Maternal and Child Health

Question 1

• Wiht respect to the newborn, define the following terms:
  
  • gestatoin
    
    • preterm
    • term
    • post term
  • birth weight
    
    • low
    • very low
    • extremely low

Answer 1

• Gestation:
  
  • ​Preterm: <37 completed weeks
  • Term: 37 - <42 weeks
  • Post term: >42 weeks
• Birthweight (BW)
  • Low (LBW): <2500 gm
  • Very low (VLBW) <1500 gm
  • Extremely low (ELBW) <1000gm

Question 2

• Define:
  
  • Neonate, early and late period
  • Infant
  • Toddler
  • Child
  • Adolescent

Answer 2

• Age ranges
  
  • Neonate: 0-28 days
    
    • Early neonatal period: 0-6 days
    • Late neonatal period: 7-28 days
  • Infant: 1-11 months
  • Toddler: 1-3 years
  • Child: <18 years (but varies by country)
  • Adolescent: 10-19 years

Question 3

• What were the top 3 causes of child deaths in 2016?
• Why?
• When do most of these deaths happen?

Answer 3

• The top 3 causes in 2016 were:
  
  • Neonatal causes (first 28 days of life: 46%)
  • Pneumonia (13%)
  • Diarrhoea (8%)
• Progress in reducing deaths in older children, especially due to pneumonia and diarrhoea, has been much better than in neonates. Therefore, neonatal deaths (deaths in the first 28 days of life) now make-up a higher proportion of all under five deaths.
• In the first week of life.

Question 4

What are the most common threats to a healthy childhood?

Answer 4

Look at the Save the Children End of Childhood Report 2017

Stolen childhoods identifies the following 8 major risks to childhood and adolescence:

• under-5 mortality
• malnutrition
• out-of-school children
• child labor
• early marriage
• adolescent births
• displacement by conflict
• child homicide

Question 5

What are the SDGs directly relevant to child health?

Answer 5

Question 6

What are the Take Home Messages in the unit on Global Childe Health?

Answer 6

• Remarkable progress in recent years in improving under 5 survival
• But 5.6m under 5 deaths occurred in 2016 – most in developing countries and most preventable
• Neonatal deaths now 46% of all under 5 deaths and proportion rising (mostly in low birthweight infants)
• Pneumonia and diarrhoea are the leading causes of death after the neonatal period
• “First 1000 days” critical period for improving outcomes for children
• The SDGs set ambitious targets for child survival and nutrition but many countries are unlikely to meet the targets

Question 7

What is this?

Answer 7

• Bitot’s spots are the buildup of keratin located superficially in the conjunctiva, which are oval, triangular or irregular in shape. These spots are a sign of vitamin A deficiency and are associated with drying of the cornea. In 1863, PierreBitot (1822-1888), a French physician, first described these spots.

Question 8

What is this?

What else should one look for in this clinical situation?

Answer 8

• keratomalacia, one of they eye signs of vitamin deficiency
• eye signs of vitamin A deficiency:

– dry conjunctiva or cornea, Bitot spots (below)

– corneal ulceration

– keratomalacia

Children with vitamin A deficiency are likely to be photophobic and will keep their eyes closed. It is important to examine the eyes very gently to prevent corneal rupture

Question 9

What is this?

Describe this condition.

Answer 9

• skin changes of kwashiorkor:

– hypo- or hyperpigmentation

– desquamation

– ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears)

– exudative lesions (resembling severe burns) often with secondary infec- tion (including Candida).

Question 10

How is shock defined in a malnourished child?

Answer 10

• Lethargy/unconsciousness AND cold hands plus either
  
  • slow capillary refill or
  • rapid pulse

Question 11

How are moderate and severe malnutrition and stunting defined.

Answer 11

• Malnutrition
  
  • Severe: Wt:Ht >3 SD below National Centre for Health Statistics reference values or >70% below median or or an MUAC <110 (child 1–5 years)
  • Moderate: Wt:Ht 2-3 SD below or 70-79% below median
• Stunting
  
  • Severe Ht-for-age >3 SD below reference or <85% below median
  • Moderate Ht-for-age 2-3 SD below reference or 85-89% below median

Question 12

• A 23 year old woman is brought to your clinic in rural Malawi by her husband. She has a history of bipolar disorder, manic type, and has had an episode of mania after each of her three pregnancies.
  The couple have heard that medicine can prevent a recurrence of this illness and are asking for a prescription. They say they are likely to have more children.

What is the recommended drug for prophylaxis in this case?

Answer 12

• chlorpromazine
• lithium, carbamazepine, valproate and haldol are all teratogenic

Question 13

• When should a placenta be diagnosed as retained?

Answer 13

• Different authorities provide different cut-off points as to how long should one wait to diagnose a retained placenta. However NICE puts it at 30 min and WHO (which is perhaps the most flexible) at 1 hour. Removal of a retained placenta should be attempted at every level of facility including the basic one. One common and effective method is using pethidine and diazepum; which relieves pain, helps relax perineal muscles and can expedite delivery of the placenta and reduce blood loss. There is no evidence to suggest benefit of using prophylactic antibiotics.
• The reason for not attempting manual removal early is because this has itself been shown to increase the risk of post-partum hemorrhage.

Question 14

How do you define tachypnea in children?

Aged 1-5 yrs?

2-12 months

neonates (0-2 mo)

Adults?

Answer 14

• The agreed rates for tachypnoea per minute are >30/min in an adult, >40/min 1–5 years, >50/min 2–12 months, >60/min when younger than 2 months. Distinguish tachypnoea (increased rate of breathing) from dyspnoea (the distressful conscious necessity to increase the rate/depth of breathing). Tachypnoea >30/minute in an adult, associated with a pulse rate >120/min and/or blood pressure <90 mmHg, points to an acute respiratory crisis.

Simple oximetry is a most useful tool, in such cases, for indicating the use supplemental oxygen.

Question 15

What is diff dx of febrile child with reduced LOC?

Answer 15

Question 16

Carpopedal spasm?

How do you respond?

Answer 16

• Think hypocalcemia
• If non-emergent, give oral calcium gluconate (Tim Dempsey)
• emergent (e.g. septic, reduced loc)
  
  • 0.3 ml/kg 10% ca gluconate
  • repeat if needed

Question 17

• What is the commonest cause of acidosis in critically ill child?
• What clinical findings would support this dx?
• How to manage?

Answer 17

• hypovolemia or shock
• Clinical findings:
  
  • tachypnea
  • tachycardia
  • delayed cap refill, cold peripheries
  • reduced or poor per pulse volume
  • hypotension
  • clinical signs of dehydration
• Manage
  
  • whole blood & reevaluate
  • fluids & reevaluate
    
    • 20 ml/kg rl or ns
    • mainenance eg dex/sal at 4 ml/kg/hr

Question 18

Differential dx of Febrile child with a rash

Answer 18

• bacterial: meningococcus, pneumococcus, scarlet fever
• Viral: measles, rubella, parvovirus, adenovirus, HHV6, enterovirus, paraechovirus
• Parvovirus B19: fifth disease, slapped cheek syndrome

Question 19

What is the FANC?

Answer 19

• 2001 WHO model for antenatal care
  
  • 4 visits
    
    • before 16 wks
    • 24-28 wks
    • 32 wks
    • 36 wks
• supplanted by WHO 2016: Positive Pregnancy Experience

Question 20

What were the main recommendations for Antenatal Care made in the WHO 2016 Policy:

Positive Pregnancy Experience

Answer 20

• FANC 8
  
  • first visit 12 wk gestn then
  • 20, 26, 30, 34, 36, 38, 40
• Context-spec rec re Maternal assessment
  
  • Anemia: CBC or Hgb to dx
  • Assymptomatic Bacteriuria Dx with urine culture or if n/a then microscopy over dipstick
  • Int Part Violence: Inquire where able
• Gest DM - class hyperglycemia as GDM or DM in preg
• Tobacco - screening for past & present exp to first and 2nd hand smoke
• Substance Use
• HIV: PITC - Provider Initiated Test and Counselling, STD testing
• TB: if prev > 100/100,000 screen in ANC (cs)
• Fetal Assessments
  
  • ​abd palp or SFH for fetal assessment (cs)
• Health Systems Interventions
  
  • woman-held case notes rec
  • midwife-led cont care where systems in place and working (cs)
    *

Question 21

What is Perinatal Death Rate

Answer 21

• deaths from 28 wks gestation to 1 wk old/# live births

Question 22

What is a stillbirth?

How many globally per year.

What is the Stillbirth Rate in SSAfrica.

What stilbirth rate for every country is the WHO “Every Newborn Action Plan” target for 2030?

Answer 22

• death after 28 wk gestation
• 2.6 Million Stillbirths/yr
• Africa SB rate is about 30/yr
• ENAP Target SBR is 12/1000 by 2030

Question 23

What is an early neonatal death?

What is a late neonatal death?

How Many Neonatal Deaths/Yr globally?

Answer 23

• death before 7 days
• death from 7-28 days
• 2.8 million

Question 24

Perinatal Mortality Rate

Answer 24

• deaths from 28 wk gestation to 1 wk old/# of births

Question 25

Global Burden of Maternal Mortality

How many maternal deaths per year?

Compare MMR SSA & HIC:

/100,000 live births

Life Time Risk

Answer 25

• 303,000 Mat deaths/yr (WHO 2015)
• /100,000LB: SSA 239 to HIC 12 (20x)
• LTR: SSA 1/36 to HIC 1/4900 (136x)

Question 26

Define:

1. Maternal Mortality
2. Late Maternal Death
3. Preg-related Death

Answer 26

1. Death of a woman:
   
   • while pregnant or within 42 days after termination of pregnancy
   • irrespective of the duration and the site of the pregnancy
   • from any cause related to or aggravated by the pregnancy or its management
   • but not from accidental or incidental causes
2. Deaths cased by direct or indirect obstetric causes >42 days but <1 yr after termination of pregnancy
3. Deaths while pregnant or within 42 days of termination of pregnancy irrespective of cause

Question 27

Define the Maternal Mortality Ratio (MMR) and give equations relating it to the Maternal Mortality Rate

What are the weaknesses of the MMR.

Answer 27

• Maternal Mortality Ratio (MMR) - number of maternal deathe in a given time period per 100,000 live births during the same period
• MMR = # mat deaths/#live births x 100,000
• or
• MMR=MMRate/General Fertility Rate (GFR)
• or
• MMR=1(1-LTR)^1/TFR
• MMR expresses ‘obstetric risk’ - reflects only the risk of death once pregnant
• Weaknesses
  
  • ​misses cumulative mortality with # of preg
  • preg not producing live birth excluded in denominator
  • hard to measure
  • narrow focus on mortality and misses complications and disability

Question 28

Define Maternal Mortality Rate (MMRate)

What does it indicate?

Weakness?

Answer 28

• # of mat deaths in a given period per 1000 women of reproductive age during the same time period
• MMRate = # mat deaths/# WRA x 1000
• MMRate = MMR x GFR
• MMRate = 1(1-LTR)^1/35

(WRA=Wom of Rep Age; GFR=General Fert Rate; LTR=Lifetime Risk; MMR=Mat Mort Ratio)

• Indicates burden of maternal death in rep age female popn - captures both risk of death per preg or per total birth (inc live and still births)
• Weakness: conceasl the effects of different levels of fertility

Question 29

Define Lifetime Risk (wrt death related to pregnancy)

Answer 29

• reflects the prob of a woman dying from mat causes over course of reproductive lifespan
• LTR = 35 x MMRate
  
  • = 1-(1-MMRatio)^{<span>TFR</span>}
  • = 1-(1-MMRate)³⁵
• takes into account the probability of death tdue to maternal causes each time a woman becomes pregnant (MMR & TFR)

Question 30

Define Proportion of Maternal Death among Death of Females of Reproductive Age (PDMF)

How does this compare in High Income and LM Income Countries?

Answer 30

• = # maternal deaths in a period/# women aged 15-49 yrs in same period
• Range is <1% in many HIC
• Up to 45% in LMIC

Question 31

Why do Mothers Die?

What is the current Global MMR?

What is the WHO SDG ‘Saving Mothers’ Lives’ Global Goal for 2030?

Answer 31

1. Hemorrhage 27%
2. Indirect Causes - diabetes, hypertension, anemia, malaria, HIV, TB etc. 27%
3. Hypertension 14%
4. Sepsis 11%
5. Abortion 8%
6. Embolism 3%
7. Other direct causes 10%

• Current Global MMR 216/100,000 LB
• SDG Goal <70 by 2030

Question 32

• What are the steps for a Maternal Death Audity?
• Having collected data for Maternal Death Review (registers, all available records and confidential interviews with families and HW’s), briefly outline remaining steps

Answer 32

1. Identify cases
2. Data Collection
3. Analysis of Findings
   
   • team meeting to review
   • quantitiative analysis to identify trends looking at time of death, partographs, mode of delivery
   • qualitative to identify factors and barriers to care. 3 delays model to identify arease where quality of care substandard
   • establish cause of death
4. Recommendations & Action
   
   • SMART: Smart, Measurable, Achievable, Realistic and Time Bound goals
   • what went well
   • action points for 3 priority areas
   • champions/coaches to improve
5. Evaluation and refinement

Question 33

What are the main causes of maternal deaths and the key interventions that could prevent them?

Answer 33

Question 34

What is EmOC?

Answer 34

• Emergency Obstetrical Care: A package of medical/surgical interventions required to treat the seven major direct obstetric (and neonatal) complications.
  
  1. Hemorrhage
  2. Pre-eclampsia or eclampsia
  3. Sepsis
  4. Obstructed labour
  5. Ectopic Pregnancy
  6. Ruptured uterus
  7. Newborn Distress

Question 35

What are the Signal Functions for EmOc?

(7 Basic and 2 comprehensive)

Answer 35

Question 36

What are the 6 UN process indicators for EmOC?

Answer 36

Question 37

Addressing the 3 delays in EmOC affecting pregnancy outcome and what factors may influence them?

Answer 37

Question 38

Hypertensive Disorders in Pregnancy:

• Differentiate between
  
  • chronic hypertension
  • pih
  • pre-eclampsia superimposed on ch
  • pre-eclampsia
  • eclampsia
• define proteinuria for pre-eclampsia

Answer 38

• proteinuria>300 mg in 24 hr urine
• Pr:Cr ratio >0.3 when dipstick > 2+
• in absence of proteinuria HELLP syndrome dix pre-eclampsia

Question 39

Outline the management of Eclampsia?

In case of continuing seizures in spite of 1st line tx then what?

Answer 39

• see diagram
• for seizure MgSO₄
  
  • _​4 g iv over min 5 min or 10 gm IM then maintenance 1 g/hr or 2.5 gm q 4 prn im use LIVKAN chart to monitor vitals, tdr’s, u/o for safety
  • Ca gluconate 1 gm IV (10ml10%10min) antidote in case of areflexia or resp depression
• fetal brady for 3-5 min after seizure common, not emergent
• control BP
  
  • hydrazine 5 mg bolus iv q 30 min
  • labetolol 10-20 mg iv psh rpt q 10-20 min with doubling dose to max 80 mg
  • oral nifedipine
• evaluate for delivery
• In case of continuing seizures 2 gm IV more MgSulf or increase infusion or give
  
  • thiopentone
  • phenytoin
  • diazepam

Question 40

Define SIRS.

Answer 40

• •Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F) •Heart rate of more than 90 beats per minute
• •Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension
• (PaCO 2) of less than 32 mm Hg
• •Abnormal white blood cell count (>12,000/μL or < 4,000/μL or >10% immature [band] forms)
• The Society of Critical Care Medicine (SCCM), March 2015 USA

Question 41

Causes of fever during pregnancy.

Causes of fever after delivery.

Answer 41

• Causes of fever during pregnancy.
  
  • UTI/Pyelonephritis
  • Septic abortion
  • Chorioamnionitis
  • Chest infection
  • Malaria
  • Typhoid or non typhoid salmonellosis
  • Hepatitis
  • Meningitis
  • Phlebitis
  • Other: TB, HIV, appendicitis etc
• Causes of fever after delivery
  
  • Puerperal sepsis
  • Endometritis, pelvic cellulitis, pelvic abscess, peritonitis
  • Wound infection after CS
  • UTI/Pyelonephritis
  • Malaria, enteric fever
  • Pneumonia
  • Mastitis, breast abscess
  • Phlebitis

Question 42

How many maternal deaths in 2015?

What was MMR (Maternal Mortality Ratio?)

What proportion of global births attended by skilled health personel?

Answer 42

• 303,000
• 210 deaths/100,000 live births (2013)
• 71%

Question 43

What are the 5 Goal 3: Good Health & Well Being targets for SDG wrt Maternal and Child Health.

MMR?

neonatal mortality?

under 5 mortality?

Answer 43

1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
3. By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes
4. Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all

Question 44

What percentage of pregnancies in Sub-Saharan Africa occur in girls 15-19 yr old?

Answer 44

• 35%

Question 45

• What is Quality in Health Care?
• What are the 7 Pillars to operationalize this concept for pregnant women and newborn according to WHO.
• Tools for quality?

Answer 45

• “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice”

Institute of Medicine 2001

• Health care should be:
  
  1. Safe
  2. Effective
  3. Timely
  4. Efficient
  5. Equitable
  6. People-centred
• Tools
  
  • Maternal death audit/review
  • Maternal death Surveillance & Response
  • Perinatal death audit/review
  • Standards based audits

Question 46

• Diff Dx for genital bleeding in early pregnancy?
• (Organize by
  
  • Upper - Uterus & amniotic sac
  • Middle - Cervix or vagina
  • Lower - Bladder, anus or vulva

Answer 46

Question 47

Algorithm for management of suspected Ectopic preg in resource poor setting?

Answer 47

Question 48

What is the risk of recurrence of ectopic pregnancy in the next pregnancy?

Answer 48

• 10-17%

Question 49

• Incidence, presentation, US appearance of Molar Pregnancy.
• What is risk of malignant change?
• Post evacuation management?
• Management of malignancy?
• Cure Rate?

Answer 49

• risk of malig change 1/10
• f/u serial preg tests
• avoid preg for 12 mo (at least 6 months of normal HcG levels)
• if preg test pos and not pregnant suspect recurrence and do full involvement inc cxr & rpt evacuation
• Malignancy (Gest Trophoblastic Dis) tx with methotrexate, very good cure rate.

Question 50

Outline Management of miscarriage

Include dosage of med.

Answer 50

• wait and watch ok if pt can remain under observation or lives nearby with no transport difficulties
• Manual Vaccuum Aspiration is preferred surgical method, no need for anesthetic, safe and effective
• Misoprostol if available, under observation. Watch pt swallow or insert it yourself PV
• Dosage 6-800 mcg
• Evacuation of retained prod of conception (ERPC) risk perforation and need anesthesia, but good if all else fails or not available
• Beware risks of septic abortion, heavy bleeding
• should wait at least 2 weeks before conception

Question 51

List the complications of unsafe abortion

Answer 51

• sepsis
• peritonitis
• hemorrhage
• poisoning
• uterine, cervical or vag injury
• visceral injury
• psych. damage
• infertility

Question 52

Medical options for treatment of abnormal uterine bleeding.

Answer 52

• (GnRH analogues eg Lupron, Zoladex are Gonadotropin Releasing Hormone)

Question 53

What are risk factors for Cervical Cancer?

How many women die each year from Cervical Cancer (2015)?

Answer 53

• 270,000, nearly as many as maternal deaths (303,000)

Question 54

How does HIV influence the incidence and progression of Cervical Cancer?

Answer 54

• occurs in younger age group
• more aggressive, progresses and metastasizes more rapidly
• twice as frequent as HIV -ve
• happens at highter CD4 than Kaposi’s sarcome and other HIV-related cancers

Question 55

What strains of HPV are targeted by HPV vaccines?

Answer 55

• Cervarix - HPV 16&18 prevents 70% cervical ca
• Gardasil ( + 6, 11)
• Gardasil 9 (+5 more: 31, 33, 45, 52, 58) Prevents 90%

Question 56

What is the commonest site for ischemic injury and Vaginovescular Fistula due to obstructed labour?

Answer 56

• junction of bladder and urethra

Question 57

Female Genital Mutilation

Classification

Answer 57

• Type 1: part or all of clitoris removed
• Type 2: clitoris and part or all of labia
• Type 3: infundibulation - above + bringing together labia majora to cover urethra and most of vag opening

Question 58

• Female Genital Mutilation

1. How many girls alive today have been mutilated?
2. Which countries have highest rates (>80%)
3. In which countries are >1/2 of procedures performed by medical professionals?

Answer 58

1. 200 million
2. Somalia, Egypt, Sudan, Mali
3. Sudan, Egypt

Question 59

Legal status of FGM

• 1993 Vienna World Conference on Human Rights did what?
• legal status in countries where practiced?

Answer 59

• VWC
  
  • classified FGM as form of violence against women
  • acknowledged that it fell under the purview of international human rights law
• 24/29 enacted decrees or legislation concerning FGM

Question 60

Surgical Repair of FGM?

Answer 60

• defibulation and clitoral repair
• positive effect on pain and sexual arousal

Question 61

• WHO position on FGM
  
  • Guiding principles?
  • Recommendations

Answer 61

• Guiding Principles
  
  1. harmful practice, victims should have quality health care
  2. all stakeholders should work towards prevention
  3. medicalization (perf by hc providers) never acceptable
• Recommendations
  
  • deinfibulation for prevention and tx of obstetric complications due to type 3
  • antepartum or intrapartum deinfibulation
  • for prevention and tx of recurrent uti and retention
  • CBT for psych probs

Question 62

Placenta Previa

• how common?
• role of cervical cerclage?
• general principles?

Answer 62

• common, about 0.5% of deliveries, usually undiagnosed
• reduced risk of delivery before 34 wks GA
• admit or refer, generally conservative approach

Question 63

Placental Abruption

• how presents?
• how common?
• how serious?
• Management:

Answer 63

• usually painful bleeding
• less common than previa, about 6.5/1000 preg
• >10 x perinatal mortality
• Management
  
  1. Deliver to avoid DIC
  2. Blood (fresh)
  3. Analgesia
  4. Mother
  5. Fetus

Question 64

• Post Partum Hemorrhage
• Definition?

Answer 64

• Def
  
  • blood loss >500 ml for SVD and >1000 mls for CS delivery
  • may be less if anemia or small stature: any amount leading to CV compromise

Question 65

PPH Prevention

• How? (rec of FIGO, ICM, WHO)
• Active Management of third stage of labour (AMTSL)
  
  • durg alternatives?
• Role and effects of controlled cord traction
  
  • what does it do and not do?

Answer 65

• how?
  
  • give utertonic drug within 1st minute of birth
  • clamp and cut cord
  • controlled cord traction
  • =/- rubbing uterus q 15 min for first 2 hr
• AMTSL
  
  • decreases incidence of PPH by 68%
  • oxytocin by 40% (NNT=12)
  • Misoprostol sl less effective (NNT=18) but cheap, heat and light stable, no syringe
  • recommended dose 6-800 mg
  • advance community distribution of misoprostol not recommended as more risks than benefits
• Controlled Cord Traction
  
  • reduces
    
    • ​duration of 3rd stage
    • incidence of PPH
    • risk of retained placenta
  • no effect on
    
    • incidence of severe PPH
    • need for blood transfusion

Question 66

Post partum hemorrhage

• how common is it?
• how many deaths?
• Common causes?

Answer 66

• about 10% of all deliveries
• 130,000 deaths per year
• Common causes 4 T’s
  
  • Tone 70%: uterine atony
  • Trauma 20%: lacerations, hematomas, inversion, rupture
  • Tissue 10%: retained tissue, invasive placenta
  • Thrombin 1%: coagulopathies

Question 67

Post-Partum Hemorrhage: Management

• Physical Management: how?
• Uterotonics?
• Antifibrinolytic?
• Surgery?

Answer 67

• ensure bladder empty
• Compression minimum 5 minutes
  
  • bimanual compression of uterus or
  • aortic compression
• Uterine Balloon Tamponade (UBT)
  
  • if no response to uterotonics or uterotonics not available
  • temporary measure while transfer or referral
  • success up to 84%
  • can be used with topical Tranexamic Acid
• Non-pneumatic Antishock Garment
  
  • decreased mat mortality from 6.3 to 3.5%
  • reduced severe morbidity and halved emergency cs from 8.9% to 4.0%
• Uterotonics
  
  • Oxytocin 10 IU IM, if not response then 20 IU in 500 ml NS to run slowly over 2-4 hrs
  • IM Ergometrine 0.5 mg, no more than 4 mg - risk of CVA
  • combi available Syntometrine
  • Ergo better than Oxy or Misoprostol but causes marked increase in BP
• Antifibrinolytic: Tranexamic Acid
  
  • only within 3 hrs of childbirth, beyond that more harm than good
• Surgery:
  
  • B-Lynch (Brace) Sutre or Hysterectomy

Question 68

• Management of Retained Placenta
• How long before removal? (NICE vs WHO)
• Prophylactic Antibiotics?

Answer 68

• NICE 30 min
• WHO 60 min
• No evidence of benefit.

Question 69

Obstructed Labour

• outline causes
• if prolonged obstructive labour remember to catheterize min 10 days to prevent obstetric fistula

Answer 69

• Powers: inadequate contractions/dysfx labour
• Passage: CPD proportion
• Passenger: abn presentation or fetal abnormality
• Psyche: lack of companion during labour

Question 70

• Assisted Vaginal Delivery
• What are the Indications
• What are the necessary conditions to proceed?
• When should you Stop?

Answer 70

• Ind
  
  • expedite second stage
  • Maternal condition: severe anemia, prosthetic valves, renal disease
  • Fetal condition: distress, cord prolapse
• Need
  
  • Live, term baby (>34 completed weeks)
  • adequate dilatation
  • adequate descent
  • adequate contractions
• Stop!!!
  
  • take no more than 30 min
  • no advance with each pull
  • cup slips off twice

Question 71

What are the main risks for placenta accreta/increta/percreta?

(based on UK study)

Answer 71

• main risks are previous LSCS (OR 15), diagnosed previa (OR 65)
• overall risk if previous LSCS or diagnosed previa about 1/20
• Conclusions: women with both prior caesarean delivery and placenta praevia have a high incidence of placental accreta/increta/percreta. There is a need to maintain a high index of suspicion of abnormal invasion in such women and preparations for delivery should be made accordingly.

Question 72

What are WHO recommendations for intrapartum care for a +ve childbirth experience (2018 - not yet implemented anywhere).

Answer 72

• Changes include:
  
  • Latent phase definition: up to 5cm cervical dilatation with some cervical effacement
  • Active labour: from 5cm cervical dilatation
  • Length of first stage (primips: normally not beyond 12
  • hours and multips: 10 hours)
  • Slower than 1cm/hour cervical dilatation not a routine indicator for obstetric intervention
  • FH auscultation during and for at least 30 seconds after contraction. If abnormal, prolong auscultation for at least three contractions.

Question 73

Skilled Birth Attendant

• What is the WHO definition? (2004)
• What proportion of births in Africa were attended by one?
• Globally?

Answer 73

• An accredited health professional – such as a midwife, doctor or nurse
• Educated and trained to proficiency in the skills needed to manage
• normal pregnancy, childbirth and the immediate postnatal period
• identify, manage and refer women and newborns with complications
  
  • _{WHO. Making pregnancy safer: the critical role of the skilled attendant. WHO 2004.}
• just over 50% in Africa
• Globally 22%: i.e. nearly 31 million unattended births

Question 74

Companion in Labour

• What is the evidence? (Cochrane review, Hodnett et al 2013)

Answer 74

• Women who received continuous labour support were more likely to:
  
  1. give birth ‘spontaneously’, i.e. no CS, vacuum nor forceps
  2. less likely to use pain relief
  3. more likely to be satisfied
  4. had slightly shorter labours.
  5. their babies were less likely to have low five minute Apgar scores

Question 75

Partograph

• What is it?
• What is the evidence for benefit?

Answer 75

• “simple inexpensive tool providing a continuous pictorial overview of labour” used to identify and manage obstructed labour inc referral and transfer.
• a good thing, however systematic review 2013:
  
  • no diff between partograph and non-partograph use in CS, instrumental vag delivery, Apgar score

Question 76

Assessing Progress in Labour

• What are the 4 p’s?
• What are NICE (2007) parameters for 1st stage of labour?

Answer 76

• power, passage, passenger, psyche
• should include:
  
  • cervical dilatation of 2 cm in 4 hrs
  • descent and rotation of fetal head
  • changes in strenght, duration and frequency of contractions

Question 77

• Amniotomy/Rupturing of Membranes
• Role in Normal Labour?
• Effects?

Answer 77

• Not part of normal labour
  
  • ​increased risk of Mat to Child Transmission of HIV
  • increased risk of infection
  • not effective method of shortening spont labour
  • increases risk of CS
  • Increases risk FH abn
  • increased pain following ROM
• if labour slowing, use benign methods first: movement, change of position

Question 78

• Intermittent auscultation vs continuous cardiotocography

Answer 78

• CTG associated with fewer neonatal seizures BUT
• no diff in cp, infant mortality or other standard measures of neonatal well-being
• CTG associated with increased rated of CS and instrumental delivery
• no evidence for CTG for low risk pregnancy
• if no risk factors for fetal hypoxia intermittent auscultation is recommended

Question 79

What are WHO recommendations for recording fetal heart in labour?

Answer 79

• 1st stage: q 30 minutes for 60 sec after a contraction
• 2nd stage: q 5 min
• good practice to record mat pulse with every FH recording

Question 80

Nutrition in Labour

• Cochrane review Singata et al 2013: what are the findings?

Answer 80

• no benefit or harm from eating & drinking in labour in women at low risk of anesthesia
• eating and drinking allows woman to feel normal and healthy
• fasting/denial of food and drink may result in dehydration & acidosis
• combined with fatigue leads to increased risk of augmentation of labour and instrumental delivery so
• EAT DRINK AND BE MERRY

Question 81

Harmful Practices in first stage

List them (7)

Answer 81

1. vag exam without indication
2. vag exam without consent
3. routine rupture of membranes
4. perineal shaving
5. enemas
6. pinching abdomen
7. abusive behaviour

Question 82

Second Stage of Labour

• how should women push?
• effect of upright positions?
• harmful practices?

Answer 82

• no evidence to suggest woman needs to be taught to push: should be encouraged to push spontaneously
• a “no noise” rule is unacceptable
• upright positions lead to:
  
  • shorter 2nd stage
  • less instrumentation
  • fewer episiotomies
• harmful to push down on fundus

Question 83

Care of the perineum

• suggestions
• harmful practices
• antenatal perineal massage?

Answer 83

• application of warm compresses may reduce perineal trauma
• inconclusive evidence re benefit of flexion of presenting part
• hands off or hands poised technique
• continuous sutures best for repair
• promote pelvic floor exercises
• harmful:
  
  • ​perineal stretching
  • routine episiotomy
• antenatal perineal massage by woman or partner in 3rd trimister is effective in reducing perineal trauma for 1st vag delivery

Question 84

Active Management of 3rd Stage

• Cochrane review 2015 findings
• Active management means?

Answer 84

• coch review: active vs expectant management of 3rd stage reduces risk of severe primary PPH (RR 0.34)

1. oxytocin 10 iu iv/im
   
   • if no Skilled Birth Attendant or oxytocin, give misoprostol 600 mcgm daily
2. Controlled Cord Traction by SBA recommended
3. assess pp uterine tone abdominally to r/o atony
4. CCT recommended method for removal of placenta at CS

Question 85

Immediate Care of Newborn

Answer 85

• deliver baby onto abdomen or into arms of mum
• immediate thorough drying with warm clean towel
• assess breathing and if required manage resuscitation
• wipe eyes
• skin to skin contact (keep warm) + hat or head cover
• delay cord clamping 1-3 min
• early start of breastfeeding and exclusive breastfeeding
• Vit K 1 mg IM

Question 86

What are the Stages of the Demographic Transition?

Answer 86

• Stage 1: High birth rate, fluctuating high death rate
• Stage 2: Declining death rate, continuing high birth rates.
• Stage 3: Declining birth and death rates
• Stage 4: Low death rates and low, but fluctuating birth rates

Question 87

Sustainable Dev Goal wrt Family Planning.

Answer 87

• By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.

Question 88

• Measures to improve fertility
• Measures to reduce fertility

Answer 88

• Improve fertility
  
  • baby bonuses
  • family allowances
  • maternal and parental leave
  • subsidize childcare, tax incentives
  • subsidized housing
  • flexible work schedules
  • campaigs to promote the sharing of parenting and household work between spouses
• Reduce fertility
  
  • integrate FP programmes into PHC systems
  • provide access to RH services
  • promoting the responsibility of men in SRH
  • raising the minimum legal age at marriage
  • improving female education and employment opportunities
  • discouraging son preference
  • providing low cost, safe and effective contraception

Question 89

Unsafe Abortions

• How many per year?
• How many deaths?

Answer 89

• 21.6 million women worldwide, 18.5 million in LMIC
• 47,000 deaths

Question 90

What is the Pearl Index?

Answer 90

• method used to determine pregnancy failure rate
• PFR = # of pregnancies x 100 women/12 mo of use

Question 91

Three Delays Model

What is it?

Answer 91

• a model at looking at barriers to access

Question 92

Diarrhea & Dysentery

What are WHO definitions?

Answer 92

Question 93

For deaths under 5, what percent occur in the first month?

Answer 93

• 46% in first month
  
  • 16% preterm complications
  • 11% intrapartum-related events
  • 7% meningitis
  • 5% congenital
  • 1% tetanus
  • only 0.3% diarrhea
  • 3% other
• 54% from 1-59 months
  
  • 13% pneumonia
  • 8% diarrhea
  • 6% injury
  • 5% malaria
  • 4% congenital
  • 2% meningitis
  • 2% preterm birth complications
  • 1% measles
  • 12% other

Question 94

Burden and causes of diarrhea in under 5’s

• How common?
• Who gets it?
• How much pathogen attributable?
  
  • which pathogens?

Answer 94

• 1 episode of moderate/severe diarrhea/5 children/yr
• greatest frequency in infants
• 90% pathogen attributable
• 40% had 2 or more pathogens identified
• 75% attributable to 6 pathogens
  
  • Shigella spp
  • Rotavirus
  • adenovirus 40/41
  • heat stable enterotoxin producing E. coli (ST-ETEC)
  • cryptosporidium spp.
  • campylobacter spp.

Question 95

Consequences of diarrhea under 5 from Global Enteric Multicenter Study

Answer 95

• 60 days f/u 2% cases vs 0.3% controls died OR 8.5)
• most (61%) occurred > 1 wk after diarrhea (when no longer receiving care)
• 56% of deaths occurred at home
• diarrhea associated with subsequent growth faltering

Question 96

Headline figures 2014 for weight/ht for worlds under 5’s.

• Wasting and Stunting, how defined?
• How many stunted? %age?
• How many wasted?
• Overweight? How many and how defined.

Answer 96

• WHZ score <-2
• Stunted:
  
  • 159 million stunted
  • in Africa, though percentage falling 23.8%, total number of stunted children is rising because population increasing
• Wasting:
  
  • 50 million, 7.5% severely wasted
• Overweight (z score>2)
  
  • 41 million
  • Industrialized countries 15%
  • Africa 7%, Asia 5%

Question 97

What is Enteric Environmental Dysfunction (EED)

or Environmental Enteropathy?

Answer 97

Food Nutr Bull. 2015 Mar;36(1 Suppl):S76-87.

Environmental enteric dysfunction: an overview.

Crane RJ, Jones KD, Berkley JA.

Abstract

BACKGROUND:

Environmental enteric dysfunction (EED) refers to an incompletely defined syndrome of inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine. It is widespread among children and adults in low- and middle-income countries. Understanding of EED and its possible consequences for health is currently limited.

OBJECTIVE:

A narrative review of the current understanding of EED: epidemiology, pathogenesis, therapies, and relevance to child health.

METHODS:

Searches for key papers and ongoing trials were conducted using PUBMED 1966-June 2014; ClinicalTrials.gov; the WHO Clinical Trials Registry; the Cochrane Library; hand searches of the references of retrieved literature; discussions with experts; and personal experience from the field.

RESULTS:

EED is established during infancy and is associated with poor sanitation, certain gut infections, and micronutrient deficiencies. Helicobacter pylori infection, small intestinal bacterial overgrowth (SIBO), abnormal gut microbiota, undernutrition, and toxins may all play a role. EED is usually asymptomatic, but it is important due to its association with stunting. Diagnosis is frequently by the dual sugar absorption test, although other biomarkers are emerging. EED may partly explain the reduced efficacy of oral vaccines in low- and middle-income countries and the increased risk of serious infection seen in children with undernutrition.

CONCLUSIONS:

Despite its potentially significant impacts, it is currently unclear exactly what causes EED and how it can be treated or prevented. Ongoing trials involve nutritional supplements, water and sanitation interventions, and immunomodulators. Further research is needed to better understand this condition, which is of likely crucial importance for child health and development in low- and middle-income settings.

Question 98

What pathogens appear to be associated with enteropathy and growth faltering?

Answer 98

Pathogens associated with enteropathy and growth faltering

Colonisation with mucosal damage – rather than overt diarrhoea:

• • Campylobacter
• • EAEC (enteroaggerative E. coli)
• • Giardia

Kosek MN. Causal Pathways from Enteropathogens to Environmental Enteropathy: Findings from the MAL-ED Birth Cohort Study. EBioMedicine 2017;18:109-117.

Question 99

Malnutrition - Summary

• What are the major types of malnutrition and what are their % prevalences?
• Undernutrition contributes to what percentage of deaths?
• Emerging interest on pathophysiology leading to …?

Answer 99

Major types of malnutrition are
– Stunting (chronic; 24% world’s children)

– Wasting (acute; 7.5%)
– Overweight / obesity (6%)
– Plus micronutrient deficiency

Undernutrition underlies 45% of all deaths; most occurring in mild/moderate undernutrition

Multiple/interlinked underlying causes – but recent focus on effect of enteropathogens on gut health/function

Question 100

WHO Definitions of Adolescence

what are they?

Answer 100

• • Adolescence: 10-19
• • Youth: 15-24
• • Young people: 10-24

Question 101

Define Reproductive Health

Answer 101

• A state of complete physical, mental and social well being (not merely the absence of disease and infirmity) in all matters relating to the reproductive system and to its functions and processes.

Question 102

Risk Factors/Threats to Reproductive Health

Answer 102

• Risk factors concepts….
• – Individual level
• Maritalstatus
• Age
• Employment
• Alcohol
• Educationalattainment
• Ability to discuss with an appropriate other
• – Peer/partner level
  
  • • Sexually activepeers or • History of forced sex
  • • Olderpartner
• – Family level
  
  • ▪ Residence
  • ▪ Orphan status
  • ▪ Perceived parental strictness
• – Societal level

Question 103

Gillick Competence (UK)

What is it?

Answer 103

• Gillick Competence

“As a matter of Law the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.” Lord Scarman 1985

Question 104

Fraser Guidelines (UK)

What are they?

Answer 104

• “It is lawful for doctors to provide contraceptive advice and treatment without parental consent provided the YP:
  
  • – will understand the professional’s advice;
  • – cannot be persuaded to inform their parents;
  • – is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment;
  • – is likely to suffer physical or mental harm if not prescribed
  • – best interests require them to receive contraceptive advice or treatment with or without parental consent

Question 105

What is the mnemonic and approach to emergency assessment and management of convulsing or comatose child.

Answer 105

• Airway
• Breathing
• Circulation
• Coma
• Convulsions
• Dehydration
• Require Immediate Treatment

Question 106

C-Coma and Convulsions

Answer 106

• A - Alert? If not
• V - respond to Voice? if not
• P - respond to Pain?
• U - unresponsive
• P & U means Coma
• then
  
  • ​give O2
  • if glucose <2.5 mmol/L (or <3 if malnourished) then
  • give 5 ml/kg 10% dextrose
  • recheck glucose after 30 min
  • if still low, repeat
• Seizure? (child>2 wk)
  
  • if IV access give Diazepam 0.25 mg/kg IV
  • if not then give Diazepam 0.5 mg PR
  • wait 10 min
  • Diaz 0.3 mg/kg IV or 0.5 mg/kg PR
  • wait 10 min
  • Phenobarbitone 20 mg/kg IM
  • wait 20 min
  • Phenobarbitone 20 mg/kg IM
  • wait 20 min
  • Phenytoin 18 mg/kg over 20 min IV
  • or
  • Paraldehyde 0.4 ml/kg PR or 0.2 mg/kg IM
• *

Question 107

Assessment of Coma

Outline 2 simple scoring systems

Advantages and disadvantages of each

Answer 107

• AVPU simple, quick, broad categories, good for triage, less for monitoring over time
• Blantyre Coma Scale more complicated but quick
  
  • more detailed scoring better for monitoring over time
  • good for cerebral malaria or meningoencephalitis

Question 108

Status Epilepticus

Define (Int League Against Epilepsy 2015)

Answer 108

• Abnormally prolonged seizures after t1; and long term consequences after t2
  
  • ​Generalized: t1=5 min; t2**=30 min
  • Focal: t1=10 min; t2=60 min
• 60% of children neurologically healthy prior to first episode of SE
  *

Question 109

Febrile Child with altered concsciousness or neurological signs DDx

Answer 109

• Febrile convulsion with intercurrent illness eg malaria, viral or bacterial infection (6 mo to 6 yr)
• cerebral malaria
• intracranial infections: meningitis, cerebral abscess, encephalitis
• hypoxia of any cause
• hypoglycemia of any cause
• other elyte or metabolic disturbances
• cerebrovascular accidents
• head injury/trauma
• seizure disorder (epilepsy)
• hypertensive encephalopathy
• poisoning eg etoh, tricyclics, organophosphates

Question 110

Common causes of COMA without convulsions

Answer 110

• subclinical seizures (nb v common in cereb malaria)
• post-ictal
• hyperglycemia
• renal failure

Question 111

DDx of seizure-like episodes

Answer 111

• reflex-anoxic seizure/breath holding attack leading to seizure e.g. after stress
• “pseudo-seizures”
• rigors: all over the place
• tetanus/muscle spasms
• Rabies (agitation and spasms)

Question 112

Treatment pathway for seizures

Outline

1st and 2nd line with or without iv access

Answer 112

• First line - no iv access
  
  • Diazepam rectal
  • Paraldehyde rectal or im
  • lorazepam rectal or intranasal, IM
  • midazolam oral, intranasal, IM
• If IV acces:
• First Line: diazepam IV or lorazepam IV
• Second Line after twice benzos:
  
  • IV valproate
  • IV Phenobarb
  • IV Phenytoin
  • IM Phenobarb
  • (IV Levetiracetam)

Question 113

Risks and beneftis of anticonvulsants, adverse effects

Answer 113

• Diazepam
  
  • resp depression 15%; efficacy 51%
• Lorazepam
  
  • resp depression 3%; efficacy 76%
• Valproate 76% efficacy
  
  • smaller risk of cardiorespiratory adverse effects, broad spectrum
  • risk of hepatooxicity and pancreatitis in long-term use
• Phenobarb 74% efficacy
  
  • eheap, available, risk of resp depression
  • IM ltd evidence except for cerebral malaria but limited evidence
• Phenytoin 50% efficacy
  
  • risk of arrhythmia and hypotension
  • difficult to administer

Question 114

• Viral CNS infection in children from malaria - endemic area of malawi study 2013
• what were broad findings?

Answer 114

• mortality 18% overall
• 32% P. falciparum parasitemia of whom 21% died
• 26% at least one virus of whom 33% died
  
  • mostly adenovirus; mumps, human herpes virus 6, rabies, cytomegalovirus, herpes simplex virus 1, and enterovirus were also important
  • 9% had both cerebral malaria and viral infection
• A third of the children who met the case definition for cerebral malaria had viral infections, including a quarter of the children who had the characteristic retinal changes thought to be diagnostic of cerebral malaria. Although fewer patients had viral infection than parasitaemia, more children with viral infection died, even when patients with rabies—which is uniformly fatal—were excluded.

Lancet Glob Health. 2013 Sep;1(3):e153-60.

Viral CNS infections in children from a malaria-endemic area of Malawi: a prospective cohort study.

Mallewa M, Vallely P, Faragher B, Banda D, Klapper P, Mukaka M, Khofi H, Pensulo P, Taylor T, Molyneux M, Solomon T.

Abstract

BACKGROUND:

Fever with reduced consciousness is an important cause of hospital admission of children in sub-Saharan Africa, with high mortality. Cerebral malaria, diagnosed when acute Plasmodium falciparum infection and coma are recorded with no other apparent reason, is one important cause. We investigated whether viruses could also be an important cause of CNS infection in such patients, and examined the relative contribution of viral pathogens and malaria parasitaemia.

METHODS:

We did a prospective cohort study in Blantyre, Malawi. From March 1, 2002, to Aug 31, 2004, we enrolled children aged between 2 months and 15 years who were admitted to hospital with suspected non-bacterial CNS infections. Children with a cerebrospinal fluid (CSF) white cell count of less than 1000 cells per μL and negative bacterial microscopy and culture were deemed to have suspected viral CNS infection. Blood was examined for asexual forms of P falciparum. PCR was done on CSF or on post-mortem brain biopsy specimens to detect 15 viruses known to cause CNS infection.

FINDINGS:

Full outcome data were available for 513 children with suspected viral CNS infection, of whom 94 (18%) died. 163 children (32%) had P falciparum parasitaemia, of whom 34 (21%) died. At least one virus was detected in the CNS in 133 children (26%), of whom 43 (33%) died. 12 different viruses were detected; adenovirus was the most common, affecting 42 children; mumps, human herpes virus 6, rabies, cytomegalovirus, herpes simplex virus 1, and enterovirus were also important. 45 (9%) of the 513 children had both parasitaemia and viral infection, including 27 (35%) of 78 diagnosed clinically with cerebral malaria. Children with dual infection were more likely to have seizures than were those with parasitaemia alone, viral infection only, or neither (p<0·0001). 17 (38%) of the 45 children with dual infection died, compared with 26 (30%) of 88 with viral infection only, 17 (14%) of 118 with parasitaemia only, and 34 (13%) of 262 with neither (p<0·0001). Logistic regression showed children with a viral CNS infection had a significantly higher mortality than did those who did not have a viral CNS infection (p=0·001).

INTERPRETATION:

Viral CNS infections are an important cause of hospital admission and death in children in Malawi, including in children whose coma might be attributed solely to cerebral malaria. Interaction between viral infection and parasitaemia could increase disease severity.

Question 115

Global and Child Health

• 2016: how many deaths under 5
• what proportion neonatal?
• leading causes neonatal period?
• what proportion of newborn deaths occur on 1st day of life?
• What are SDG’s for 2030 for child health
• What is neonatal mortality rate in 2016
  
  • globally, in SSA and SA?
• What are under 5 rates?

Answer 115

• 5.6 million, most in dev countries, preventable
• neonatal deaths now 46% of all under 5 deaths, most preventable
• pneumonia and diarrhea leading causes
• 36% newborn deaths occur on 1st day of life
• SDG end preventable deaths for neonates and under 5’s by 2030
  
  • neonatal mortality to 12/1000 live births
  • under 5 to 25/1000 live births
• Currently nnmr NA & E 3, globally 19/1000, SSA & SAsia 28
• under 5’s NA 6, globally 41/1000 but SSA 79 and SAsia 47

Question 116

What is IMCI?

what are its aims?

components?

Answer 116

• Integrated Management of Childhood Illness
• integrated approach to child health that focuses on well-being of whole child
• aims
  
  • to reduce death, illness and disability and to promote improved growth and development
• components
  
  • improve overall health systems
  • improve family and community health practices
  • improve case management skills of health care staff

Question 117

Does IMCI work?

Cochrane Review 2016 comparing IMCI to usual practice shows?

Answer 117

• infant and child mortality may be reduced (low certainty evidence)
• otherwise
  
  • no evidence of better vaccine and vit a coverage
  • no evidence of consistent effect on prescribing
  • little/no effect on stunting
  • no studies to assess parent/carer satisfaction

Question 118

Child Health terminology: Define

• preterm
• term
• post-term
• Birthweight
  
  • LBW
  • VLBW
  • ELBW
• Neonate
  
  • Early
  • Late
• Infant
• Toddler
• Child
• Adolescent

Answer 118

• Child Health terminology: Define
• preterm: <37 wk
• term: 37-42 wk
• post-term: >42 wk
• Birthweight
  
  • LBW: <2500 gm
  • VLBW: <1500 gm
  • ELBW: <1000 gm
• Neonate: 0-28 days
  
  • Early: 0-7 days
  • Late: 7-28 days
• Infant: 1-11 months
• Toddler: 1-3 yrs
• Child: <18 yrs (but varies by country)
• Adolescent: 10-19 yrs

Question 119

Save the Children End of Childhood Report 2017

What are the 8 major risks to childhood and adolescence?

Answer 119

1. under five mortality
2. malnutrition
3. out-of-school children
4. child labour
5. early marriage
6. adolescent births
7. displacement by conflict
8. child homicide

Question 120

SDG’s directly relevant to Child Health

What are they?

what are the targets for stunting, wasting?

neonatal and under 5 mortality?

Answer 120

• by 2025 reduce number of stunted under 5’s by 40%
• reduce and maintain childhood wasting to <5%
• neonatal mortality to at least <12%
• under 5 mortality to at least <25%

Question 121

Take Home Messages for Global Child Health

Answer 121

• remarkable progress in reducing < 5 survival
• but 5.6 million under 5 deaths in 2016, most in dev countries, most preventable
• neonatal deaths now 46% of all under 5 deaths and proportion rising (mostly in low birth weight children)
• pneumonia & diarrhea leading causes of death in neonatal period
• “First 1000 days” critical for improving outcomes in children
• SDG’s set ambitious targest for child survival and nutrition but many countries unlikely to meet targets

Question 122

Evaluation of Febrile Child: Red Flags

Answer 122

Clinical features with good “red flag” value

• Globalassessment/behaviour

– Parental concern LR+ 14.4

– Clinician instinct LR+ 23

• Temperature

– T >=40C in low prevalence setting

– In high prevalence setting, raised temperature no rule in value, and absence of fever had good rule out value

• Circulatory & respiratory

– Cyanosis LR+ 3 to 52
– Rapid breathing LR+ 1.3 to 10
– Shortness of breath LR+ 1.1 to 9
– Poor peripheral circulation LR+ 1.5 to 39

Clinical features with good “red flag” value

Meningeal irritation LR+ 2.6 to 275

Petechial rash LR+ 6 to 84

Several clinical features need to be considered to r/o SBI

Effective safeguards to ensure children w/o red flags are not missed

(van den Bruel A, Lancet 2010)

Question 123

How well do vital signs identify children with serious infections in pediatric emergency care?

Thompson M, Arch Dis Child 2009; 94:888-893

Answer 123

• Children with serious/intermediate infections were significantly more likely than those with minor infections to have
  
  • temp >39⁰C
  • tachycardia
  • saturations < 94%
  • cap refill time >2 s
• Having >1 of these was 80% sensitive and 39% specific for serious or intermediate infection

Question 124

What is the FEAST PET score?

Answer 124

• a risk score using 8 clinical variables to assess the risk of death in African Children
  
  1. temp
  2. hr
  3. cap refill time
  4. conscious level
  5. severe pallor
  6. resp distress
  7. lung crps
  8. weak puls volume
• shown to be good (AUROC of 0.77-0.86) in African op hospital setting
• Georg EC, BMC Medicine 2015

Question 125

Fever and rash in Child DDX

Answer 125

• common presentation in children
• Bacterial
  
  • meningococcus, pneumococcus, scarlet fever
  • also rickettsiea, enteric fevers
• Viral
  
  • measles, rubella, parvovirus, adenovirus, HHV6, enterovirus, paraechovirus
    
    • HHV6-sixth disease, roseola infantum or exanthem subitum
    • Parvovirus B19-fifth disease, slapped cheek syndrome
  • also arboviruses

Question 126

Meningoccoccal disease

Which form of the disease has highest mortality?

Diagnosis?

Answer 126

• life threatening meningococcal disease rarely presents as meningitis but mostly as septicemia, often with a rash
• approx 70% of cases of meningococcal disease have septicemic component
• approx 20% of those with septicemia present with maculopapular rash
• 50% with MPR progress to petechial purpuric rash
• mortality now greatest in those with MPR alone (i.e. no signs of meningitis)
• Diagnosis:
  
  • ​sx and signs +
  • culture from csf or blood
  • microsopy: gram stain from csf or skin lesions
  • Ag detection: latex agglutination
  • DNA detection: PCR better than blood culture

Question 127

Non-malarial Fever

• What has been effect of decline in malaria incidence in children and adults?
• what infections are often underdiagnosed and should be considered?

Answer 127

• non-malaria febrile illness more common with decline in malaria
• decline in malaria associated decline in invasive disease esp Non-typhoid Salmonella (note also assoc with leprosy, HIV and NTS)
• need to know causes of NMRI in order to guide tx
• child mortality also declining due to HiB, pneumococcal vaccines
• effect of improved malaria dx with RDT has been increased Antibiotic use
• most common cause of NMFI is resp tract inf
• need more sensitive RDT for malaira in context of low malaria transmission
• malaria overdiagnosed
• consider Bacterial zoonoses (leptospirosis, Q fever, spotted fever rickettsioses, brucellosis) and arboviruses e.g. Chikungunya
  
  • Crump JA PLoS Negl Trop Dis 2013

Question 128

Non-malarial fever in Children and URI’s

Elfving K, Plos One 2016, northern tanzania, diagnostic study of under 5’s

Answer 128

• compared dx and tx of uncomplicated febrile illness in <5 yr with IMCI guidelines and final dx using PCR, np and rectal PCR
• majority of infections were viral uri’s similar to Western setting
  
  • RSV, inf A/B, rhinovirus
  • GAS, Shigella
  • 74% had abx but only 22% had infections considered to require abx according to IMCI
  • concluded precision of IMCI to guide abx use was low

Question 129

Non-Malarial Fever in under 10’s

D’Acrmeno V, NEJM 2014

Answer 129

• diagnostic study of under 10’s at op centre in northern Tanzania
• of all comers, only 9% malaria
  
  • of 11% with systemic infection HHSV6 and parvovirus B19 most common
  • others CMV, Rickettsia, Leptospira, Coxiella, toxo, EBV, chickepox
• about 1/10th of total had severe illness, of whom most common dx were Malaria, pneumonia, URI, typhoid, gastroenteritis, bronchiolitis

Question 130

Measles epidemiology

How many cases 2016?

Is eradication feasible? Why or why not?

Effect of vaccination?

Answer 130

• approx 90,000, first time under 100,00
• yes, no animal reservoir, no chronic infection, single serotype, safe and effective vaccine
• WHO goal to eliminate by 2020
• 79% drop in measles deaths btw 2000 and 2014
• 2014 85% of children had one dose by 1st bday
• from 2000 to 2014 measles vaccination prevented about 17 million deaths: one of best buys in public health

Question 131

Describe course and Natural Hx of Measles

Answer 131

• incubation 7-21 days
• fever cough coryza conjunctivitis
• Kopliks spots - small white lesions on buccal mucosa might be visible during prodrome
• rash lasts 3-5 days
• malnourished kids: pigmented rash that desquamates during recovery
• in uncomplicated measles, clinical recovery begins soon after appearance of rash
• complications in up to 40% of patients. Risk of complication in very young and malnourished.

Question 132

What mneumonic is useful for remembering how many days after rash various exanthems appear?

Answer 132

• Really Sick Children Must Take No Exercise

1. Rubella (alt Varicella for Very for shingles)
2. Scarlet Fever
3. Chicken Pox
4. Measles
5. Typhus
6. Nothing
7. Enteric Fever (Typhoid, paratyphoid)

Question 133

Complications develop partially due to temporary immune suppression.

List 10 and the signs by which they present.

Answer 133

1. Pneumonia: cough and tachypnea
2. Croup, necrotising tracheitis: stridor when quiet
3. Dehydration: severe diarrhea
4. Malnutrition: recent severe wt loss
5. Possible blindness: corneal damage or Bitot spots
6. Otitis media: ear pain or discharge
7. Encephalitis: sleepy, convulsions, focal signs
8. Dehydration: diarrhea, inability to eat or drink
9. Dysentery: blood in stools
10. Cancrum oris: severe stomatitis

Question 134

Measles Encephalitis: 3 presentations

what are they,

who do they affect

and what is their time course

Answer 134

Question 135

Management of Measles

1. Mild
2. Severe
3. Prevention and F/U

Answer 135

1. Mild Measles
   
   • small, frequent feeds
   • acetaminophen
   • saline gtts for blocked nos
   • oral hygeine for rinsing mouth
   • ocular hygeine
   • Vitamin A capsule (2 doses in 2 days)
   • 200,000 IU/day>12m, 100,00 IU 6-12 m, 50,000 IU<6m
   • oral rehydration solution
   • use oral antibiotic
   • Admit if signs or symptoms of severe measles
2. Severe measles
   
   • iv antibiotics
   • O₂ for pneumonia
   • tx croup with nebulized adrenaline
   • diarrhea: oral rehydration and antibiotics if bloody stool
   • otitis media: antibiotics and regular aural hygeine
   • xeropthalmia: protective eye pad and aural hygeine
   • malnutrition. treat to SAM guidelines
   • encephalopathy
3. Prevention and f/u
   
   • adequate nutrition
   • watch for TB, often seen after measles
   • chronic persistent diarrhea
   • gammaglobulin (if available) for susceptible contacts if <1 yr old
   • improve vaccination coverage

Question 136

Measles Diagnosis

Answer 136

• measles specific IgM-blood/saliva, >4 da after onset of rash
• PCR virus RNA throat swab, saliva, blood, urine

Question 137

Centor Criteria

What are they?

What percent of pts with ARF don’t get sore throat?

Answer 137

• prediction of pharyngeal GAS infection
  
  1. tonsillar exudate
  2. tender or enlarged ant cervical nodes
  3. absence of cough
  4. history of fever >38
  5. 3-14 yrs old (subtract 1 if >45)
• presence of 3-4 suggests chance of GABS 40-60%
• absence of 3 or 4 suggests 80% chance pt doesn’t have infection, likely doesn’t need Abx
• 2/3 of pts with ARF don’t get sore throat

Question 138

Jones Criteria for diagnosis of acute rheumatic fever.

(but low sensitivity in high risk populations for ARF/RHD)

Answer 138

• Need evidence of preceding GAS/Strep pyogenes (throat swab or rising ASOT) + 2 major or 1 major + 2 minor manifestations. Presence of chorea or carditis many not need evidence of GAS.
• Major manifestations
  
  • Carditis: chf with sob, pericarditis with rub or new heart murmur
  • polyarthritis: temp, large joints, usually legs and moving up
  • chorea
  • erythema marginatum: lon lasting rash begins on trunk or arms as macules and spreads out to form snake-like ring while clearing in middle. never starts on face, made worse with heat.
  • subcut nodules: painless firm, over bones or tendons, typically back of wrist, outside elbow, front of knees
• Minor manifestations
  
  • arthralgia
  • fever
  • elevated ESR or CRP
  • EKG evidence of prolonged PR interval

Question 139

Treatment of Rheumatic Fever

Answer 139

• anti-inflammatories usually have dramatic effect
  
  • salicilates 1st line, start at 80-100 mg/kg/d to acheive plasma conc 200-300 mg/L x 2 wks then
  • reduce to 60-70 mg/kg/day for 3-6 wk
  • lab and clinical rebound may happen after 2-3 wk but usually resolves spontaneously
  • do not shorten illness but are analgesis and antipyretic
• Steroids proven only in severe carditis, appear to reduce mortality during acute attack
• oral pred 1-2 mg/kg/day (max 80 mg/day)
• in extreme cases IV methylprednisolone
• taper after 2-3 wk, overlap with salicilates
• treat ht failure as needed with
  
  • ​bed rest, steroids, diuretics, then dig carefully so as not to worsen ht block
  • surgical tx prn for valve dis
• Chorea
  
  • ​usually benign, but not always
  • tx Haldol
  • steroids said to be ineffective (but Ann disagrees)
  • plasmapheresis and IVIG in resistant disease
  • long-term antistrep prophylaxis

Question 140

• What is:
  
  1. primary prophylaxis of RF?
  2. secondary prophylaxis?

Answer 140

1. active screening for sore throat (not for assymptomatic carriers) and prompt treatment of pharyngitis with oral Abx
2. regular dosing with abx after RF
   • Rheumatic fever with carditis and residual heart disease (persistent valvular disease†)
     
     • 10 years or until age 40 years (whichever is longer); lifetime prophylaxis may be needed
   • Rheumatic fever with carditis but no residual heart disease (no valvular disease†)
     
     • 10 years or until age 21 years (whichever is longer)
   • Rheumatic fever without carditis

5 years or until age 21 years (whichever is longer)

Question 141

What is ETAT?

• What are the Emergency Signs requiring immediate emergency treatment?
• What are the Priority signs? ie next in line

Answer 141

• Emergency Triage, Assessment and Treatment
  
  • a standardized approach to improve emergency care for children
• Emergency Signs (ABBCCCD)
  
  1. A: Airway Obstruction
  2. B: Breathing: Central Cyanosis
  3. B: Breathing: Severe Respiratory Distress
  4. C: Circulation: Profound Shock (the most common problem in low resource settings).
  5. C: Coma: Unconscious or only responding to pain
  6. C: Convulsions
  7. D: (severe) Dehydration from severe diarrhea
• Priority (3TPRMOB) ⇒ front of queue to see ASAP
  
  1. Tiny Baby: < 2mo old
  2. Temperature: v. high >39.5⁰C
  3. Trauma: major trauma
  4. Pallor: severe palmar pallor
  5. Poisoning: mother reports poisoning
  6. Pain: child in severe pain
  7. Restless/Irritable/Floppy
  8. Respiratory Distress
  9. Referral: has urgent referral letter
  10. Malnutrition/ marasmus
  11. Oedema: of both feet
  12. Burns: severe burns

Question 142

ETAT recommended interventions

Severe resp distress

Answer 142

• Airway
• Breathing
  
  • O_2, salbutamol neb, adrenalin, steroids
  • bag & mask

Question 143

ETAT: no circulation

Answer 143

• if slow or absent pulse
• rescue breaths, b&m, chest compressions
• adrenaline if no better after 4 min
• glucose 2-5 ml/kg 10% glucose
• bolus saline or rl 10 ml/kg
• if shock (weak fast pulse and cap refill >3 s)

Question 144

ETAT: shock & malnutrition

Answer 144

• if unconscious
  
  • IV fluids 15 mg/kg RL w 5% dextrose
  • over 1 hr
• if NOT unconscious
  
  • do NOT use IV fluids
  • give ReSoMal oral/NG 5 ml/kg q 30 min for 1st 2 hrs

Question 145

• ETAT: shock/sev dehydration & no malnutrition
• ETAT: Severe Anemia?
• ETAT: Severe Infection?

Answer 145

• Shock/dehydration
  
  • RL 30 ml/kg
    
    • if < 12 mo give over 1 hr
      
      • then 70 ml/kg over 5 hr
    • if > 12 mo give over 30 min
      
      • then 70 ml/kg over 2.5 hr
• Severe Anemia
  
  • give 10 ml/kg pc or 20 ml/kg whole blood
• Severe Trauma, needs blood
  
  • fluid bolus 10 ml/gk while waiting

Question 146

• ETAT Fluid Guideline 1: Severe Malnutrition with Severe Dehydration or Severely Impaired Circulation

Answer 146

• if tolerates Oral/NGT fluids
  
  • check blood glucose
  • treat < 3mmol/l with 5 ml/kg D10
  • then
    
    • ReSoMal 5 ml/kg q 30 min x 2 hr
    • ReSoMal 5-10 ml/kg q hr x 2-10 hr
    • then
      
      • Refeeding Starter F75
• if doesn’t tolerate Oral/NG then IV/IO
  
  • gl <3.0 mmol/L give 5 ml/kg D10
  • Give 15 ml/kg ¹/₂ strength Darrows wih 5%Dex over 1 hr
  • if no improvement then maintenance fluids 4 ml/kg/hr and
    
    • Blood ASAP 10 ml/kg over 3 hrs
  • if improvement rpt 15 mls/kg then give ReSoMal 10 ml/kg/hr
    
    • then refeeding starter F75

Question 147

• ETAT Fluid Guideline 2: Severe Dehydration without malnutrition +/- Shock
• 2 or more of
  
  • lethargy/unconsciousness
  • sunken eyes
  • unable to drink/drinks poorly
  • skin pinch goes back very slowly (>2 sec)

Answer 147

Question 148

• ETAT Fluid Guideline 3: Shock with Sev Anemia
• Pallor, hgb, lethargy

Answer 148

• give whole blood 20 ml/kg and reassess
• if not available give backed cells 10 ml/kg
• give oxygen
• Treat cause: int or ext bleeding, malaria, infection/sepsis

Question 149

• ETAT Fluid Guideline 4: Shock due to Severe Infection

Answer 149

• give O₂, IV/IO access
• 10-20 mls/kg 30-60 min
• Reassess hands, cap refill, pulse, LOC
• If better start Antibiotics, maint fluids ringers or 0.9% saline with dextrose
• If no better start Antibiotics
• 10 ml/kg bolus over 1 hr
  
  • > 2mo max 4 x 10 ml/kg
  • <2 mo max 2 x 10 ml/kg
• if still not improving give blood 20 ml/kg over 1 hr
• (Worsening? think Fluid overload? Anemia? Consider blood or slowing fluid. Consider CPAP.

Question 150

Fluid Guideline 5: Shock due to Trauma

Answer 150

• stop ext bleeding and call surgeons
• order blood urgently
• Give 10 ml/kg 0.9% saline over 20 min
• if improving give maint fluids
• if not improving
• rpt 10 ml/kg saline (max 40 ml/kg) if no blood available
• give blood ASAP 10 ml/kg over 20 min

Question 151

FEAST Trial Lessons

Answer 151

Question 152

• ETAT: Coma and Convulsion

Answer 152

Question 153

6 yr old with Headache, Cough, Fever

Convulsions

What is Differential Dx?

Answer 153

• Hypoglycemia
• Acute Bacterial meningitis
• cerebral malaria
• tb meningitis
• encephalitis
• tetanus
• rabies
• cerebral abscess
• subdural empyema
• febrile convulsions (look for primary)
• S. typhi
• fungal meningitis
• aseptic meningitis
• Bacterial endocarditis + embolism
• non-infectious
  
  • Tumour
  • toxins
  • venous sinus thrombosis

Question 154

• Normal Blood Gases

Answer 154

• pH: 7.35 – 7.45
• pO2: 10 – 14kPa* (75-105 mm Hg)
• pCO2: 4.5 – 6kPa* (34-45 mm Hg)
• Base excess (BE): -2 – 2 mmol/l
• HCO3: 22 – 26 mmol/l

*1kPa = 7.5mmHg. p stands for the ‘partial pressure of…’

Question 155

What are the numbered Exanthems?

Answer 155

Question 156

What is this?

what is its significance?

Answer 156

• one of the major Jones criteria for Rheumatic Fever: a long-lasting rash that begins on trunk or arms as macules and spreads outward to form a snake-like ring while clearing in the middle. Never starts on the face and is made worse with heat.

Question 157

What is this?

Typical of what rash?

Answer 157

Circumoral Pallor

Scarlet Fever

Question 158

Describe the timeline of the major Jones criteria?

Which come first?

later?

Answer 158

• polyarthritis, carditis and erythema marginatum tend to start in 1st month
• Chorea and subQ nodules in 2nd and 3rd
• Erythema marginatum, chorea and nodules may be longer lasting

Question 159

Differentiating Measles from Scarlet Fever.

Associated symptoms

rash texture

Answer 159

• Measles:hoarse voice, barking cough
• Scarlet Fever
  
  • sandpaper rash
  • diff eating and drinking
  • ear discharge
  • diarrhea

Question 160

What kind of virus is the measles virus?

Answer 160

• Measles is caused by the measles virus, a single-stranded, negative-sense, enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae

Question 161

What are the causes of neonatal mortality?

Answer 161

1. 36% Preterm Birth Complications
2. 24% Intrapartum-related events
3. 16% Meningitis
4. 11% Congenital anomalies
5. 7% Other

Question 162

Subcategories of preterm births:

What are they?

Answer 162

• Extremely preterm (<28 wks)
• Very preterm (28-32 wks)
• Moderate to late preterm (32-37 wks)

Question 163

What causes preterm births?

Contributing Factors?

Answer 163

• Not Known
• multiple pregnancies
• maternal infections
• inadequate birth spacing
• maternal undernutrition
• maternal chronic disease

Question 164

Recommendations to improve preterm birth outcomes:

What are they?

Answer 164

• For mother
  
  • corticosteroids in event of imminent preterm birth from 24-34 wks
  • if at risk of low ca intake, calcium supplementation
• For babies
  
  • Kangaroo care esp if <2000 gm at birth
  • CPAP for tx of RDS
  • start 0₂ therapy with 30% rather than 100%
  • Other:
    
    • prompt tx of bact infections
    • management of jaundice
    • management of hypoglycemia and seizures
    • management of feeding

Question 165

What is Shown Here?

How do you read it?

Answer 165

Question 166

Steroids for preterm labour

What are the benifits?

Answer 166

• Reductions in
  
  1. mortality
  2. rds
  3. intraventricular hemorrhage
  4. necrotizing enterocolitis
  5. systemic infections in 1st 48 hrs
• most studies in high income studies

Question 167

Benefits of Ca supplementation to pregnant mothers

Answer 167

• reductions in
  
  • maternal hypertensive disorders
  • pre-eclampsia
  • pre-term birth

Question 168

Kangaroo Mother Care

What are the components?

Benefits to baby

Answer 168

• Components
  
  • exclusive and frequent breastfeeding
  • skin to skin contact
  • support for mother-infant
  • early discharge
  • follow-up care
• Benefits to baby
  
  • reduced mortality
  • reduced risk of hypothermia
  • reduced nosocomial infection
  • increased wt gain 4 gm/day
  • increased rates exclusive breastfeeding

Question 169

Definitions Low Birth Weight Infants

What area has highest rate of LBW infants?

Answer 169

• LBW: <2500 gm
• vLBW: 1500 to 2500 gm
• extremely LBW: <1000 gm
• South Asia 28% LBW
• SSA 13%
• E & NA 6-7%

Question 170

Guidelines on Optimal Feeding of LBW infants in Low and Middle Income Countries

Answer 170

• mother’s own breast milk
• donor human milk when not available
• if n/a standard infant formula
• supplement vLBW infants who fail to gain wt despite adequate breast milk with human-milk fortifier (protein and mineral supplement)
• LBW infants should be put on breast when stable
• vLBW should receive enteral feeds from day 1 i.e. breastmilk 10 mg/kg and make up remaining fluid iv. increase feeds by 30 ml/kg/day
  *

Question 171

Benefits of breastmilk v formula to prem newborn?

Answer 171

• improved nutritional, immunological, developmental outcomes
• reduced incidence infections
• reduced necrotising enterocolitis
• better neurodevelopmental outcomes

Question 172

Supportive feeding LBW newborns

How?

Answer 172

• cup, spoon, nasogastric, orogastric feeds
• expressed breast milk
• breast milk banks
• iv fluids/tpn if too unwell to tolerate feeds
• micronutrient supplementation
  
  • Vit D, ca, phos
  • fe
  • vit K at birth

Question 173

post discharge outcomes at 23 months for preterm/lbw (Rwanda 2011-13)

med bw 1650 gm, med gest age 33 wk

Answer 173

• alive 54%
• feeding diff 47%
• sx of anemia reported by parents 40%
• stunted 78%
• wasted 9%
• abnormal dev screening 67%

Question 174

Factors to consider in discharge of prem, lbw baby

For baby

For mother/carer

Answer 174

• Baby
  
  • no danger signs or signs of infection
  • gaining weight on breastfeeding alone
  • maintain temp in normal range in open cot
  • all scheduled vaccines?
  • post discharge weekly wt and assessments until reaches 3 kg
• Mother/carer
  
  • mother confident and able to care
  • exclusive breastfeeding
  • keeping baby warm
  • aware of danger signs and how to seek care

Question 175

1. What proportion of vaccines for children is typically wasted?
2. Measles vaccines need to be kept at what temp?
3. If vaccines are frozen?
4. Conjugate meningococcal vaccines available for?
5. Frozen vaccines?
6. Source of main costs for vaccines?
7. GAVI stands for
8. How do you tell if DPT has been frozen?

Answer 175

1. 30%
2. 4 to 8⁰ C
3. Some are spoiled (eg DPT) others not (eg measles, oral polio)
4. ACW135Y (not B) - Bexsero is a protein based (not polysaccharide conjugate vaccine)
5. Measles, Oral Polio
6. bottles
7. Global Alliance for Vaccines and Immunizations
8. Use Shake test.

Question 176

What Vaccines are included in the Expanded Programme on Immunization (EPI)?

Answer 176

• BCG - TB
• OPV - Polio
• DPT - Diphtheria, Whooping cough and Tetanus
• Measles
• Haemophilus influenzae b, pneumococci, Meningococcus A, rotavirus, rabies, Yellow fever, Japanese B encephalitis, HPV
• Additional booster doses for measles, diphtheria, whooping cough, tetanus

Question 177

Most Basic Immunization Schemes?

Review

Answer 177

Question 178

Has Polio been eradicated?

Answer 178

• No but nearly
• If polio is the next disease to be successfullyeradicated, this will represent only the third time thishas ever been achieved, after smallpox and rinderpest. … Only three countries remain where the disease is endemic—Afghanistan, Pakistan and Nigeria.
• Rinderpest was eradicated in 2010. Rinderpest is believed to have originated in Asia, later spreading through the transport of cattle. The rinderpest virus (RPV) was closely related to the measles and canine distemper viruses. The measles virus emerged from rinderpest as a zoonotic disease between 1000 and 1100 AD, a period that may have been preceded by limited outbreaks involving a virus not yet fully acclimated to humans.

Question 179

What is this and how do you interpret it?

Answer 179

• Has the diptheria vaccine been frozen?
• Well maintained vaccine
  
  • smooth and cloudy
  • no sediment
• Vaccine frozen
  
  • not smooth, presence of granules
  • settles faster, sediment

Question 180

Which vaccines are “freeze dried”?

What is their shelf life after reconstitution?

Answer 180

• Measles
• BCG
• Yellow Fever
• 6 hours

Question 181

Which vaccines can not be frozen?

Answer 181

• DPT, DT, TT
• i.e. Toxoids

Question 182

When was HiB vaccine introduced globally?

What vaccines does Gavi support introduction to Africa?

Answer 182

• Global coverage 64%
• As Below +
  
  • MenAfric - conjugated Men A vaccine
  • Rotavirus
  • conjugated pneumococal vaccines

Question 183

Compare combined vs prog only pill in terms of mech of action

Answer 183

• •Combined:
  
  • most effective method because they inhibit midcycle gonadotropin surge and prevent ovulation
• •Progestin only pills:
  
  • do not mainly not inhibit ovulation
• Both types act by
  
  • •altering cervical mucus making it thick, viscid and scanty
  • •alter endometrium
  • •alter ovarian responsiveness to gonadotropin stimulation

Question 184

You are supervising the children’s ward in a district hospital in Tanzania.

Mariama, a 4 month old, has just been admiTed from clinic with a diagnosis of severe pneumonia.

This was based on the presence of grunEng, nasal flaring, lower chest wall indrawing a respiratory rate is 72/ minute and no other emergency signs.

She is receiving oxygen, is wearing a bonnet and is wrapped in a blanket.

• What are the likely pathogens and what initial antibiotic therapy would you prescribe?

Answer 184

• Same as children worldwide
• Bacterial
  
  • Strep pneumonia
  • H. flu
  • Staph aureus
  • Klebsiella
• Viral
  
  • RSV
  • Influenza A & B
  • Metapneumovirus
  • Adenovirus

Question 185

1. According to WHO ICMI, what antibiotic therapy would you prescribe for a young child?
2. Would you do anything differently if child HIV +ve?

Answer 185

• Pneumonia
  
  • oral amoxicillin 80 mg/kg/day, split bid
  • fast breathing - 3 days (5 if HIV +ve)
  • chest indrawing - 5 days
• Severe pneumonia
  
  • IV/IM Ampicillin 50 mg/kg or benzylbenicillin 50,000 U/Kg q 6 hrs x 5d
  • IV/IM gentamycin 7.5 mg/kg daily
• 2. If child HIV+ve, for non-sev pneumonia (chest indrawing) use same regimen as for severe pneumonia. Otherwise no different.

Question 186

• According to ICMI guidelines, what is appropriate supportive care for young child with pneumonia>

Answer 186

• suction to clear secretions
• treat fever over 39⁰ with acetaminophen
• if wheeze give bronchodilator; steroids when appropriate
• daily maint fluids app for age
  
  • encourage bf and oral fluids
  • only if can’t drink, then ng tube
• eat asap

Question 187

• According to ICMI, what should you consider if child with pneumonia remains unwell with persistent fever, not feeding? - dx?
• What are 2nd line abx?

Answer 187

• complication eg empyema
• staph pneumonia?
• Malaria or other infection (eg uti?)
• Antibiotics give as prescribed?
• 2nd Line
  
  • Severe pneumonia
    
    • IV/IM ceftriaxone
  • HIV +ve
    
    • IV/IM ceftriasone
  • Staph pneumonia
    
    • gent 7.5 mg od
    • clox 50 mg/kg qid

Question 188

• ICMI clinical signs of severe dehydration in child with diarrhea.
• What are they?
• How would you rehydrate?

Answer 188

• Diarrhea plus any 2 of
  
  • ​lethargy
  • sunken eyes
  • very slow skin pinch
  • unable to drink or drinks poorly
• and check for severe malnutrition
• IV/IO fluids immediately 100 ml/kg RL or NS as
• <12 mo 30 ml/kg over 1 hr then 70 ml/kg over 5
• >12 mo 30 ml/kg over 30 min then 70 ml/kg over 2.5 hr
• record baseline wt, vs, esp RR, temp, reassess every 15-30 min

Question 189

• According to ICMI what is plan A and what is it used for ?
• Home rehydration in child with diarrhea but no dehydration.

Answer 189

• breastfeed frequently and for longer at each feed
• if exclusively breastfed, then ORS or clean water in addition
• if not exclusively breastfed, then give one or more of ORS, soup, yoghurt, rice water or clean water
• fluid additional to usual intake
  
  • <2 yr: 50-100 ml after each loose stool
  • _>_2 yr: 100-200 ml after each loose stool
• Zn supplements for 10-14 days

Question 190

According to ICMI, what is plan B and when should it me used?

Answer 190

• prior to discharge from hospital after Plan C rehydration or in child with diarrhea with signs of mild dehydration.
  
  • 2 or more of
    
    • restlessness, irritability
    • sunken eyes
    • drinks eagerly, thirsty
    • skin pinch returns slowly (but <2sec)
• volume of ors by table for wt (or age 2nd best) or wt in kg x 75ml to be given over 4 hrs
• Zn supplements
• reassess after 4 hrs and reclassify to Plan A, B, C

Question 191

• If a severely dehydrated child with diarrhea has a convulsion and seems jittery a few hours after Plan C rehydration, what would you consider?

Answer 191

• suspect hypernatremia if
  
  • jittery movements
  • increased muscle tone
  • hyperreflexia
  • convulsions
  • drowsiness, coma
• if so, replace fluid deficit more slowly, over 48 rather than 24 hrs.
• measure Na more frequently and aim to reduce slowly (<0.5 mmol/L/hr)

Question 192

Define MAM (Moderate Acute Malnutrition) and SAM (Severe Acute Malnutrition).

Answer 192

• MAM and SAM
• In children aged 6 – 59 months:
  
  • MAM:
    
    • MUAC ≥11.5 cms and <12.5 cms and
    • no oedema
  • SAM
    
    • Weight-for-length/height <-3 SD / z score or
    • MUAC < 11.5 cms or
    • Nutritional oedema (oedema of both feet)

Question 193

What syndrome is this?

What are the clinical features?

Answer 193

• What are the main clinical features?
  
  • thin, flaccid skin (“little old man” appearance)
  • reduced fat and muscle
  • Alert, irritable
• p.s. distinguish “Secondary SAM” e.g. inadequate intake due to neurological compromise from “Primary SAM”

Question 194

What syndrome is this?

What are the main clinical features?

Answer 194

• Kwashiorkor
  
  • oedema (pitting, bilateral; limb, periorbital)
  • flaky-paint dermatitis
  • dry, thin, depigmented hair
  • hepatomegaly
  • apathy, misery, lethargy

Question 195

Appetite Test:

What is it and what is it used for?

Answer 195

• to decide whether or not an acutely malnourished child needs admission or can be managed as an outpatient

Question 196

What is RUTF (Ready to Use Therapeutic Food)?

Answer 196

• developed 1997 Andre Briend
• peanut paste
• vegetable oil
• powdered milk
• powdered sugar
• Vitamins (A, B-complex, CDEK)
• minerals (ca, phosphorus, potassium, mg, zn, cu, fe, iodine, Na, selenium)
• each 92 gm foil sachet provides 500 kcal or 2.1 MJ
• palatable, lipid-rich paste
• no cooking required
• low water content=shelf-life 3-4 months at ambient tropical temp
• but take with water

Question 197

In addition to therapeutic feeding, what other interventions should a child between 6 and 59 months receive?

Answer 197

• On intitial presentation
  
  • broad spectrum oral antibiotic for 7 days (controversial)
  • Vit A, folic acid, antihelminthics (albendazole or mebendazole)
  • antimalarials as required
  • RUTF 200 kcal/kg/day for 1-2 wks
• F/U q 1-2 wk
  
  • measure wt gain, growth, resupply RUTF
• Discharge, (often after minimum of 2 months)
  
  • WFH/L z score > -2 or MUAC > 12.5 cm and
  • no edema for at least 2 weeks

Question 198

How is the in-patient management of SAM organized into 2 phases and 10 steps?

Answer 198

Question 199

1. How would you assess hydration status in SAM?
2. What criteria are used for severe dehydration in a child with SAM and diarrhea?
3. How would you manage severe dehydration in SAM? What oral rehydration solution would you use?
4. What other common complications would you look out for?

Answer 199

1. Difficult! Signs of dehydration are also signs of SAM?
2. Same as for non-malnourished - any 2 of
   
   • lethargy
   • sunken eyes
   • skin pinch > 2 secs
   • unable to drink/drinks poorly
3. Avoid IV/IO fluids
   
   • oral rehydratoin using ReSoMal but more slowly than in non-SAM children
4. Common complications during rehydration
   
   • hypothermia
   • hypoglycemia
   • infection
   • electrolyte impalance (esp K and Mg def)
   • specific micronutrient deficiencies (e.g. Vitamin A, thiamine)

Question 200

Transition from stabilization phase from SAM

1. After acute treatment, how would you assess whether or not he has reached the stabilization phase?
2. What are the main elements of care during this period?
3. When are children ready for discharge?

Answer 200

1. Reached stabilization phase when
   
   • return of appetite
   • no hypoglycemia
   • less/resolved edema
   • (+ diarrhea less/resolved)
2. Elements of care
   
   • Nutritional rehab (F100/RUTF; macro and micronutrients inc Fe)
   • continue to treat eye probs, skin probs etc
   • sensory stimulation
   • maternal education
   • referral to comm program/fu arrangements
3. Ready for discharge?
   
   • clinically well/med probs resolved; alert
   • completed antibiotic course
   • feeding well
   • edema reduced/resolved

Question 201

Rehab Phase of SAM (contd)

1. What is expected wt gain?
2. What are likely causes of por wt gain?

Answer 201

1. expected wt gain
   
   • 10 gm/kg/day
   • poor is < 5 gm/kg/day
2. causes of poor wt gain: many possible - careful comprehensive review
   
   • not completing feeds/being fed enough
   • feeds not made up correctly
   • untreated infection (eg TB)
   • persistent diarrhea
   • inadequate stimulation/neglect

Question 202

Publich Health measures to prevent malnutrition.

Answer 202

• prevention lbw
• delayed cord clamping/vit k at birth (anemia)
• Nutrition: early start of breast feeding (within 1 hr); exclusive breast feeding to 6 mo; healthy weaning with continued breast feeding
• vit A supplementation 6-59 months
• preventive zinc supplementation
• Water Sanitation Hygeine/prevention of diarrhea

Question 203

Newborn case:

• A baby is born after 8 months of gestation
• Mum has had a previous fresh stillbirth after prolonged obstructed labour
• Mum is HIV negative and has had 3 antenatal care visits
• She has had tetanus toxoid boosters during pregnancy; blood pressure and urine dipstix were normal
• Baby was born at 05.00 by Caesarean section due to prolonged labour
• Rupture of membranes occurred 25 hours before delivery
• Condition at birth: pale and floppy with heart rate of 40/min and no respiratory effort
• Required 5 minutes of bag and mask ventilation before establishing spontaneous respirations. Heart rate picked up to over 100/min by 1 minute

1. What other information do you want?
2. What are your working diagnoses?
3. What immediate investigations are required?
4. What immediate treatments?
5. What basic equipment?
6. What complications would you expect?
7. What will your management plan be for the next few days?

Answer 203

1. Additional info needed
   
   • Birthweight
   • Did mom have fever?
   • Amniotic fluid foul smelling or purulent?
   • Additional care other than resusc (thermal control, early breast feeding)?
2. Working dx
   
   1. late preterm
   2. intrapartum hypoxemia (birth asphyxia)
   3. hypoxic ischemic encephalopathy
   4. neonatal bacterial infection
   5. hypoglycemia
3. What immediate investigations?
   
   1. glucose, ca if possible
   2. blood culture (+LP once stable) if possible
   3. CRP, electrolytes, CKMB, serum cr, transaminases if available (unlikely)
4. What immediate treatments needed?
   
   • parenteral amp and gent
   • glucose if low, ca if low
   • phenobarb if convulsions
5. What equipment?
   
   • IV cannulas and infusion sets, NGT, glucometer, oximeter, oxygen
6. Expected complications
   
   • septic shock
   • hypothermia, hypoglycemia
   • convulsions
7. Management plan
   
   • parenteral abx
   • try breastfeeding. If unsuccessful, feeding by NGT with expressed breast milk
   • thermal control; skin to skin once fever resolved
   • close monitoring (convulsions, resp distress, feeding tolerance, urinary output)
   • routine care (vit k, vaccines as per national protocol)

Question 204

Considering a case in which baby was born at 8 month gestation after prolonged labour, floppy at birth, septic, continued floppy.

An exercise in constructive review, prevention and control.

1. What are immediate and antecedent and root causes of this baby’s illness?
2. How might it have been prevented?
3. How will you use such cases in training nurses?
4. What policies can you institute to help in future?
5. How might these impact the district?

Answer 204

1. Causes
   
   • prematurity
   • prolonged rom
   • hx of prev obstructed labour, ?risk factor such as short stature?
   • 3 delays: decision, access to facility, timely care provision, quality of care
2. Prevention?
   
   • mother should have attended 4 ANC session if possible (now recommending 8)
   • earlier C-section
   • antibiotics to Mom
   • Early initiation of abiotics to baby
   • closer monitoring from birth (esp because APGAR not ok at 5 min)
3. Use in training
   
   • review in depth to identify areas for improvement in prevention and management of illness in neonates as it comprises common causes of neonatal mortality and morbidity
   • Ensure no blame culture is in place before reviewing it
   • Ensure decisions taken after review are effectively implemented
4. Policies arising
   
   • • to improve recognition of danger signs & babies at risk of serious illnesses (ETAT)
   • • to allow close monitoring of all babies
   • • to improve training of staff in neonatal care
   • • to ensure availability of protocols, drugs and med equipment
5. Impact on district
   
   • complications of prematurity, infections and birth asphyxia are commonest causes of neonatal mortality. Improving management will contribute in reducing neonatal mortality.

Question 205

Critique of IMCI strategy

Answer 205

• tool for reorganization

Question 206

Critique of IMCI

Answer 206

see notes