Sepsis and/or meningitis

Question 1

list signs of Clinical dehydration vs. Clinical shock in a child

Answer 1

Clinical dehydration
 Appears to be unwell or deteriorating
Altered responsiveness
Decreased urine output
Skin colour unchanged
Warm extremities

Clinical shock
Decreased level of consciousness
Pale or mottled skin
Cold extremities

Question 2

Management of dehydration in a child

Answer 2

Oral rehydration
• Preferred option
• 50ml/kg low-osmolarity ORS solution over 4 hours + maintenance – little and often
• Continue breastfeeding
• Continue usual fluids – avoid high
sugar content fluids
• Consider NGT fluids if fails to tolerate

I.V.
• Consider fluid bolus
• Isotonic solution e.g. 0.9% sodium chloride with 5 % glucose – deficit & maintenance
• Monitor response
• Monitor electrolytes
• Bewareofhypernatremic dehydration
• Slowrehydration
• To reduce sodium by 0.5 mmol/hr

Question 3

Clinical features of Septic shock

Answer 3

• History–fever,rash,irritability, poor feeding
• Clinicalfeatures
• A + B – tachypnoea, shallow
breathing, recessions
• C–tachycardia,increasedCRT,low BP (late sign), cool peripheries (beware of warm shock)
• D–alteredconsciousness • E–rash

Question 4

Management of septic shock

Answer 4

Management
• A + B – Oxygen, positive pressure,
intubation
• C–fluidbolus–20ml/kg(mayneed more), inotropes
• Treatment–
• Antibiotics,
• Manage temperature,
• Correct metabolic & clotting abnormalities

Question 5

Clinical features of Anaphylaxis in a child

Answer 5

• History–allergy,suddenonset wheezing
• Clinicalfeatures
• A–hoarseness,stridor
• B–tachypnoea,wheeze,cyanosis, decreased spO2
• C–tachycardia,pale,clammy, hypotension
• Skin–Urticarialrash

Question 6

Management of anaphylaxis in a child

Answer 6

Management • A–supportit • B–oxygen
• Intramuscular Adrenaline 1:1000
• Nebulisers • C–fluids
• Other
• Iv hydrocortisone • Iv chlorphenamine

Question 7

Clinical features Status epilepticus in children

Answer 7

• History–epilepsy,familyhistory, illness, last meal
• Clinicalfeatures
• A+B–tachypnoea,erraticbreathing,
cyanosis
• C–tachycardia,variableBP
• E–rash,neurocutaneousmarkers

Question 8

Management of Status epilepticus in children

Answer 8

• A + B – oxygen, intubation
• Don’teverforgetglucose
• PR Diazepam / Buccal Midazolam
• C – fluids
• Iv Lorazepam
• PRParaldehyde
• Iv Phenytoin
• Other
• Considersepsis
• Correct metabolic abnormalities

Question 9

Key differences when prescribing antibiotics in children vs adults

Answer 9

• Handling of drugs / dosing cannot always be extrapolated e.g Vancomycin, Ertapenem
• Tetracyclines contraindicated in children under 12 years ( BNF – others use 8 years ) (deposition in growing bone and teeth, by binding to calcium, causes staining and occasionally dental hypoplasia)
• Quinolones - adverse effects on cartilage development in juvenile animals through the inflammation and destruction of weight-bearing joints
• Macrolide antibiotics in the first two weeks of life appears to convey a risk of IHPS

Question 10

Neonatal infection types

Answer 10

• Early / Late GBS
• HSV
• Listeria
• Chlamydia/gonococcal
• CMV
• TB

Question 11

Microbes responsible for Neonatal meningitis

Answer 11

• Group B Streptococcus — 50 percent of cases • E. coli — 25 percent
• Other gram-negative rods — 8 percent
• Listeria monocytogenes — 6 percent
• Streptococcus pneumoniae — 5 percent • Group A Streptococcus — 4 percent
• Haemophilus influenzae — 3 percent

Question 12

Why can any bacteraemia in neonates led to meningitis?

Answer 12

permeable BBB

Question 13

Microbes responsible for infants and child meningitis

Answer 13

Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b

Question 14

Microbes responsible for adolescent meningitis

Answer 14

Neisseria meningitidis, Streptococcus pneumoniae

Question 15

CSF changes in meningitis

Answer 15

• Cell count > 20 cells/uL abnormal in neonates ( > 5 in others )
• CSF protein > 1.0 g/L abnormal in neonates ( 0.4 in others )
• Lymphocytic picture in Listeria
• Neutrophilic response in early phase of enterovirus meningitis

Question 16

Importance of E.Coli 0157 diarrhoea in HUS

Answer 16

Haemolytic Uraemic syndrome in children – 83 % associated c E coli 0157

Treating infection with antibiotics more likely to cause HUS

Diarrhoea (often bloody)

Haematological – microangiopathic haemolytic anaemia , thrombocytopenia, acute renal failure

Question 17

Management of Babies that are born to Hepatitis B positive mothers

Answer 17

• Babies that are born to Hepatitis B positive mothers, should be vaccinated within 24 hours of birth and referred for follow-on vaccinations at 1, 2 and 12 months of age with a blood test for infectivity status
• Specific indications for Hepatitis B immunoglobulins depending on HB eAg/Ab status and birthweight ( Green Book )
• No need for CS , allowed to breast feed

Question 18

Management of Maternal Hepatitis C infection

Answer 18

• Risk of acquisition 2-8% • Allowed to breast feed • No need for CS
• Baby needs follow up testing HCV PCR at 6 wks , 12m , HCV Ab at 12 m and 18 m

Question 19

Management of Maternal Syphilis infection

Answer 19

• Send a venous blood sample for serum RPR and treponemal IgM (take blood from the neonate, not the umbilical cord) at birth and 3 monthly until negative
• Approximately half of all neonates with congenital syphilis are normal on initial examination
• Further testing and treatment indicated if mother inadequately treated or infant has clinical signs consistent with syphilis

Question 20

Management of HIV PEP for infant very low risk

Answer 20

• - Two weeks’ zidovudine monotherapy is recommended if all the following criteria are met:
• Mother has been on cART for longer than 10 weeks
AND
• Two documented maternal HIV viral loads <50 HIV RNA copies/mL during pregnancy
at least 4 weeks apart
AND
• Maternal HIV viral load <50 HIV RNA copies/mL
at or after 36 weeks

Question 21

Management of HIV PEP for infant low risk

Answer 21

• Extend to 4 weeks’ zidovudine monotherapy:
• If the criteria for very low risk not fulfilled but maternal HIV VL is <50 HIV RNA at or after 36wks
• If baby born prematurely (<34 weeks) but most recent maternal HIV VL is <50 copies/mL

Question 22

Management of HIV PEP for infant at high risk

Answer 22

• Use combination PEP if maternal birth HIV VL known to be or likely to be >50 copies/mL on day of birth, if uncertainty about recent maternal adherence or if VL not known.
• Neonatal PEP should be commenced very soon after birth, certainly within 4 hours.
• In the context of known maternal resistance to zidovudine with VERY LOW or LOW risk,zidovudine monotherapy is still
recommended for infant PEP.

Question 23

Advice on Breastfeeding in HIV

Answer 23

• UK recommendation is to avoid breastfeeding with support for formula milk
• Women who are virologically suppressed on cART with good adherence and who choose to breastfeed may be supported to do so, but should be informed about the low risk of transmission of HIV through breastfeeding in this situation.
• Breast fed infants need regular HIV tests

Question 24

Infant testing for HIV

Answer 24

• During the first 48 hours and prior to hospital discharge
• If HIGH RISK, at 2 weeks of age
• at 6 weeks (at least 2 weeks post cessation of infant prophylaxis*)
• at 12 weeks (at least 8 weeks post cessation of infant prophylaxis *)
• On other occasions if additional risk
• HIV antibody testing for seroreversion should be checked at age 18–24 months
*In very low risk neonatal PEP is for 2 weeks

Question 25

For infants born to HIV-infected mothers, what changes are made to their immunisation schedule?

Answer 25

• For infants born to HIV-infected mothers, the routine primary immunization schedule should be followed at 2, 3 and 4 months
• Bacille Calmette-Gue ́rin (BCG) vaccine should not be given until the infant is confirmed uninfected, with two negative HIV DNA PCRs off ART but if very low risk or low risk of MTCT BCG can be given at birth