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Acute flaccid paralysis

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

       Examination
            o Signs of respiratory distress
            o Movement of the chest
            o General signs- e.g clubbing
            o Signs of heart disease
       Investigation
            o CXR
            o Infection screen
            o Peak flow
            o 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
           a. Lack of schooling
           b. Child labour
           c. Poor nutrition
           d. 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
           a. Find relatives first
           b. Fostering
           c. Adoption
           d. 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
            o Onset, duration
            o Associated symptoms
            o ? menarche
            o trauma
            o assault/abuse
            o medication- overdose
            o foreign body
       Examination
            o General health
            o Tanners staging
            o Signs to try to exclude the above
            o May need examination under anaesthesia (depends on other findings)
       Management
            o 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).
2nd line – carbamazepine
3rd 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              Ampicillin iv/ Amoxicillin po high
                                                              dose
                        Or
                                                              or
                        Macrolide po – if suspected M.
                        pneumoniae or Chlamydia spp.          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
             o   Initial diagnosis of a renal or abdominal mass, possible renal vein or inferior vena cava (IVC)
                 thrombus

             o   Information regarding liver and other kidney

        Computed tomography scan of the chest and abdomen

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

             o   Liver metastases

             o   Status of opposite kidney

             o   Lymph node assessment

             o   Status of chest with respect to metastases

        Magnetic resonance imaging

             o   Typically, these tumors appear inhomogeneous when using gadolinium-enhanced MRI
             o   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

				
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Description: Acute flaccid paralysis