 month-old boy who was born at home and has never
attended a health facility in his life; he has been referred by the clinic
sister with a history of fever, vomiting and irritability for 2 days. She
thinks he may have meningitis.
a)
Complete the following table concerning the usual
causative agents by age for bacterial meningitis. (5)
|
Age
Group |
Causative
organism |
|
0
– 3 months |
Group
B Strep |
|
E
Coli and other coliforms |
|
|
Listeria monocytogenes |
|
|
|
|
|
4
months – 5 years |
Pneumococcus |
|
H
influenzae |
|
|
Meningococcus |
|
|
MTb |
|
|
>
5 years |
Meningococcus |
|
Pneumococcus |
|
|
MTb |
|
|
Haemophilus influenzae |
b)
List THREE predisposing factors for bacterial
meningitis. (3)
-Respiratory infections 1
mark each
-HIV infection and other
immunodeficiency states
-Otitis
media
-Mastoiditis
-Head trauma
-Haemoglobinopathies
- fracture cribriform
plate
-myelomeningocoele
-VP-shunt
c)
Outline the pathogenesis of bacterial meningitis in
point form. (4)
– Pathogen colonises the mucosal epithelium
-
enters the blood stream
-
it then crosses the blood brain barrier
-
survives in the CSF
-
host immune response leads to inflammation of the meninges
-
disruption of the blood brain barrier: cellular and
cytokine (e.g. IL-1 and TNF) infiltration leading to capillary blockage and
leak and obstructed flow
-
oedema and increased intracranial pressure
-
infarcts
-
encephalopathy and other symptoms
d)
Lumbar puncture is considered the most important
early diagnostic test for meningitis. List TWO contraindications to the
performance of this test. (2)
·
Space demanding lesion
·
Signs of significantly raised intracranial
pressure(depressed LOC, Cushing’s triad, papilloedema,
posturing)
·
Focal signs
·
Skin sepsis at the puncture site
·
Uncorrected coagulopathy
·
Acute spinal trauma
There were no contraindications to
lumbar puncture. His CSF result is as follows:
Polymorphs 680 / mm3
Lymphocytes 110 / mm3
Protein 0.98 g/dl
Glucose 2.0 mmol/l
Gram
stain negative
Culture
negative at 72 hours
e)
List three differential diagnoses that should be
considered other than bacterial meningitis: (3)
Partially treated bacterial
meningitis
TBM
Cryptococcal
meningitis if immunocompromised
Viral meningitis e.g. mumps
Neighbourhood syndrome e.g. tumour,
CNS leukaemia, abscess
Other
f)
Sipho’s serum sodium is measured
as 119 mmol/L. This is
attributed to a syndrome of inappropriate anti-diuretic hormone (SIADH). List
FOUR possible symptoms associated with this syndrome. (2)
Any: loss of appetite, nausea,
vomiting
Headache,
malaise, lethargy
Confusion,
combativeness
Irritability
Muscle cramps
Coma
Convulsions
Death
g)
Briefly outline the management of Sipho’s
SIADH.
(2)
·
Treat the cause (meningitis) and maintain cerebral
perfusion.
·
Correct sodium and water imbalance
·
Asymptomatic: restrict fluids to 50-60% normal
requirements
·
Symptomatic: hypertonic saline (3%) careful infusion
to raise serum sodium at 0.5mmol/hour; monitor serum sodium levels and urine
output.
h)
You interpret the CSF result as indicating that Sipho most likely has bacterial meningitis. Discuss Sipho’s immediate management. (5)
Untreated bacterial meningitis leads to 100 %
mortality:
·
Manage as a medical emergency (ABC)
·
Rapid treatment to minimise damage
·
Initially with empiric antibiotic therapy based on
local/national guidelines(Ceftriaxone would be the
first choice)
·
Review with laboratory results to optimise targeted
therapy
·
Complete recommended courses
·
Provide supportive and adjunctive care e.g. steroid
therapy prior to antibiotic use, reduce intracranial pressure, maintain
cerebral perfusion with appropriate fluid therapy, and provide adequate
analgesia and nutrition.
·
If indicated timely neuroimaging
to detect and manage complications e.g. hydrocephalus, subdural
i)
Discuss the use of steroids in the management of
meningitis. (2)
·
Antibiotic therapy accelerates bacterial death
leading to the release of bacterial cell-wall products into the CSF further escalating
the release of inflammatory cytokines, inflammatory response and increased
intracranial pressure.
·
A frequent sequela
associated with meningeal inflammation is sensorineural hearing loss. Steroids modify the
inflammatory response. Clinical studies have shown steroids to be beneficial in
reducing hearing loss in children with haemophilus influenzae meningitis.
·
No clear evidence exists for meningitis due to
pneumococcal and meningococcal infections.
·
Steroids are also of benefit in tuberculous
meningitis in reducing morbidity
j)
What is the approximate complication rate following
bacterial meningitis in (i) neonates and (ii) older
children.
For
neonatal meningitis the complication rate is quite high –estimated at 30%, for older age groups it is about 10%. (2)
k)
List SIX complications of bacterial meningitis (other
than death) (3)
The complications of bacterial
meningitis include: (max 5 marks - ˝each)
-Rapidly
progressive manifestations of shock and septicaemia (especially with meningococcal meningitis)
-Increased
intracranial pressure resulting in coma and / or herniation
Focal
neurologic signs due to vascular occlusion leading to cranial nerve and stroke
Dural
venous sinus thrombosis
Hydrocephalus
Subdural
effusions
Ataxia
Seizures
early or late (cerebritis, infarction or electrolyte
disturbances)
SIADH
Blindness
Deafness
Mental
retardation
Cerebral
palsy in the vulnerable age group
l)
List
THREE interventions to prevent meningitis in young South African children
(3)
Good nutrition including breast
feeding
Adequate socioeconomic conditions
No overcrowding
Avoidance of environmental exposure
to smoke
Immunisations
Prophylaxis
Avoidance of vitamin and
micronutrient deficiencies
Prevention of acquired
immunodeficiency states
Good maternal education
m)
What are a doctor’s public health responsibilities in
a case of bacterial meningitis? (2)
In the case of meningococcal
meningitis- urgent notification, close contact tracing and administration of
prophylactic antibiotics. The same can probably done for haemophilus influenza meningitis if there are contacts
under the age of 5 years especially if unimmunised. Ensure imunisation.