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Last modified: 31 March 2004 For review: 2005 1

PROVINCE OF KWAZULU-NATAL HEALTH SERVICES

ISIFUNDAZWE SAKWAZULU EMPILO

KWAZULU-NATAL PROVINSIE GESONDHEIDSDIENSTE

P R A C T I C A L M A N A G E M E N T G U I D E L I N E S F O R S I C K C H I L D R E N I N K W A Z U L U - N A T A L

These guidelines are for the use of medical personnel working with children in KZN. They have been developed through the contribution of all staff members of the Pietermaritzburg Metropolitan Paediatric Service and have drawn on written and verbal input from far and

wide.

The guidelines are a starting point and not an end point in the management of common and/or serious paediatric problems. They do not preclude the appropriate and timely call for help from senior/specialist paediatric staff

within the province. They aim to assist in the development of common approaches to managing common/serious paediatric problems, and to assist with the more efficient movement of patients along referral pathways.

Every effort has been made to ensure that suggested management is in line with current

best practice and with the Essential Drugs Lists, and that drug doses are correct. Individual practitioners remain responsible for ensuring correct management and drug

dosing when caring for their patients.

Contents 1) Cover Page 2) Format for standardised case management 3) Principles for Admission, Discharge and Referral 4) Acute Respiratory Tract Infection 5) Acute Severe Asthma 6) Upper Airway Obstruction 7) Diarrhoeal Disease: Overview 8) Diarrhoeal Disease: Initial Fluid Management 9) Diarrhoeal Disease: “Metabolic” Management 10) Hepatitis A 11) Looking after children with Chronic Liver Disease 12) Constipation 13) Criteria for diagnosing AIDS 14) AIDS: Taking Consent 15) AIDS: Inpatient Care 16) AIDS: Ambulatory Care 17) The Fitting Child 18) Tuberculous Meningitis 19) Glomerulonephritis 20) Nephrotic Syndrome 21) Urinary Tract Infection 22) Innocent Murmurs 23) The Paediatric ECG 24) Microcytic Anaemia

Please direct general enquiries to: Paediatric Department, Grey’s Hospital, Private Bag X9001, Pietermaritzburg, 3200

Any errors, suggestions for improvement etc. should be forwarded by email to [email protected]

Electronic versions are available on request All guidelines can be freely copied and used – please acknowledge source





P O S S I B L E F O R M A T F O R S T A N D A R D I S E D C A S E M A N A G E M E N T P R O T O C O L D E V E L O P M E N T

1. What is the Problem? State the problem Define the problem

2. Why is it Important? Morbidity Mortality

3. What is the Severity? Grading system for assessing severity

4. What are the Implications of Severity? Nil if... Ambulatory care if... Admit if... Refer if...

5. What is the cause? Conditions to exclude Definitive diagnosis necessary Investigations necessary

6. What is the Management Ambulatory: state In-patient: state or refer to in-patient protocol In-transit: state

7. What is the Follow Up? Nil if... Level 1 if... Level 2 if... Level 3 if...

8. What are the Preventive Measures? Home-based Health service-based

9. What Information Should be Given to Caregivers? The condition The management The prognosis The follow up The prevention





R E F E R R A L , A D M I S S I O N & D I S C H A R G E C R I T E R I A Broad Principles

Whilst specific conditions may have their own indications for admission, discharge or referral to the next level of

care, these are often influenced by the socio-economic circumstances of affected children and their families or by the skills or facilities present at different health institutions providing care. It is therefore more important to identify

principles guiding the admission, discharge or referral of sick children that can be applied to all clinical settings and to compliment these principles with more specific guidelines for individual disease entities.

Admission: To make a diagnosis. For initiation of complex treatment. When the management required cannot be provided at the lower level of care: Oxygen Intravenous fluids Parenteral therapy Nebulisers NG feeds Monitoring of fluid balance etc.

For monitoring when possible deterioration is anticipated.

Discharge: When a child is stable or The level of care required can be provided at a lower level of care

Referral: Children with a diagnosis but who still require investigation of an underlying cause, eg nutritional rickets,

hypertension, etc Diagnostic dilemmas - children requiring a diagnosis Poor response to treatment Development of complications Real or anticipated deterioration in clinical condition Requires management not available at that level of care

The urgency of a referral should be determined by the degree of threat to life or well-being.

All referrals must respect the culture beliefs and practices of the child and his/her family. Families must understand and accept the purpose of the referral. Health care workers must recognize and avoid futile referrals which serve no purpose. Only stable patients should be referred.




A C U T E R E S P I R A T O R Y T R A C T I N F E C T I O N ( A R I ) ARI’s account for 5 million deaths per annum worldwide. ARI is the second biggest cause of death in children in South

Africa. Cause of death is HYPOXIA.

Step 1: Make the Diagnosis

Symptoms include: fever, cough, runny nose, fast breathing, grunting, wheezing, and difficulty feeding Signs include: pyrexia, tachypnoea, air-trapping, crackles, wheezes, bronchial breathing, recession, and cyanosis

(late) Step 2: Decide on the Presence/Absence of Lower Airway Obstruction (LAO) A child has LAO if the lungs are hyperinflated. Indicators of LAO are:

Wheeze +/- prolonged, active expiration Subcostal recession

Step 3: Assess and grade severity: RELATE TO MANAGEMENT OPTIONS Indicators of severity include:

1) Respiratory rate (breaths per minute): < 2 months >60 2 months – 1 yea r >50 1 – 6 years >40

2) Chest indrawing/recession 3) Feeding difficulty 4) Cyanosis

Grade severity…

Respiratory Rate

Feeding difficulty +/-Indrawing/Recession +/-

Cyanosis

Management

Severe ARI > normal for age Present Immediate oxygen and admission

Moderate ARI > normal for age Absent Specific home treatment

Mild ARI Normal for age Absent Symptomatic home treatment only

Step 4: Consider the Differential Diagnosis

1) Foreign body 2) TB + nodes 3) Acidaemia (especially in diarrhoeal disease) 4) Asthma 5) Pneumothorax 6) Empyaema 7) Myocarditis + CCF (ALWAYS feel peripheral pulses in children with severe ARI’s 8) Croup 9) CNS problems: central AND peripheral

Step 5: Do a Chest X-Ray:

When the diagnosis of ARI is in doubt (if TB or foreign body is suspected, do AP and lateral views) In children who need admission

Then… Last modified: 30 March 2004 1 For review: 2005

Patients needing admission (Severe ARI +/- LAO) 1. Oxygen (humidification is unnecessary!!!)

Start OXYGEN in POPD if the child is cyanosed, distressed or the O2 saturation is <90%

NEVER transport a child who NEEDS oxygen without oxygen In the ward, give OXYGEN to all children (until “sats” indicate otherwise) and monitor O2 saturation 2 hourly Use a nasal catheter (FG 8 feeding tube with nostril holes cut and a flow of 2l/min), or a headbox (minimum flow

5l/min), according to oxygen saturation 2. Bronchodilators

If LAO is present, give one dose of a nebulised bronchodilator: >18 months SALBUTAMOL (Venteze) or FENOTEROL (Berotec) 1ml:1ml saline <18 months IPRATROPIUM (Atrovent) 1ml:1ml saline

Re-assess after this dose and continue further nebulisations only if there is a clinical improvement with the first dose. Record whether there has been a response. Continue with β2 stimulant +/- IPRATROPIUM as often as 3 hourly

Consider oral SALBUTAMOL as soon as possible (this decreases nursing load AND brings patient closer to discharge)

3. Fluids: Feed with milk (by N/G tube if necessary) at the usual recommended volume for age. Use EBM in breastfed infants.

Preferably feed 3 hourly to avoid gastric distension

NEVER remove a child from a headbox for feeds If IV fluids are used, no more than 50-60 ml/kg/day should be given as maintenance if the child is NPO. Give less

intravenous fluid if the child is getting milk feeds as well 4. Antibiotics

IV AMPICILLIN 100mg/Kg/day in 4 doses AND

If <3/12 or immunocompromised, IV GENTAMICIN 7,5/Kg/day in a SINGLE dose If HIV + PCP suspected, use IV COTRIMOXAZOLE 1,25ml/kg/day in 4 divided doses (or PO 2,5 ml/kg/day in 4

doses) For IV antibiotics, use a saline lock (“short line”) when possible (i.e. whenever a child is tolerating feeds)

5. Vitamins Use high-dose VITAMIN A in all cases of ARI requiring admission (and document on inside cover)

< 1 month 50 000U per os today and tomorrow 1 month – 1 year 100 000U per os today and tomorrow > 1 year 200 000U per os today and tomorrow

6. Steroids Of no benefit (except possibly in PCP: see separate guideline)

7. Physiotherapy Is dangerous and contraindicated while children are tachypnoeic.

Patients requiring specific home treatment (Moderate ARI +/- LAO) Antibiotics AMOXYCILLIN:

<6 months 62,5mg 8 hourly for 5 days >6 months 125mg 8 hourly for 5 days

or: COTRIMOXAZOLE < 6 months 2,5ml 12 hourly for 5 days > 6 months 5ml 12 hourly for 5 days

Bronchodilators If LAO present give SALBUTAMOL 0,15mg/kg/dose 6 hourly for up to two weeks

It is important to explain to the caregiver that the child should gradually improve but the cough may persist for 2-3 weeks. Give an extra feed a day for a week once the child is recovering (if the child is not obese)

Patients Requiring Symptomatic Treatment only (MILD ARI) The patient probably has an upper respiratory tract infection.

PARACETAMOL for fever Simple cough remedy (warm black tea, sugar and a squeeze of lemon) NORMAL SALINE 2 drops in each nostril as often as needed (1-6 hourly)

To come back if: Difficult feeding Difficult breathing

DANGER: there is more than an “ARI” if… There is Failure to Thrive * There is a household TB contact * There is a persistent or chronic cough





A C U T E S E V E R E A S T H M A Immediate Management Oxygen

In acute severe asthma, hypoxia kills. Oxygen is the priority. Give 100% O2 by face mask (5 l/min). If available use a pulse oximeter to determine oxygen saturation. Aim for oxygen saturation of >93%.

Severity assessment An initial assessment of severity on arrival of the child and prior to nebulisation is essential for planning ongoing management:

SEVERITY Mild Moderate Severe

PEFR (% predicted) >80 60-80 <60 Respiratory rate <40 >40 >40

Pulsus paradoxus Not palpable Not palpable Palpable Wheezing Expiratory Expiratory & Inspiratory Soft breath sounds

Speech Normal Normal Impaired Feeding Normal Impaired Impaired

Place in the most severe category in which there are 2 or more features. Peak expiratory flow rate (PEFR) is the most important measurement in children over 5 years.

Under 5 years the respiratory rate is the most helpful single measurement. A rate of more than 40/min is cause for concern.

All children classified as SEVERE on arrival should be admitted, regardless of response. Bronchodilator

1) UNDER 6 YEARS, OR VERY DISTRESSED SALBUTAMOL 8mg/ml (Venteze) or FENOTEROL 1mg/ml (Berotec) 2ml in 2ml normal saline by nebulisation. Use a flow rate of 5 l/min and ensure the nebulisor is working properly.

AND IPRATROPIUM BROMIDE (Atrovent), 1st Dose only, 1ml in 1ml saline.

2) OVER 6 YEARS, NOT VERY DISTRESSED, AND ABLE TO USE SPACER FENOTEROL (Berotec) or SALBUTAMOL (Venteze) by metered dose inhaler. USE A SPACER. Give 5 puffs into the spacer allowing the child to breathe normally for 5 breaths between each puff.

AND IPRATROPIUM BROMIDE (Atrovent). Administer as for salbutamol/fenoterol but 1st dose only

REPEAT fenoterol or salbutamol after 20 minutes if no response, but do NOT repeat ipratropium. Steroids

PREDNISONE 2 mg/Kg orally stat (max. dose 40 mg). If vomiting, use dexamathasone 0,3 mg/Kg IM or IV. Adrenaline & Intravenous Salbutamol

CALL FOR HELP Patients in extremis with a very severe attack should be given 0,01 ml/kg adrenaline 1:1000 subcutaneously

immediately, and salbutamol (15 ug/Kg IV over10-15 minutes) if unable to use a nebuliser.


After nebulilsation or MDI, assess response... RESPONSE NO RESPONSE

Mild Moderate Severe PEFR (% predicted) 70-90% 50-70% <50

Respiratory rate <40 >40 >40 Pulsus paradoxus <10 mmHg 10-20 mmHg >20 mmHg (palpable)

Wheezing Expiratory Expiratory & Inspiratory Soft breath soundsSpeech Normal Normal Impaired

Place in the most severe category in which there are 2 or more features.

Then, depending on response… If Good Response (i.e. “mild” for 1 hr after treatment):

1) Continue steroids for 5 days if: poor control >1 day before presentation more than 1 dose bronchodilator needed

2) Review current management. 3) Discharge on appropriate medication. Ensure adequate follow-up.(See “Follow Up” below.)

If Poor Response (i.e. “moderate” or “severe” after 2 doses of bronchodilator 20 minutes apart):

MODERATE: admit to high care SEVERE: admit to high care

In Ward: 1) OXYGEN via face mask (5 l/min) or nasal catheter (2 l/min) plus saturation monitoring 2) BRONCHODILATOR by nebulisation using SALBUTAMOL or FENOTEROL 1-6 hourly and IPRATROPIUM

BROMIDE (ATROVENT) 6 hourly. Frequency of nebulisation should be reviewed often. The goal is to return the child to future home maintenance therapy as quickly as possible.

3) PREDNISONE 2 mg/kg/day (max. dose 40 mg), daily mane 4) MONITOR AND CHART PEAK EXPIRATORY FLOW RATE (age 5-6 years and above) before and after each

nebulisation 5) MAINTAIN HYDRATION by Encouraging to drink according to thirst. IV fluids are unnecessary unless vomiting

or clinically dehydrated Unnecessary:

Chest X-rays and antibiotics are not necessary as a routine in an acute attack. Do a chest X-ray if you suspect a pneumothorax.

Dangerous:

Sedatives Intravenous theophylline Before Discharge

An attack of acute severe asthma indicates failure of maintenance management. Therefore: 1) Review the causes and possible precipitating factors. Intervene where feasible 2) Adjust maintenance drug management if necessary 3) Ensure the patient/parents understand the aims and details of management 4) Discuss with the patient/parents a plan for managing future emergencies 5) Steroid dependant patients should be seen by the paediatrician before discharge 6) Discharge on maintenance medication, including prednisone 2 mg/kg/day (max. dose 40 mg) for up to 14 days

if necessary, then stop (unless on maintenance steroids) Follow-Up All patients who have been admitted should be followed up at the Asthma Clinic until home maintenance therapy is well established. Once this is achieved consideration can be given to referring patients for Level 1 follow up.





U P P E R A I R W A Y O B S T R U C T I O N CROUP (LARYNGOTRACHEOBRONCHITIS): the commonest cause of upper airway obstruction

A confident clinical diagnosis of this condition can be made if the following features are present: 1) Child was previously well 2) < 2 years of age 3) Gradually progressive inspiratory obstruction

which manifests as STRIDOR 4) Barking cough

5) Onset a day or 2 after the an upper respiratory infection.

6) Mild fever (<38°C) may be present. 7) The child is well, apart from the respiratory

obstruction Features suggesting another cause:

1) Dramatic onset of severe obstruction (foreign body)

2) Incomplete immunisation (diphtheria) 3) Dysphagia or the patient prefers a sitting

position (epiglottitis, retropharyngeal abscess)

4) Systemic “toxicity” with erythematous rash (Staphylococcus)

5) Aphonia in a black child with a previously hoarse voice (laryngeal papillomatosis).

Investigations

1) Chest X-ray is not necessary nor are neck x-rays

2) X-ray lateral neck and AP is necessary only if there is serious doubt about the diagnosis of viral croup

3) Blood gasses are unreliable in assessing the need for intervention and may aggravate the problem by making the child cry

ASSESSMENT OF SEVERITY is an assessment of severity of Airway Obstruction

Grade I INSPIRATORY stridor only Grade II Inspiratory and EXPIRATORY stridor Grade III ACTIVE EXPIRATION (i.e. visible or palpable contraction of abdominal

muscles) and/or PALPABLE PULSUS PARADOXUS Grade IV Apathy and/or cyanosis

This GRADING SYSTEM is applicable to UAO caused by CROUP only Stridor becomes softer as the obstruction becomes more severe.

Management All grades of obstruction…

1) Antibiotic (amoxil) if bacterial infection is suspected: fever > 38 C “toxic” purulant sputum concommitant ARI

2) ACYCLOVIR (IV) if oral Herpes simplex and if post measles

3) KEEP THE CHILD COMFORTABLE (the mother/carer is best at doing this) - crying and hyperventilation increase the oedema

4) Continue oral feeding 5) Avoid painful procedures

6) Paracetamol if febrile 7) If unable to console the child in any other way,

chloral hydrate (50 mg/Kg/dose 4-6 hourly), and tube feed to maintain hydration

8) STEROIDS: PREDNISONE 2 mg/Kg orally or dexamethazone 0,5 mg/kg intravenously, provided that: no measles in the past

month no oral Herpes repeat in 24 hours if no

improvement


In addition…

GRADE I Manage at home, provided:

conditions are favourable the obstruction is not getting worse in our setting, it is probably advisable to admit

all GRADE II

1) Hospitalise. 2) ADRENALINE NEBULISATIONS (1 ml of 1:1

000 in 1 ml saline) every 15 minutes, or more

often, till improved then every 30 minutes till

grade I, then prn 3) Consider nebulised steroid

GRADE III 1) Monitor O2 saturation (oximeter) 2) CONTINUOUS ADRENALINE

NEBULISATIONS for two hours and hope that the child improves to Grade II

3) If the obstruction remains at Grade III, consult the Paediatrician on call

4) If the obstruction progresses (at any time) to Grade IV then…

GRADE IV 1) Continuous adrenaline nebulisations using

100% 02 2) URGENT INTUBATION, preferably in theatre 3) Intubation in casualty or ward only if time does

not permit transfer to theatre. In this case remember to use an ETT 2 sizes smaller than usual for age. Intubate under etomidate 0,3mg/kg IV slowly

Transfer to the nearest ICU with the ETT well secured and with the child in head box oxygen after making contact with the ICU personnel

O R O P H A R Y N G E A L O B S T R U C T I O N The commonest MISSED cause of upper airway obstruction

Clinical Features Mouth breathing Nasal speech Recurrent otitis media Postnasal discharge with night-time cough

Frequent snoring at night which may wake the child from sleep

Obstructive sleep apnoea Child AND mother are sleepy during the day

In children, snoring is NEVER normal

Consequences Of Snoring/Obstructive Sleep Apnoea

Daytime drowsiness and irritability Learning problems

Enuresis Cor pulmonale

Aetiology

1) Allergic rhinitis 2) Adenoidal hypertrophy 3) Tonsillar hypertrophy

4) Pierre-Robin Sequence 5) "Floppy pharynx" as in Down Syndrome

Investigations 1) X-ray posterior nasal space (lateral view) 2) Oxygen saturation awake and especially

during sleep

3) Chest X-ray and ECG if cor pulmonale present

Indications For Adenoidectomy And Tonsillectomy 1) Three or more episodes of acute otitis media

in preceding 12 months 2) Secretory otitis media 3) Obstructive sleep apnoea syndrome 4) All children undergoing tonsillectomy

5) Two or more of the following: mouth breathing snoring recurrent sinusitis

ADMIT if ANYTHING on history or examination suggests obstructive sleep apnoea REFER TO ENT if any of above indications are present

URGENT referral to ENT if history of obstructive sleep apnoea. Do not waste time with an X-ray. Endoscopy will be done in ENT clinic in Durban

Last modified: 30 March 2004 1 For review: 2005




D I A R R H O E A L D I S E A S E 1. Definition

Diarrhoea is the frequent passage of loose watery stools, secondary to an infection of the GIT. It remains one of the main killers of children in the developing world

2. Why is it Important? Morbidity: common, delays healing/exacerbates comcommitant illness, precipitates kwashiorkor/marasmus Mortality: one of the commonest causes of preventable/avoidable mortality in the developing world

3. What is the Severity? Extravascular Volume

Overhydrated↑ Normal ↔ 5% dehydrated↓ 10% dehydrated Intravascular volume:

Hypervolaemia↑ Normal ↔ Hypovolaemia↓ Life threatening ↑liver warm feet ↑heart rate gasping

full neck veins normal pedal pulses poor pedal pulses absent pedal pulses

↑respiratory distress responsive ↓consciousness BP < 60 mm Hg

gallop rhythm urine ≥ 2 ml/kg/hr oliguria / anuria not responsive

4. What are the Implications of Severity? Ambulatory care if...

drinking eagerly, hydration normal, normovoleamic Admit if...

drinking poorly, vomitting excessively, dehydrated, hypovolaemic PLUS readmission admitted within past 28 days for diarhoeal disease young infant < 28 days old / 1 - 3 months malnutrition kwashiorkor / marasmus / wt for ht < 3rd centile / wt < 3rd centile fever temperature ³ 38°C infection measles, HIV, urinary tract, meningitis, pneumonia, septicaemia, other dysentery blood and/or mucus in stool PR exam [Y / N] fits / encephalopathy hypoglycaemia blood glucose < 2.6 mmol/ l HIV/AIDS positive lab tests, clinical features (lymphadenopathy, hepatosplenomegaly, FTT) Significant complications and other problems:

pH < 7.2 K+ < 2.0 K+> 6 Na+<120 Na+> 150

Refer if...

metabolic “chaos”, only once normovolaemia has been established.

Last modified: 30 March 2004 2 For review: 2005

5. What is the cause? Conditions to exclude Infant: breastmilk stools, malabsorption syndromes Toddler: toddlers diarrhoea Older child: organophosphate poisoning Definitive diagnosis necessary

Usually not Initial Investigations depend on severity at presentation

acid-base serum Na+ , K+, Cl urea, creatinine FBC, diff blood glucose Chest X ray abdominal X ray Mantoux blood culture HIV serology urine dipstix urine MC&S urine Na+ , K+, Cl- lumbar puncture coagulation screen

stool MC&S ÿ serum salicylate

6. What is the Management Ambulatory:

ORS plus extra food in recovery phase, don’t stop breastmilk, milk, food In-patient:

see guideline: DD – initial management including fluids In-transit:

ensure prescribed fluids are continued, ensure oxygen is given

7. What is the Follow Up? Nil if...

in most cases Level 1 if..

concomitent nutritional compromise Level 2 if...

encephalopathic during illness Level 3 if..

.malabsorption syndrome

8. What are the Preventive Measures? Home-based: handwashing, food preparation, ORS Health service-based: IMCI guidelines

9. What Information Should be Given to Caregivers? The condition: self limiting The management: replace fluid losses The prognosis: depends on complications The follow up: as above The prevention: as above





D I A R R H O E A L D I S E A S E : I N I T I A L M A N A G E M E N T I N C L U D I N G F L U I D S Fluid management in acute gastroenteritis

Hypovolaemic shock IV 20 ml/kg colloid or isotonic crystalloid fluid as fast as possible repeat volume expander in 10 ml/kg boluses until pulses easily palpable or evidence of venous distension (liver enlarging, full veins) Maintenance < 1 year 120 ml/kg/24 hrs (or breast ad lib) 1 -2 years 100 ml/kg/24 hrs 2-3 years 85 ml/kg/24 hrs > 3 years 70 ml/kg/24 hrs Rehydration give over 12hrs if well nourished, but over 24 hours if malnourished (PEM) 5% dehydrated 50 ml/kg/24 hrs ≥10% dehydrated 100 ml/kg/24 hrs (do not give more than 100 ml/kg) Losses initial estimate for replacement 20 - 30 ml/kg/24 hrs or 30 - 50 ml / loose stool Notes 1 Calculate requirements after hypovolaemic shock has been corrected 2 IV fluids: use ½ DD unless otherwise indicated 3 oral fluids: withold formula, but not breast, until rehydrated (6 - 12 hours) then use ORF for rehydration & losses; breast or formula for maintenance

Example Calculation of fluids: for an infant weighing 5 Kg, 5% dry, still having frequent watery stools Maintenance: 120 ml/kg/24 hrs 120 x 5 = 600 ml/24 hrs Rehydration: 50 ml/kg/24 hrs 50 x 5 = 250 ml Ongoing losses: ±20 ml/kg/24 hrs 20 x 5 = 100 ml Total requirements: 190 ml/kg/24 hrs = 5 x 190 ÷ 24 = 40 ml/hr = 80 ml 2 hrly = 120 ml 3 hrly Give as: if taking orally and not vomitting milk 100ml x 6 + 15ml/hr If NPO 40 ml/hr


Investigations Children with uncomplicated gastroenteritis will not normally need laboratory investigations. The tables give guidelines for commonly required investigations.

do ALL these tests… …in ANY of these conditions

urine multistix acid base, Na, K, urea

creatinine blood glucose (dextrostix), haemoglobin (or FBC)

severe or life threatening illness any "red flag" (readmission, < 6 months,

malnutrition, fever infection, dysentery, fits/encephalopathy, hypoglycaemia, HIV/AIDS, the much older child)

failure to improve despite adequate fluid therapy hypotonia/poor head control, ileus/abdominal

distension respiratory distress excessive vomiting and minimal diarrhoea anuric despite adequate rehydration doughy skin turgor/questionable home preparation

of ORF

Other common tests… …and their indications chest X ray suspected pneumonia, TB

abdominal X ray suspected intestinal obstruction; perforation, NEC blood culture neonate, suspected infection, kwashiorkor lumbar puncture neonate, meningitis, convulsion urine mcs neonate, septicaemia, UTI, kwashiorkor stool mcs dysentery (blood in stool), pyrexia, diarrhoea > 7 days serum Cl persistent metabolic acidosis

serum salicylate level traditional Rx, unexplained metabolic acidosis, raised anion gap

HIV serology lymphadenopathy, failure to thrive/wasting

Differential diagnosis

of diarrhoea gastroenteritis, parenteral diarrhoea due to eg pneumonia, otitis

media, UTI; HIV

of blood and mucus in stool

invasive organism eg shigella, amoeba, NEC, campylobacter

surgical conditions eg intussusception haemorrhagic colitis following enemas with toxic

substances

of vomiting gastroenteritis (Norwalk, rotavirus) meningitis, UTI, pyloric stenosis, intestinal

obstruction, otitis media, tonsillitis





D I A R R H O E A L D I S E A S E : I N I T I A L M A N A G E M E N T I N C L U D I N G F L U I D S Fluid management in acute gastroenteritis

Hypovolaemic shock IV 20 ml/kg colloid or isotonic crystalloid fluid as fast as possible repeat volume expander in 10 ml/kg boluses until pulses easily palpable or evidence of venous distension (liver enlarging, full veins) Maintenance < 1 year 120 ml/kg/24 hrs (or breast ad lib) 1 -2 years 100 ml/kg/24 hrs 2-3 years 85 ml/kg/24 hrs > 3 years 70 ml/kg/24 hrs Rehydration give over 12hrs if well nourished, but over 24 hours if malnourished (PEM) 5% dehydrated 50 ml/kg/24 hrs ≥10% dehydrated 100 ml/kg/24 hrs (do not give more than 100 ml/kg) Losses initial estimate for replacement 20 - 30 ml/kg/24 hrs or 30 - 50 ml / loose stool Notes 1 Calculate requirements after hypovolaemic shock has been corrected 2 IV fluids: use ½ DD unless otherwise indicated 3 oral fluids: withold formula, but not breast, until rehydrated (6 - 12 hours) then use ORF for rehydration & losses; breast or formula for maintenance

Example Calculation of fluids: for an infant weighing 5 Kg, 5% dry, still having frequent watery stools Maintenance: 120 ml/kg/24 hrs 120 x 5 = 600 ml/24 hrs Rehydration: 50 ml/kg/24 hrs 50 x 5 = 250 ml Ongoing losses: ±20 ml/kg/24 hrs 20 x 5 = 100 ml Total requirements: 190 ml/kg/24 hrs = 5 x 190 ÷ 24 = 40 ml/hr = 80 ml 2 hrly = 120 ml 3 hrly Give as: if taking orally and not vomitting milk 100ml x 6 + 15ml/hr If NPO 40 ml/hr


Investigations Children with uncomplicated gastroenteritis will not normally need laboratory investigations. The tables give guidelines for commonly required investigations.

do ALL these tests… …in ANY of these conditions

urine multistix acid base, Na, K, urea

creatinine blood glucose (dextrostix), haemoglobin (or FBC)

severe or life threatening illness any "red flag" (readmission, < 6 months,

malnutrition, fever infection, dysentery, fits/encephalopathy, hypoglycaemia, HIV/AIDS, the much older child)

failure to improve despite adequate fluid therapy hypotonia/poor head control, ileus/abdominal

distension respiratory distress excessive vomiting and minimal diarrhoea anuric despite adequate rehydration doughy skin turgor/questionable home preparation

of ORF

Other common tests… …and their indications chest X ray suspected pneumonia, TB

abdominal X ray suspected intestinal obstruction; perforation, NEC blood culture neonate, suspected infection, kwashiorkor lumbar puncture neonate, meningitis, convulsion urine mcs neonate, septicaemia, UTI, kwashiorkor stool mcs dysentery (blood in stool), pyrexia, diarrhoea > 7 days serum Cl persistent metabolic acidosis

serum salicylate level traditional Rx, unexplained metabolic acidosis, raised anion gap

HIV serology lymphadenopathy, failure to thrive/wasting

Differential diagnosis

of diarrhoea gastroenteritis, parenteral diarrhoea due to eg pneumonia, otitis

media, UTI; HIV

of blood and mucus in stool

invasive organism eg shigella, amoeba, NEC, campylobacter

surgical conditions eg intussusception haemorrhagic colitis following enemas with toxic

substances

of vomiting gastroenteritis (Norwalk, rotavirus) meningitis, UTI, pyloric stenosis, intestinal

obstruction, otitis media, tonsillitis





D I A R R O E A L D I S E A S E : “ M E T A B O L I C M A N A G E M E N T ” Metabolic acidosis

Five causes: Hypoperfusion, hypoxia, dead tissue, exogenous anions, bicarb losses With mild illness this needs neither measurement nor treatment. Restoration of intravascular fluid volume will allow the acidosis to be corrected by the kidneys. Indications for lab tests are given on page 2.

If pH < 7.1, half correct acidosis as a slow bolus: calculation : ml 8.5 % NaHCO3 = ½ x 0.3 x body weight in kg

NB. Exercise caution in patients with K+ < 3.4 mmol/l or Na+ > 145 mmol/l Exercise caution if patient is hypoventilating

Hypokalaemia 1) IF K < 3.4: Give oral Rx: 100 mg KCl / kg/dose (=1ml/kg/dose MIST POT CHLOR) 6 hourly for 2 days (maximum 3 g / day or 750 mg / dose)

1 g KCl = 10ml KCl = 13.4 mmol K+

2) IF K< 2.0 MMOL/L Give IV Rx: add 2 ml KCl (15% solution) to 200 ml ½DD (to give a concentration of 40 mmol/litre K+). Monitor acid-base & electrolytes 4-hourly till K+ >2,5mmol/l

1 ml 15 % K C l = 2 mmol K; maximum possible is 40mmol/litre

Hyperkalaemia (K> 4.5) Establish cause: eg renal failure; excess supplementation; tissue necrosis 1) IF K> 6.0 MMOL/L:

stop all K intake - NB check both prescription and fluid therapy charts; check acid-base status; correct acidosis; monitor urine output; preferably monitor ECG (peaked tall T waves, broad QRS, ventricular fibrillation); 4 hourly serum K, acid-base, urea, creatinine

2) IF K> 7.0 MMOL/L: This is life threatening. Manage as above, and commence stepwise treatment:

1) nebulised salbutamol 1 ml in 2 ml saline; repeat 3 hrly PRN (fenoterol is also used for this purpose) 2) IV 10% calcium gluconate 0.5 ml/kg over 5 minutes; repeat hourly if necessary (Use cardiac monitor and stop

immediately if bradycardia occurs) 3) Kayexalate 1 g / kg/dose per os or as retention enema; repeat 6 hourly if necessary 4) NOTIFY CONSULTANT (insulin infusion and/or dialysis may be needed)


Hyponatraemia –if Na < 130 mmol/l If on oral fluids, repeat serum Na in 4 hours. If on IV fluids, or if serum Na falling on oral fluids, supplement sodium intake with IV normal

saline. Add 2 ml 15% KCl and 20 ml 50% dextrose water to 200 ml normal saline.

m m o l N a = w e i g h t i n K g x 0 . 6 x ( 140 - serum Na ) ml normal saline = 6 x mmol Na

Monitor serum Na 12 - 24 hourly - aim to correct over 24 hours. Change back to ½ DD once serum Na > 130 mmol/l

Hypernatraemia (Na > 150)

Potential complications – these are highly likely with Na > 160 mmol/l cerebral oedema: due to serum Na falling too rapidly convulsions: due to serum Na falling too rapidly permanent brain damage Failure of serum Na to drop is usually due to inadequate fluid replacement

1) IF NA> 150 MMOL/L

Monitor Na 4-6 hourly. Aim to decrease serum Na by 1 - 2 mmol/hour Aim to correct dehdration over 24 hours Use ½ DD for rehydration (not 5% dextrose water) Ensure that normovolaemia is attained and maintained Half correct metabolic acidosis only if pH < 7.1 (see above for details) Counsel parents and follow-up long term for probable neurological deficit





A C U T E I N F E C T I O U S H E P A T I T I S / H E P A T I T I S A Diagnosis Make a clinical diagnosis:

i.e. age > 6 months Bilirubin in urine Other clinical features are variable, and include recent onset jaundice (<3 weeks), nausea, anorexia, vomiting,

malaise, and a tender, palpable liver WITHOUT signs chronic liver disease:

palpable spleen clubbing hard liver oedema pale nails

WITHOUT clinical complications: bleeding altered level of consciousness dehydration

Management No investigations Manage at home: isolation is not required Notify as “viral hepatitis, undifferentiated”

Indications For Admission Severe persistent vomiting and/or dehydration Hepatic coma/precoma = any form of altered level of consciousness

1) check blood sugar level, set up a 10% dextrose infusion 2) do “baseline” investigations: INR, LFT’s1, hepatitis A&B serology, FBC, venous blood gasses 3) admit directly to high care 4) inform paediatrician

Information To Parents 1) Bring your child back if the jaundice lasts longer than 3 weeks 2) Return immediately if there is:

persistent vomiting drowsiness ataxia

3) Your child may return to school once the jaundice has cleared

1 “LFT’s”: Specifically request total and conjugated bilirubin, total protein & albumin, ALP, LDH and ALT. The “rest” add no further information, and to request them by writing LFT’s on the laboratory form is a waste of money.





L O O K I N G A F T E R C H I L D R E N W I T H C H R O N I C L I V E R D I S E A S E Basic Supportive Care

1 Pruritis 1) Phenobarbitone and Rifampicin sometimes work and are worth trying. Discontinue if no effect 2) Antihistamines sometimes work, try hydroxizine 3) Ursodeoxycholic acid (Ursotan) is the last resort. 10mg/kg/day in three divided doses (very expensive)

2 Nutrition Increase total calorie intake by 10 - 20 % to make up for fat malabsorption, poor intake and anorexia

1) Milk is a good source of energy despite high fat content - so give an extra glass each day 2) If the child is failing to thrive try an MCT-containing milk :

Portagen Pregestimil tastes horrid Prenan

3 Vitamins A: Give double dose of MVT’s i.e. 2 mls/kg of multivitamin syrup D: Give up to 5000iu if the child has rickets. 1 alpha 0,025-0,05 micrograms per day, is a last resort and usually

only used in patients awaiting liver transplant E: Not present in MVT preparations. Give infants 100iu daily and older children 200mg - 400mg daily K: Give 5mg weekly and watch INR

4 Ascites 1) Spironalactone 2 - 3mg/kg/day as a once daily dose 2) 20% Albumin infusions (5 - 7 ml/kg/day ) with Lasix 1mg/kg IVI stat as necessary

5 Varices 1) Warn the mother to look out for upper GIT bleeds (vomiting blood) and to bring her in promptly 2) Resuscitate (do not over-resuscitate) and refer to the appropriate surgical department

Bleeding may have stopped because of decreased venous pressure. Too much or too rapid fluid during resuscitation may lead to a fast rise in venous pressure causing clot dislodging and FURTHER BLEEDING





C O N S T I P A T I O N Clinical features: Distinguish between…

1) TRUE CONSTIPATION Infrequent or irregular passage of unduly hard stools - most commonly in children under 5 years, associated with an anal fissure. 2) FAECAL LOADING Ineffective and incomplete evacuation of stool from the colon, with faecal build-up:

stools may not be hard and faeces may not be felt on abdominal palpation common over 5 years of age, presenting with abdominal pain and/or soiling (involuntary

leakage of small amounts of soft or watery stool)

UNCOMMONLY, constipation may be due to organic causes such as anorectal malformations, Hirshsprung’s disease and hypothyroidism, or in the older child degenerative leiomyopathy (pseudohirschsprung’s)

3) ENCOPRESIS Apparently “wilful” passage of normal stool in inappropriate places; usually associated with severe psychological problems.

Investigations 1) X-ray abdomen - straight film only 2) Urine dipstix 3) Others to exclude organic causes, as clinically indicated (in the older child, consider a rectal biopsy if leiomyopathy

may be the cause)

Management Faecal Loading

Management is similar no matter the underlying cause/origin

1) FAECAL CLEARANCE 1) Fleet or Microlax enema twice a day for 3 days (if

not already used) 2) Balanced electrolyte/polyethylene glycol solution

(Golytely) catharsis (20ml/kg/hour until stools become water-like, 4-8 hours) Requires admission Check effectiveness with repeat x-ray

abdomen 2) EXPLANATION The bowel needs to be re-educated (this takes time i.e. months not days) 3) MAINTENANCE 1) Fibre: bran, fruit, vegetables, whole grain bread

and cereals 2) Metamucil/Fybogel

4) BOWEL RE-TRAINING 1) Regular toilet after meals, regardless of

whether urge is present. An unhurried approach is important (read a book while sitting)

2) Star chart, with rewards for producing the goods

5) ENCOURAGEMENT Involve child as much as possible in management

6) LAXATIVES Use in severe cases only first line: (osmotic laxative) sorbitol (3-

15ml/day, after breakfast) if no response: (peristaltic laxative) Senokot

(1-2 tabs nocte) or bisacodyl (Dulcolax, 5-10mg nocte)

Acute Constipation + Anal Fissure 1) Treat this seriously, to avoid development of

chronic faecal loading 2) Fibre: as above

3) Laxatives: as above 4) If fissure present, use anaesthetic cream applied to

the anal verge

Follow up all cases of faecal loading and constipation until “resolved”.





M O D I F I E D C R I T E R I A F O R D I A G N O S I N G A I D S Children presenting with any of the following (modified) CDC

category C conditions are considered to have AIDS 1) SERIOUS BACTERIAL INFECTIONS,

1) multiple or recurrent (i.e. any combination of at least 2 culture-confirmed infections within a 2-year period), of the following types: septicaemia, pneumonia, meningitis, bone or joint infection,

2) or abscess of an internal organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses,

3) and indwelling catheter related infections).

2) ENCEPHALOPATHY At least one of the following progressive findings present for at least 2 months in the absence of a concurrent illness other than HIV infection that could explain the findings: 1) failure to attain or loss of developmental milestones or loss of intellectual ability; 2) impaired brain growth or acquired microcephaly, demonstrated by head circumference

measurements or, if available, CT or MRI; 3) acquired symmetric motor deficit manifested by 2 or more of the following: paresis, pathological

reflexes, ataxia, or gait disturbance.

3) PNEUMOCYSTIS CARINII PNEUMONIA (PCP) As suspected in young infants (with peak incidence 3-6 months) with severe respiratory distress and hypoxia, and a paucity of auscultatory signs, or in whom induced sputum confirms the presence of the organism

4) WASTING SYNDROME In the absence of a concurrent illness other than HIV infection that could explain the following findings: 1) persistent weight loss >10% of baseline, OR 2) downward crossing of at least 2 percentiles on the weight-for-age chart, OR 3) below 5th percentile on weight-for-height chart on 2 consecutive measurements, more than 30 days

apart,

PLUS

chronic diarrhoea (i.e. at least 2 loose stools per day for >30 days),

OR

documented fever for >30 days, intermittent or constant.

5) EXTRAPULMONARY OR DISSEMINATED TB 6) OPPORTUNISTIC INFECTIONS AS DOCUMENTED IN THE CDC REVISED CLASSIFICATION SYSTEM FOR HIV INFECTION IN

CHILDREN LESS THAN 13 YEARS OF AGE (1994) 7) MALIGNANCIES: LYMPHOMA, KAPOSI’S SARCOMA





H I V / A I D S Taking Caring consent

The HIV status of a child is important in making management decisions which BENEFIT THE CHILD. All children who are suspected of having HIV infection on clinical grounds should be tested as soon as the suspicion occurs and before admission where possible. The Testing and Counselling Service is a good one, but often there isn’t

time, or it is the wrong time, to use this service.

Pre-test Counselling The first contact must be used for pre-test counselling and testing. If a child is being cared for by a person other than the mother find out about that person’s relationship to the child and if that person is the de facto caregiver ask consent from her. Unrelated casual caregivers should be asked to fetch the mother as a matter of urgency. In the absence of a suitable caregiver ask for superintendent's consent. Important points for Pre-test Counselling:

1) The room should be quiet and private 2) Make sure that the carer understands that you are testing for the HIV which causes AIDS and that she

understands what AIDS is 3) Emphasise that by testing the child you are actually testing the mother and the father/current partner 4) Emphasise that HIV infection is very common 5) Emphasise that there is no cure for AIDS - we can help but not cure the child 6) Tell the carer when you expect to get the result and give it to her as soon as possible

Post-Test Counselling Almost everybody nowadays has heard of and is aware of the significance of being infected with HIV. Post-test counselling is an emotional experience for both counsellor and carer whether the result is positive or negative. Be prepared emotionally and clinically. Encourage the carer to ask questions. Important points for post-test counselling

1) Allow sufficient time 1) Repeat all that you discussed during pre-test counselling and check the carer's understanding 2) Discuss the baby’s prognosis both for this illness and long term 3) Tell the carer that HIV weakens the child and the child is likely to have frequent admissions 4) Stress the importance of good nutrition, PCP prophylaxis and regular follow up 5) Discuss the mother's health and prognosis and check her HIV to eliminate lab error on the baby 6) Discuss telling the father (and current partner, if not the father) and offer to help break the news 7) Discuss safe sex 8) Discuss future pregnancies 9) Encourage her to tell a member of her family that she trusts e.g. her mother or sister

Document pre- and post-test counselling in the clinical notes, and document results on the NEW results sheet. Use follow up visits to re-inforce all information provided in counselling sessions.





I N P A T I E N T C A R E O F T H E C H I L D W I T H H I V / A I D S Extra care for children needing admission

Pneumocystis carinii Pneumonia (PCP)

Acute Respiratory Infections in infants with known or suspected HIV infection are likely to be PCP Hypoxia is a significant feature. Any child with severe hypoxia should have a rapid test to ascertain HIV exposure

Diagnosing PCP on the CXR is not easy and can vary from air trapping to segmental consolidation to bilateral white outs (any picture is possible!)

1) Give OXYGEN if necessary 2) If the child needs oxygen give oral PREDNISONE 2mg/kg/daily for two weeks and then wean over two weeks. If

NPO, give dexamethazone 0,6mg/kg/day IV in 4 divided doses; change to oral prednisone when possible. 3) Give high dose intravenous COTRIMOXAZOLE at a dose of 1.25 ml/kg/day in 4 divided doses (20mg/kg/day of

the Trimethoprim component) for 7 days, then 2,5ml/kg/day in 4 divided doses for 2-3 weeks 4) Because PCP infection is often accompanied by a bacterial infection they should also be given IVI AMPICILLIN,

CLOXACILLIN and GENTAMICIN

It seems more effective to treat aggressively from the start with IV’s rather than orals. Once the child is improving he/she can be changed to oral COTRIMOXAZOLE (2.5 ml/kg/day in 4 doses) and

Augmentin ( 20 - 40 mg/kg/day in 3 doses) If intravenous cotrimoxazole is not available, use high dose oral COTRIMOXAZOLE from the start

Other Bacterial Infections

Children who are infected with HIV and who need admission for suspected bacterial sepsis (gastro/ ARI etc) are at higher risk of invasive infections than HIV negative children. Aggressive antibiotic therapy should be considered ab initio

An attempt should be made to identify the organism by taking cultures of blood, stool, urine, CSF and pus as appropriate before starting antibiotic therapy

Candida Albicans Infections Severe candida infections are often resistant to topical therapy and FLUCONAZOLE 5 mg/kg/day for 7 days is

usually very effective, followed by ongoing topical therapy Children with stridor and oral thrush have probable candida LTB (this seems to carry a poor prognosis) For mild oral candida, smear NYSTATIN CREAM 6 hourly, rather than use the drops

Disseminating Varicella-zoster infections Chickenpox and shingles are potentially lethal in HIV-infected children All should receive ACYCLOVIR 5 - 10 mg/kg 8 hourly IVI or 5 x per day orally Severe or extensive Herpes simplex may also need treatment with ACYCLOVIR

Chest infections not responding to usual treatment Investigate for TB by taking a history and doing a Tine (in HIV, a Tine is positive if > Grade I) and gastric

washings Even if there is no positive evidence of TB and if there are persistent CXR abnormalities despite three weeks of

broad-spectrum antibiotics (e.g. amoxil for 10 days then erythromycin for 10 days) a trial of TB treatment is a good idea

TB and LIP are difficult to distinguish apart – ask for help from a colleague, and then make a best guess!!! Follow the National TB Guidelines

Prolonged Oxygen Dependency If oxygen is required for longer than two weeks, PREDNISONE 2 mg/kg/day sometimes seems to help Review after 1 week





A M B U L A T O R Y C A R E O F T H E C H I L D L I V I N G W I T H H I V / A I D S Improving quality of life through basic health measures

HIV/AIDS is a major child health Problem The incidence of HIV infection in antenatal women in the Province of the KZN was about 30% in 2001. About

33% of their babies will contract HIV infection PMB Metropole delivers about 17000 babies per year. Thus approximately 5100 babies were born last year who

were perinatally exposed to HIV infection. Of those about 1700 (without MTCT) will have been infected, 850 with effective MTCT. So, we should be seeing about 1000 new HIV infected children per year in PMB

In the under 2's, AIDS accounts for about 25-50% of admissions

HIV infection is a major health problem facing children and their carers in our region. Even in the absence of anti - retroviral drugs basic health care can make a difference to the quality and duration of their lives.

Should a mother who is HIV infected breastfeed her child? Breastfeeding carries an additional transmission risk of 14% to 50% A mother who can afford infant formula and has access to safe water should be advised not to breastfeed If a mother is poor and from an area without access to safe water, the risks of not breastfeeding may outweigh

the risks of breastfeeding in terms of an increased risk of malnutrition, gastro, ARI’s and other infections

According to National Policy, free formula feeds SHOULD be available at all clinics. Therefore poor mothers SHOULD be given this option. This is a human rights issue

Note: If you are going to advise formula feeds at the same time advise cup feeds

What other nutritional aspects are important? 1) CALORIE INTAKE

All children with HIV infection are at risk of failing to thrive 1) Give an age appropriate nutritious and balanced diet 2) Useful advice to poor mothers is to add a spoon or two of fat (margarine or cooking oil) to the child’s food to

increase nutritional density 3) Monitor and intervene early. Refer all children with HIV/AIDS to Nutrition Support Programmes in your area for

nutritional supplements i.e. milk and vitamins 2) MICRONUTRIENTS Vitamin A and Other Vitamins

Give the standard dose of a multivitamin preparation containing 3000iu Vitamin A per day e.g. Vi - Daylin 5 ml daily from birth

Folate Folate 2,5 mg per day may be of benefit in symptomatic patients

IRON If inadequate intake give prophylactic Fe to prevent Iron deficiency (Elemental iron 3 mg/kg/day)

3) PRACTICAL FEEDING ADVICE

HIV infection is often accompanied by a loss of appetite due to chronic ill health and painful swallowing. (Mouth ulcers, oral thrush). The following hints may be useful:

Anorexia: Frequent small meals (5 - 8 per day) Appetite is usually bigger in the morning so plan bigger meals in the morning Give all fluids as calorie-containing: juices, milk etc (not water) Always have favourite foods available and "bribe" the child if necessary to eat less favoured foods Company promotes appetite so make meals a social occasion and encourage activity


Painful Eating: Soft non acidic foods of even consistency i.e. mashed potatoes and mincemeat Cold liquids help to numb the mouth Avoid salty, spicy or acidic foods i.e. pickles Good oral hygiene to reduce oral infection Local anaesthetic e.g. Tgel Treat oral candida infections

What infection prophylaxis should be given? 1) PNEUMOCYSTIS CARINII PNEUMONIA

PCP is one of the biggest killers of HIV-infected infants. PCP will be the presenting illness in many infants. Prophylaxis is possible and CHEAP. Antenatal screening for HIV infection is important because it will identify at

risk infants. Identify at risk infants (antenatally preferably, but in our setting the infants usually present with clinical signs of

HIV infection) Start PCP prophylaxis at 6 weeks of age (i.e. at the same visit as first vaccine) Cotrimoxazole prophylaxis should be continued until 1 year of age unless the infant is proven to be HIV

negative by 2 PCR’s with one done after 4 months of age. This will not often be applicable in our region due to the costs of the tests. Two or more negative HIV antibody tests between 6 and 18 months of age or one negative antibody test after 18 months in the absence of HIV related illness is also proof that the child is not HIV infected.

After 1 year of age if the child is completely asymptomatic, cotrimoxazole can be discontinued. Any child who has symptomatic HIV infection should be continued on cotrimoxazole prophylaxis for life unless you are monitoring CD4 counts. We do not routinely monitor CD4 counts in PMB. If you can monitor CD4 counts then measure it at one year and if it is less than 15% then continue with PCP prophylaxis.

The recommended dose of cotrimoxazole is 5mg/kg/day of the trimethoprim component daily. This is practically just under 1ml/kg/dayof the cotrimoxazole: trimethoprim 40mg/5 ml.

2) TUBERCULOSIS PROPHYLAXIS Ask carefully about household TB contacts If there is a contact, exclude TB (Skin test and CXR and Gastric Washings for AFB's) and treat according to

national guidelines. (INH/RIF for 3 months) A child suspected as having HIV infection with a reactive tine (induration of 2 mm of any of the 4 puncture sites

or a mantoux induration of 5 mm who has no clinical evidence of TB and has a normal CXR will also need 3 months of INH/RIF)

3) MEASLES AND CHICKENPOX PROPHYLAXIS Measles: Prophylactic immunoglobulin ( 0.5ml/kg ) within 5 days of exposure to measles Chicken pox: zoster immune globulin ( 0.15ml/kg ) within 3 days of exposure chickenpox

4) IMMUNISATIONS Children with HIV infection should receive all the routine childhood immunisations. Babies born to HIV positive mothers should get BCG at birth BCG should not be given to infants with symptomatic HIV infection. Avoid measles immunisation only in severely immunosuppressed patients. Give the second measles at 12

months instead of 18 months as the immune system may be better at 12 months of age Yearly influenza vaccine is probably of benefit and should be given

5) DEWORMING Deworm with mebendezole 6 monthly, after the age of ambulation

Follow up All newborns born of HIV infected mothers should start Cotrimoxazole prophylaxis at their "first vaccine visit" at

6 weeks of age Asymptomatic children (mother is HIV positive) can be seen 3 monthly at their local clinic (but at present many

patients are refusing to go to their local clinic because of confidentiality fears) Symptomatic children should be seen monthly at the Dedicated Metropolitan Outpatient Clinics (by

appointment):

Grey’s: Monday Edendale: Thursday Northdale: Tuesday

Outpatient management of common paediatric problems in children living with HIV Children with HIV infection with intercurrent infections and other minor problems should be managed no differently

from uninfected children. However HIV infected children are prone to more serious, prolonged and recurrent infections and their mothers should be advised to come back if there is no improvement on outpatient treatment





A M B U L A T O R Y C A R E O F T H E C H I L D L I V I N G W I T H H I V / A I D S Improving quality of life through basic health measures

HIV/AIDS is a major child health Problem The incidence of HIV infection in antenatal women in the Province of the KZN was about 30% in 2001. About

33% of their babies will contract HIV infection PMB Metropole delivers about 17000 babies per year. Thus approximately 5100 babies were born last year who

were perinatally exposed to HIV infection. Of those about 1700 (without MTCT) will have been infected, 850 with effective MTCT. So, we should be seeing about 1000 new HIV infected children per year in PMB

In the under 2's, AIDS accounts for about 25-50% of admissions

HIV infection is a major health problem facing children and their carers in our region. Even in the absence of anti - retroviral drugs basic health care can make a difference to the quality and duration of their lives.

Should a mother who is HIV infected breastfeed her child? Breastfeeding carries an additional transmission risk of 14% to 50% A mother who can afford infant formula and has access to safe water should be advised not to breastfeed If a mother is poor and from an area without access to safe water, the risks of not breastfeeding may outweigh

the risks of breastfeeding in terms of an increased risk of malnutrition, gastro, ARI’s and other infections

According to National Policy, free formula feeds SHOULD be available at all clinics. Therefore poor mothers SHOULD be given this option. This is a human rights issue

Note: If you are going to advise formula feeds at the same time advise cup feeds

What other nutritional aspects are important? 1) CALORIE INTAKE

All children with HIV infection are at risk of failing to thrive 1) Give an age appropriate nutritious and balanced diet 2) Useful advice to poor mothers is to add a spoon or two of fat (margarine or cooking oil) to the child’s food to

increase nutritional density 3) Monitor and intervene early. Refer all children with HIV/AIDS to Nutrition Support Programmes in your area for

nutritional supplements i.e. milk and vitamins 2) MICRONUTRIENTS Vitamin A and Other Vitamins

Give the standard dose of a multivitamin preparation containing 3000iu Vitamin A per day e.g. Vi - Daylin 5 ml daily from birth

Folate Folate 2,5 mg per day may be of benefit in symptomatic patients

IRON If inadequate intake give prophylactic Fe to prevent Iron deficiency (Elemental iron 3 mg/kg/day)

3) PRACTICAL FEEDING ADVICE

HIV infection is often accompanied by a loss of appetite due to chronic ill health and painful swallowing. (Mouth ulcers, oral thrush). The following hints may be useful:

Anorexia: Frequent small meals (5 - 8 per day) Appetite is usually bigger in the morning so plan bigger meals in the morning Give all fluids as calorie-containing: juices, milk etc (not water) Always have favourite foods available and "bribe" the child if necessary to eat less favoured foods Company promotes appetite so make meals a social occasion and encourage activity


Painful Eating: Soft non acidic foods of even consistency i.e. mashed potatoes and mincemeat Cold liquids help to numb the mouth Avoid salty, spicy or acidic foods i.e. pickles Good oral hygiene to reduce oral infection Local anaesthetic e.g. Tgel Treat oral candida infections

What infection prophylaxis should be given? 1) PNEUMOCYSTIS CARINII PNEUMONIA

PCP is one of the biggest killers of HIV-infected infants. PCP will be the presenting illness in many infants. Prophylaxis is possible and CHEAP. Antenatal screening for HIV infection is important because it will identify at

risk infants. Identify at risk infants (antenatally preferably, but in our setting the infants usually present with clinical signs of

HIV infection) Start PCP prophylaxis at 6 weeks of age (i.e. at the same visit as first vaccine) Cotrimoxazole prophylaxis should be continued until 1 year of age unless the infant is proven to be HIV

negative by 2 PCR’s with one done after 4 months of age. This will not often be applicable in our region due to the costs of the tests. Two or more negative HIV antibody tests between 6 and 18 months of age or one negative antibody test after 18 months in the absence of HIV related illness is also proof that the child is not HIV infected.

After 1 year of age if the child is completely asymptomatic, cotrimoxazole can be discontinued. Any child who has symptomatic HIV infection should be continued on cotrimoxazole prophylaxis for life unless you are monitoring CD4 counts. We do not routinely monitor CD4 counts in PMB. If you can monitor CD4 counts then measure it at one year and if it is less than 15% then continue with PCP prophylaxis.

The recommended dose of cotrimoxazole is 5mg/kg/day of the trimethoprim component daily. This is practically just under 1ml/kg/dayof the cotrimoxazole: trimethoprim 40mg/5 ml.

2) TUBERCULOSIS PROPHYLAXIS Ask carefully about household TB contacts If there is a contact, exclude TB (Skin test and CXR and Gastric Washings for AFB's) and treat according to

national guidelines. (INH/RIF for 3 months) A child suspected as having HIV infection with a reactive tine (induration of 2 mm of any of the 4 puncture sites

or a mantoux induration of 5 mm who has no clinical evidence of TB and has a normal CXR will also need 3 months of INH/RIF)

3) MEASLES AND CHICKENPOX PROPHYLAXIS Measles: Prophylactic immunoglobulin ( 0.5ml/kg ) within 5 days of exposure to measles Chicken pox: zoster immune globulin ( 0.15ml/kg ) within 3 days of exposure chickenpox

4) IMMUNISATIONS Children with HIV infection should receive all the routine childhood immunisations. Babies born to HIV positive mothers should get BCG at birth BCG should not be given to infants with symptomatic HIV infection. Avoid measles immunisation only in severely immunosuppressed patients. Give the second measles at 12

months instead of 18 months as the immune system may be better at 12 months of age Yearly influenza vaccine is probably of benefit and should be given

5) DEWORMING Deworm with mebendezole 6 monthly, after the age of ambulation

Follow up All newborns born of HIV infected mothers should start Cotrimoxazole prophylaxis at their "first vaccine visit" at

6 weeks of age Asymptomatic children (mother is HIV positive) can be seen 3 monthly at their local clinic (but at present many

patients are refusing to go to their local clinic because of confidentiality fears) Symptomatic children should be seen monthly at the Dedicated Metropolitan Outpatient Clinics (by

appointment):

Grey’s: Monday Edendale: Thursday Northdale: Tuesday

Outpatient management of common paediatric problems in children living with HIV Children with HIV infection with intercurrent infections and other minor problems should be managed no differently

from uninfected children. However HIV infected children are prone to more serious, prolonged and recurrent infections and their mothers should be advised to come back if there is no improvement on outpatient treatment





T H E F I T T I N G C H I L D Stop the fit, remembering that it is a manifestation of another problem

Ensure safety and abort the fit Step 1: Airway

1) Ensure a patent airway and keep the jaw forward 2) Give 100% oxygen by face mask

Step 2: Diazepam

1) Abort the fit Give DIAZEPAM (Valium) INTRAVENOUSLY: 0,3 mg/Kg (max 10 mg) IVI over 2-5 minutes

Rapid administration of diazepam WILL result in respiratory arrest OR

Give DIAZEPAM RECTALLY: 5mg (1ml) under 10 Kg OR 10mg (2ml) over 10 Kg

NEVER give diazepam IMI, as bioavailability is unpredictable

2) If the child is on anticonvulsant therapy, take blood for anticonvulsant level 3) Check the blood sugar level: if low, start a ½ DD infusion 4) Check the blood pressure

Step 3: PHENOBARBITONE

1) If the fit continues and if the patient is not already on an oral anticonvulsant: Give an intravenous LOAD: PHENOBARBITONE 20mg/Kg IV OR

2) If the fit continues for a further 10 minutes: Give a further dose: PHENOBARBITONE 10mg/Kg IV

Step 4: VALIUM REPEAT or CLONAZEPAM If seizures do not stop after another 10 Minutes:

1) Repeat DIAZEPAM (Valium) 0,3 mg/Kg IVI OR

2) Give CLONAZEPAM (Rivotril): Under 10Kg: 0,5mg IVI slowly Over 10Kg: 1 mg IVI slowly

Step 5: Start a Clonazepam infusion If seizures do not stop after a further 15 minutes:

1) Consult Paediatrician on call 2) Admit to High Care/ICU 3) Start a CLONAZEPAM INFUSION: 0,3mg/kg in 200ml 5% DW starting at 5ml/hour and titrating to response

RAPID clonazepam administration WILL cause respiratory arrest High dose clonazepam infusion WILL cause excess secretion from the (upper and lower) respiratory tract


Try to Establish the Cause of the Fit Possible Causes

INFANCY AND EARLY CHILDHOOD 1) Commonest: febrile convulsions 2) More serious: meningitis and encephalitis 3) Brain damage and defects 4) Metabolic abnormalities

OVER 5 YEARS 1) Commonest: idiopathic epilepsy 2) Neurocysticercosis 3) Meningitis/encephalitis 4) Brain damage 5) Metabolic abnormalities

Take a HISTORY:

1) The current context: fever, vomiting, drowsiness, behaviour 2) The fit: generalised or focal (at onset), tonic/clonic or other (describe), alteration of consciousness, incontinence

of urine and/or faeces, duration 3) The background context: perinatal history, developmental history, family history, past medical history

(especially previous fits and medication) Do An Examination:

1) Did you check the blood pressure? 2) Look for: fever and its cause, neck stiffness, depressed level of consciousness, focal signs, middle ear disease

Investigate: Fit for the first time

1) Did you check the blood sugar? 2) U&E, Albumin, Ca&Mg, FBC, Blood Culture 3) A LUMBAR PUNCTURE must be done unless contraindicated by focal signs or signs of raised intracranial

pressure (i.e. alteration in consciousness)

A lumbar puncture may not be necessary IF there are no features of meningitis AND the child is over 2 years of age

4) Refer for an URGENT CT Scan if: There is a persistently depressed level of consciousness +/- focal signs Otorrhoea is thought to be related to the fit

5) Refer for elective CT if: The fit is focal or there are localising signs The fit is prolonged

An ultrasound can be done if the fontanel is open

6) Refer for EEG if: suspected absence attacks uncertainty about whether the child has had a convulsion (post-ictal slowing supports the

diagnosis of a seizure) myoclonic epilepsy

Investigate: Fit for a subsequent time

1) Did you check the blood sugar and blood pressure? 2) Lumbar puncture if symptoms or signs suggest meningitis

Investigate: BREAKTHROUGH seizure on medication

1) Did you check the blood sugar and blood pressure? 2) A drug level should be done at presentation (i.e. before further doses of the relevant anticonvulsant)





T U B E R C U L O U S M E N I N G I T I S An early diagnosis makes for a better outcome

What is the Problem? Tuberculous meningitis is extremely common, to the extent that it is now the commonest cause of meningitis in the Western

Cape

TBM is a basal meningitis causing a severe vasculitis, which results in infarction, particularly of the brainstem

Why is it Important? Morbidity: 80% mental handicap, 25% motor handicap Mortality: “high”

What is the Severity? Initial severity is defined by the findings at presentation. Stage 1

Non-specific symptoms and signs. May present with lethargy only. Stage 2

Meningeal signs, with neurological fallout and signs of raised intracranial pressure Stage 3

Depressed level of consciousness

Children in our setting usually present with advanced disease. Sometimes this is because of the reasonable parental thought that the child with vague symptoms will get better, sometimes it is because healthworkers have not had a high enough index of

suspicion early in the illness. Only 1/3 of TBM patients are diagnosed on their first visit!

What are the Implications of Severity? All children with suspected TBM should be admitted. All children with signs of raised ICP should have a CT Scan because the cause may be hydrocephalus, which is treatable. If your hospital has no scanner, refer to a hospital with one.

What is the cause and the associated problems? The cause in children is haematogenously disseminated AFB’s. All children with any other sign of disseminated AFB’s –like a

military appearance on Chest X-ray - should have a lumbar puncture.

1) DIAGNOSE TBM Find the household contact Skin test Chest X-ray: child and caregiver Find AFB’s: CSF, sputum, gastric washings, lymph node biopsy (tailor to age and presentation findings)

A lumbar puncture should be done in all patients unless contra-indicated by signs of raised ICP. Definitive diagnosis is essential as it determines treatment, which needs to be comprehensive and sustained

CSF FINDINGS The following findings support the diagnosis of TBM: pleocytosis with lymphocyte predominance,

high protein, low chloride. A CSF picture that differs from this does NOT exclude TBM. In TBM, the protein is usually still markedly high a month after treatment onset

Exclude other infections, especially cryptococcus (CSF) Exclude space taking lesions: tumour and abscess (CT Scan)


2) EVALUATE RAISED INTRACRANIAL PRESSURE

70% of hydrocephalus in TBM is communicating, 30% is non-communicating

Raised ICP may be due to hydrocephalus which is easily treatable, or cerebral oedema which is not easily treatable:

Do opening and closing pressures on the CSF at lumbar puncture and consider doing an air encephalogram – injecting 5ml of air after LP is the easiest, quickest and cheapest way of determining whether the hydrocephalus is “communication” or not. Do a skull X-ray within half an hour with the child sitting up.

Do a CT Scan: look for dilated ventricles, basal enhancement, areas of infarction 3) EVALUATE AND DOCUMENT NEUROLOGICAL DEFICIT

Do a thorough neurological assessment, and do a developmental screen as soon as possible after admission. The degree of recovery is often remarkable, and we should be documenting this.

4) LOOK FOR SIADH Check urine osmolality inappropriately high for serum osmolality + hyponatraemia.

What is the Management? 1) AMBULATORY: STATE

There is no place in the treatment of TBM for ambulatory care. Admit all suspected/confirmed cases. Never discharge until you are sure that you have achieved a cure.

2) KILL THE AFB’S Rifampicin 20mg/kg/day Isoniazid 20 mg/kg/day

Pyrazinamide 40 mg/kg/day Ethionamide 20 mg/kg/day

Continue treatment for six months, except for PZA, which is stopped after three months. Rarely, you could consider ambulatory care after 3 months’ inpatient management. Then the child should get DOT five times per week

If transferring a child with (suspected) TBM, initiate treatment prior to transfer

3) TREAT HYDROCEPHALUS Non-communication: Emergency VP shunt Communicating: Acetazolamide 100mg/kg/day 8 hourly PO (max 1g/day) and furosemide 1-2 mg/kg/day 24

hourly PO for one month, +/- serial lumbar punctures 4) DAMPEN THE VASCULITIS

Steroids decrease morbidity and mortality. Give prednisone 4mg/kg/day for one month then taper 5) TREAT SIADH

Give normal maintenance fluids for age (discuss with Paediatrician).

Fluid restriction is probably illogical, and it worsens hypovolaemia, thrombosis and overall outcome

What is the Follow Up? Long term follow up venue is determined by the degree of neurodevelopmental deficit. Optimisation of

neurodevelopment by physio- and occupational therapists should begin IN HOSPITAL, involving the caregiver early.

In any child with severe developmental delay, a care dependency grant should be applied for at the earliest practical opportunity. Encourage the caregiver to start obtaining the necessary documentation from early on (see separate guideline on Grants)

What are the Preventive Measures? Home-based: alleviate poverty and overcrowding Health service-based: BCG may offer some protection, notification, case finding, and DOT.

What Information Should be Given to Caregivers? Caregivers should be informed that the hospital stay will be a long one and that a neurodevelopmental deficit is possible. Assistance should be provided from very early on with learning home-based physiotherapy and occupational therapy, and with grant applications.





G L O M E R U L O N E P H R I T I S – A C U T E Clinical Presentation The classical presentation is the triad:

1) Facial oedema 2) Coke or tea-coloured urine 3) Oliguria

APSGN is uncommon before 2 years of age Impetigo is present in > 50% of cases (other associations include scabies and pharyngitis)

Severity Life threatening complications include:

1) Volume overload progressing to cardiac failure, pulmonary oedema and respiratory failure 2) Hypertension progressing to encephalopathy +/- coma +/- blindness 3) Acute renal failure

The severity of the illness is determined by the degree of hypertension and the amount of volume overload. BOTH CAN KILL. Hypertensive encephalopathy and pulmonary oedema may occur with minimal peripheral oedema and mild renal failure

Investigations Diagnose nephritis

Urine dipstix and M,C&S (go to lab quickly before casts disintegrate) Evidence of Streptococcal infection (if no impetigo present): ASOT/Anti-DNAse B, throat swab C3/C4

Evaluate Hypertension Check all pulses and do 4 limb BP’s if pulses absent or asymmetrical

Fundoscopy Fits LOC

Evaluate Volume Overload

CXR: to check for cardiomegaly, pulmonary congestion, pleural effusion Check Renal Function and Exclude Nephrotic Syndrome

Renal function: urea, creatinine, Na+ & K+, total protein/albumin (ALWAYS) Remember there may not be proteinuria in a child with nephrotic syndrome who has severe hypoalbuminaemia Monitor urine output


Management for All

Admit all children with acute nephritis (possible and probable)

1) OBSERVATIONS 1) Pulse and BP 4 hourly (more frequently if BP and Mx so dictate) 2) Daily weight 3) Daily test-tube urine displayed above patient’s bed (DAILY DIPSTIX IS NOT NECESSARY) 4) Strict intake and output measurement

A satisfactory care plan can be made using these observations and a focussed clinical assessment

2) ROUTINE CARE 1) Restrict fluid to insensible loss only (15ml/kg/24 hours) when first admitted, and until no longer volume

overloaded. Then increase to normal intake over a full day. 2) Restrict sodium intake until fluid overload is resolved. (This means: no chips, nik-naks etc and no added salt in

the food) 3) Restrict protein if urea > 20 mmol/l

3) RX 1) PENICILLIN VK 50mg/kg/day 6 hourly for 10 days (or ERYTHROMYCIN 25-50mg/kg/day 6 hourly if impetigo

present) 2) FUROSEMIDE 1-2 mg/kg/dose orally 12 hourly

Management when the child’s life is in danger 1) IF PULMONARY OEDEMA IS PRESENT:

1) Sit upright 3) Oxygen 4) Morphine 0,1 mg/Kg IVI 5) Furosemide 2 mg/Kg IVI over 5-10 minutes. (giving FUROSEMIDE fast causes deafness) If no response in 20-

30 minutes, double the dose. 6) Admit to ICU or HCU if no diuresis NOR rapid clinical improvement.

1) IF HYPERTENSION IS PRESENT:

A very important part of management is to re-establish urine flow by using adequate doses of FUROSEMIDE 1) Give additional FUROSEMIDE IVI up to a maximum of 5 mg/kg. 2) If BP > 140 systolic and/or >100 diastolic, give NIFEDEPINE (Adalat) 5 mg under tongue. NIFEDIPINE can be

given 4-6 hourly. An alternative is dihydralazine 0.1-0.8 mg/kg/dose IMI 4 hourly. 3) Monitor BP hourly thereafter until stable 4) If BP is not controlled on NIFEDIPINE, give HYDRALAZINE 1-5mg/kg/day 6 hourly orally

If Renal Failure is present:

Monitor K+, urea and creatinine

Discharge Home When: 1) Urine macroscopically clear AND oedema resolved AND blood pressure normal AND urea/creatinine normal or

falling rapidly ON

2) Normal diet and fluid intake AND OFF

3) FUROSEMIDE and anti-hypertensive agents: i.e. spontaneous diuresis has occurred

Follow Up: Should occur 3-6 monthly for two years to check urine dipstix and blood pressure





N E P H R O T I C S Y N D R O M E This condition is COMPLETELY different in pathophysiology and clinical manifestation – apart from oedema – to

acute nephritis. Managing one as the other may lead to death.

Clinical Features Characterised by the triad:

1) Proteinuria (4+ on disptix) 2) Hypoalbuminaemia 3) Hypercholestrolaemia

Important things to look for on clinical examination Despite the oedema, which may be extreme, INTRAVASCULAR VOLUME is depleted. Look for hypoperfusion

and shock Ascites Pleaural effusions Evidence of infection (remember peritonitis) Evidence of other disease process (which may indicate the underlying aetiology (e.g. SLE) Hypertension

Admit all cases of suspected nephrotic syndrome

Investigations You WILL miss the diagnosis of nephroic syndrome if you base the diagnosis on 4+ proteinuria on dipstix in case where HYPOALBUMINAEMIA is extreme, and there is no more albumin to leak out. ALL children presenting with

oedema should have their albumin levels checked. 1) MAKE THE DIAGNOSIS OF NEPHROTIC SYNDROME

Do a urine protein:cereatinine ratio on the admission urine sample or the next morning >200 mg protein/mmol creatinine is diagnostic (make sure you get the units right)

Total protein and albumin Cholestrol Complement

2) DETERMINE RENAL FUNCTION U&E and creatinine

3) FIND A CAUSE Infections: Hepatitis B, VDRL, ASOT, AntiDNAse B, HIV

4) RULE OUT A URINARY TRACT INFECTION Urine M,C&S (expect hyaline and granular casts)

5) RULE OUT TUBERCULOSIS (IN CASE STEROIDS ARE INDICATED) Cest X-ray and mantoux

6) CONSULT RENAL SERVICE FOR FURTHER MANAGEMENT PLAN Grey’s Hospital Renal Clinic is on Wednesday mornings by appointment only (033 897 3185)


Immediate management in Ward while Initiating above steps Daily urine dipstix for protein Salt restriction (no added salt to food) Prophylactic penicillin VK 250mg 12 hourly while oedema

Diuretics and fluid restriction are NOT part of the management and in a child who is already intravascularly depleted, this may have dire consequences

Indications for albumin and lasix (use only in consultation with a paediatrician): Severe periorbital oedema leading to impaired vision Hypoperfusion i.e. cold peripheries, weak pulses, hypotension Severe ascites compromising diaphragmatic function

Steroids can be started if: The child is >1 year old and < 10 years No hypertension No renal failure No macroscopic haematuria No evidence of other disease (Hep B/SLE/Syphilis?TB) Complement levels are normal

Steroid regimen Prednisone 2mg/kg/day for 6 weeks then Prednisone 2mg/kg on alternate days for 4 weeks then Taper over 2 weeks

Prevent thrombotic complications: Give aspirin 75mg – 150 mg daily

Refer to Nephrologist in Durban if: The child did not fit the criteria for starting steroids (as above) Steroid resistence (ongoing proteinuria on above regimen) Steroid dependency (recurrence of proteinuria when tapering) Frequent relapses Unacceptable steroid side effects

If a renal biopsy becomes necessary, this should only be done by an individual/in a centre where renal biopsies are performed regularly. DON’T dabble in renal biopsies





U R I N A R Y T R A C T I N F E C T I O N Clinical Features

Children rarely present with dysuria and frequency. At all ages: fever, vomiting, diarrhoea, lethargy, anorexia. In very young infants: jaundice and septicaemia also.

Diagnosis A urine dipstix MUST be done in all children with a febrile illness with no obvious cause.

Urine specimen must be fresh when tested. Mid stream specimen in older children Urine bag after cleaning perineum with warm water. This is a SCREENING test only

If both nitrites and leukocytes are negative, a UTI is excluded. If either is positive, a UTI is suggested. If the dipstix on the bag specimen is positive then a supra-pubic aspiration MUST be done (occasionally a

catheter specimen will be needed). While doing the suprapubic aspiration, have a urine sample bottle ready and open in case the child urinates – if you are quick enough, you can obtain a “clean catch” MSU

If the dipstix is positive on the suprapubic (or catheter, or “clean catch”) specimen, the urine should be sent to the laboratory for M,C&S.

A urinary tract infection is confirmed when: Midstream: pure growth >105 Suprapubic and catheter specimens: pure growth, any count Granular casts suggest pyelonephritis Mixed growth requires repeat testing

Absence of leukocytes on dipstix in a NEONATE does NOT exclude a UTI

Management Home, if no systemic features and >6 weeks of age, on:

NALIDIXIC ACID 50mg/kg/day in 4 doses x 5-7d Admit, if systemic effects or infants <6 weeks, on:

GENTAMICIN 7,5 mg/Kg/day IV/IM single dose daily (smaller gestational age related doses in neonates) OR, if renal failure present: CEFOTAXIME 100mg/Kg/day IV in 3-4 doses

OR CEFTRIAXONE 80 mg/Kg/day IV/IM daily

Also Anti fever measures Extra fluids (if no renal failure) Blood culture, U&E, FBC and BLOOD PRESSURE

In ALL cases of UTI, confirmed on a laboratory M,C&S, renal ultrasound and MCUG must be done, irrespective of age and gender.

Renal U/S and MCUG should be done 6 weeks after the UTI and nalidixic acid 25mg/Kg/day in 2 doses should be given until then.

Refer to Paediatric Surgery if a renal abnormality is detected





I N N O C E N T M U R M U R S Diagnosis is by exclusion of organic cardiac lesions.

Understanding how murmurs come to be

If you understand some basic pathophysiology you won’t be confused by some confusing terminology that is used widely and loosely. All murmurs are “flow murmurs” and are “physiological” in some way or another!

Blood Flow

Normal Abnormal (Increased)

Normal “Innocent”

Fever, Anaemia,

Hyperthyroidism etc (“functional”)

Anatomy: Vessels Valves Walls

Chambers Abnormal Co-arct,

Incompetence, VSD, HOCM,

etc

↑ ← Both

Innocent Murmurs

1) CHARACTERISTICS 1) short - except a venous hum (continuous) 2) systolic 3) Grade III or softer 4) altered by change in position 5) often “musical”

2) NORMAL PHYSICAL EXAMINATIONESPECIALLY: normal cardiac impulse femoral pulses 2nd heartsound not loud normal split

3) INVESTIGATIONS

Chest X-ray - of little use in a probable innocent murmur with no other physical signs.

ECG - in basal murmurs to exclude ASD (RSR’ pattern).

4) MANAGEMENT FBC to exclude anaemia Reassurance If in doubt, follow-up: Age > 3 months: in 1 yr Age < 3 months: in 1 month

Types of Innocent Murmurs 1) STILLS MURMUR

Midsystolic. Maximum intensity mid to lower left sternal border. Radiates to the apex and base. Musical. Differentiate this from a small VSD

2) PULMONARY FLOW MURMUR

Early to midsystolic. Upper left sternal edge. Neonates (specially prems) often have a soft

ejection murmur at the base, radiating to axillae and back. Disappears before 1 yr of age.

3) CAROTID BRUIT

Midsystolic. Best heard in the neck just above the clavicles. Differentiate from aortic stenosis which is loudest below clavicle.

4) VENOUS HUM Continuous, with diastolic component often

louder than systolic. Maximal just below clavical. Best heard with patient sitting or standing. Disappears if neck is turned or compressed.

5) APICAL MURMUR Localised. Midsystolic. High pitched, musical.





W H Y D O A P A E D I A T R I C E C G ? 1. What are the components of a clinical cardiac assessment?

You may be clever enough to make an anatomical diagnosis, but no cardiac assessment is complete without a determination of haemodynamic significance, and a ruling out of possible associations.

Cardiac assessment

Diagnosis Haemodynamic Significance Associations

Anatomy Conduction Cyanoisis Heart Failure Pulmonary Hypertension Other

Dysmorphology Infective Endocarditis

To make a cardiological assessment, we use:

Clinical acumen (including, always, 4-limb blood pressures) Chest X-ray Electrocardiogram

2. What can an ECG be used for? The ECG has a defined (and limited) use in assisting with making a diagnosis, and in determining haemodynamic significance.

ECG Usefulness

Diagnosis Haemodynamic Significance

Cardiac Non-cardiac Chamber Hypertrophy

3. What format should I use to read and report on an ECG? Before looking at the ECG tracings, write down these headings and then attempt to fill each one in. End with a summary.

1) Rate: on a 10 second strip, count the R waves & multiply by 6 2) Rhythm: ensure a P wave before each QRS 3) PR Interval: each small block is 0,04s (use lead II) 4) Axis: use Leads I and aVf to generate vectors on this diagram → → 5) Right Atrium (lead II) 6) Left Atrium (leads II and V1) 7) Right Ventricle (leads V4R and V1) 8) Left Ventricle (leads V5&6) 9) Summarise

I ⊕

aVf ⊕

NW


4. What diagnoses can be made on a paediatric ECG? A few diagnoses ARE possible on the ECG. Don’t try to work this one out – just remember it parrot fashion (it’s less difficult

than it first appears!!!)

ECG Diagnoses

Cardiac Non-Cardiac

Conduction Anatomy

Extrinsic Intrinsic ASD Configurations Ebstein

Anomaly: Q in V1: Raised ST

Segment SMA

Long PRI: ARF

SA Node: WAP LAR SVT

Massive RAH, no

RV waves

IRBBB, L-TGA, UVH,

PP>SP, AOCA

Convex: ischaemia

Baseline tremor in

limb leads

Metabolic: K+ Ca

Rx etc

AV Node: WPW

Other re-entry

tachy’s

Concave: “Peref”

Axis Pink Blue Right/Normal Secundum TAPVD

Left/Northwest “Primum”= AVSD

Common atrium

Purkinje’s: IRBBB CBBB

Long QT ( )544.0 Vin

QTRRQTc ≤−=

5. How can haemodynamic significance be ascertained on a paediatric ECG? In paediatric cardiology, irreversible pulmonary hypertension (PHT) renders the underlying cause inoperable. ALWAYS look for

right ventricular hypertrophy.

Chamber Hypertrophy

The others

Right Ventricle

RVH RAH LAH LVH

V1 R wave >12 mini blocks Upright T wave (1 week-

12 years)

II P wave >2,5 mini blocks

(high)

II P wave > 3 mini-blocks

(wide) Bifid/biphasic

V5 R wave >4 big-blocks

(high)

V4R:

> 12 mini blocks V1:

Sinusoidal V6

>3 big-blocks

Causes: PHT

RVOFTO

Causes: Ebstein TA/TS ASD

Causes: Mitral stenosis

Causes: LVOFTO

PDA

Enjoy your paediatric ECG’s, and impress your colleagues! Abbreviations: PDA=persistant ductus arteriosis; R/LVOFTO=right/left ventricular outflow tract obstrction; L,RV/AH=left,right ventricular, atrial hypertrophy; ASD=atrial septal defect; TA/TS=tricuspid atresia/stenosis; PHT=pulmonary hypertnsion; SMA=spinal muscular atrophy; peref=pericardil effusion; IR/CBBB=incomplete t/complete bundle branch block; L-TGA= l- transposition of the great arteries;





M I C R O C Y T I C A N A E M I A Failure to detect and treat IRON DEFICIENCY ANAEMIA, which is extremely common in the first two years of life,

leads to AVOIDABLE global DEVELOPMENTAL DELAY

Anaemia is defined as a haemoglobin level which is below the lower limit of normal for age. Normal Values - Lower Limits

Age Hb (g/dl) MCV (fl) Birth 13,5 100 6 weeks 9,5 80 3 months 10,0 72 6 - 12 months 10,5 70 1 - 1,5 years 10,5 70 1,5 - 4 years 11,0 74 4 - 7 years 11,0 76 7 - 12 years 11,5 78 Post-pubertal: Boys 14,0 80 Girls 12,0 80

(For the upper limit of the MCV add 15 to the lower limit.) Diagnostic approach

Low Hb for Age

WBC and platelets normal WBC &/or platelets

abnormal

Simple anaemia Complex anaemia

MCV Leukaemia

↓ (microcytosis) Normal ↑ (macrocytosis) Marrow aplasia

Iron deficiency Thalasaemia

Chronic disease

Folate deficiency Liver Disease

Anticonvulsants B12 deficiency (rare)

Reticulocyte count

↓ ↑

Chronic disease Blood Loss Haemolysis


Microcytic Anaemia Clinical History: worms, diet, blood loss, milk intake (type and quantity) Examination: co-incidental in MOST cases Management Treat for iron deficiency unless: Liver, spleen or lymph nodes are enlarged MCV < 60

1) ELEMENTAL IRON 3mg/Kg/day in 1-2 doses 2) CHECK THE HAEMOGLOBIN in 1 month. Expect a rise of 2-3g/dl in 1 month. A response to iron confirms iron

deficiency. Check monthly until normal 3) Once normal, CONTINUE TREATMENT FOR 8 WEEKS, to replenish body stores 4) Antiparasitics (give at time of diagnosis and repeat at first follow up visit)

MEBENDAZOLE (Vermox) 5ml OR 1 tablet 12 hourly for 3 days OR ALBENDAZOLE (Zentel: very expensive) 20ml OR 2 tablets stat (in children older than two years)

5) Ensure COW’S milk intake is not excessive

If No Response to Iron Therapy Consider: 1) “non-compliance” 2) ongoing blood loss 3) another diagnosis - thalasaemia 4) chronic infection 5) Then…

Ferritin

↓ ↑

Wrong dose iron

Iron not taken Decreased absorption

Ongoing blood loss

Thallasaemia Chronic infection

Investigations (when clinically applicable): 1) Serum ferritin: (iron stores) 2) Stool:

occult blood (ongoing blood loss) trichuris ova (cause of blood loss) colour change (confirm taking iron)

3) Hb electrophoresis: (confirm thalasaemia) 4) Chest X-ray 5) Tine test 6) ESR Management Manage according to clinical condition. When adherence to therapy is in doubt, consider parenteral iron (observing the special precautions in the package insert)

Refer If: 1) White cells and/or platelets also abnormal 2) Purpura, petechiae etc 3) Enlarged liver, spleen or lymph nodes 4) Rapidly dropping haemoglobin

5) Jaundice 6) No response to iron therapy 7) Heart failure (related to severe anaemia)

If FBC Is Not Available: Treat for iron deficiency anaemia without a full blood count, provided that:

the Hb level is at least 80% of the lower limit of normal for age, the child is otherwise well and specifically has no purpura, liver/spleen enlargement or jaundice.

If there is no response to iron in 1 month a full blood count is then necessary.

Information to Parents (Iron Deficiency Anaemia) 1) EXPLAIN THE NATURE OF THE CONDITION. “The blood is ‘weak’ because of a shortage of iron in the body.” 2) ADVISE ON DIET

sources: liver, meat, egg yolk, green vegetables, whole grains, legumes iron in meat is better absorbed than that in vegetables and cereals avoid tea and very high fibre diets Consider reducing or eliminating cow’s milk intake

3) TAKE IRON FOR AS LONG AS PRESCRIBED, EVEN IF THE CHILD IS FEELING WELL: take iron with food (ideally with orange juice) the colour of the stools may change to grey, or even black keep the medicine well away from young children

REMEMBER: As few as 4 iron tablets can kill a toddler

hildren in k z -n - kzn department of health< 1 month 50 000u per os today and tomorrow 1 month...

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