Maternal and Child Health Flashcards

Question

Global Burden of Maternal Mortality How many maternal deaths per year? Compare MMR SSA & HIC: /100,000 live births Life Time Risk

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

* # of mat deaths in a given period per 1000 women of reproductive age during the same time period * MMRate = # mat deaths/# WRA x 1000 * MMRate = MMR x GFR * MMRate = 1(1-LTR)^1/35 (WRA=Wom of Rep Age; GFR=General Fert Rate; LTR=Lifetime Risk; MMR=Mat Mort Ratio) * Indicates burden of maternal death in rep age female popn - captures both risk of death per preg or per total birth (inc live and still births) * Weakness: conceasl the effects of different levels of fertility

Answer 5

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

Answer 6

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

Answer 7

1. Hemorrhage 27% 2. Indirect Causes - diabetes, hypertension, anemia, malaria, HIV, TB etc. 27% 3. Hypertension 14% 4. Sepsis 11% 5. Abortion 8% 6. Embolism 3% 7. Other direct causes 10% * Current Global MMR 216/100,000 LB * SDG Goal \<70 by 2030

Answer 8

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

Answer 9

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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

* “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice” Institute of Medicine 2001 * Health care should be: 1. Safe 2. Effective 3. Timely 4. Efficient 5. Equitable 6. People-centred * Tools * Maternal death audit/review * Maternal death Surveillance & Response * Perinatal death audit/review * Standards based audits

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

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

Answer 24

* junction of bladder and urethra

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

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

Answer 30

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

Answer 31

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

Answer 32

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

Answer 33

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

Answer 34

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

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

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

Answer 40

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

Answer 41

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

Answer 42

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

Answer 43

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

Answer 44

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

Answer 45

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

Answer 46

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

Answer 47

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

Answer 48

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

Answer 49

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

Answer 50

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

Answer 51

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

Answer 52

* coch review: active vs expectant management of 3rd stage reduces risk of severe primary PPH (RR 0.34) 1. oxytocin 10 iu iv/im * if no Skilled Birth Attendant or oxytocin, give misoprostol 600 mcgm daily 2. Controlled Cord Traction by SBA recommended 3. assess pp uterine tone abdominally to r/o atony 4. CCT recommended method for removal of placenta at CS

Answer 53

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

Answer 54

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

Answer 55

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

Answer 56

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

Answer 57

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

Answer 58

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

Answer 59

* a model at looking at barriers to access

Answer 60

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

Answer 61

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

Answer 62

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

Answer 63

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

Answer 64

Food Nutr Bull. 2015 Mar;36(1 Suppl):S76-87. Environmental enteric dysfunction: an overview. Crane RJ, Jones KD, Berkley JA. Abstract BACKGROUND: Environmental enteric dysfunction (EED) refers to an incompletely defined syndrome of inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine. It is widespread among children and adults in low- and middle-income countries. Understanding of EED and its possible consequences for health is currently limited. OBJECTIVE: A narrative review of the current understanding of EED: epidemiology, pathogenesis, therapies, and relevance to child health. METHODS: Searches for key papers and ongoing trials were conducted using PUBMED 1966-June 2014; ClinicalTrials.gov; the WHO Clinical Trials Registry; the Cochrane Library; hand searches of the references of retrieved literature; discussions with experts; and personal experience from the field. RESULTS: EED is established during infancy and is associated with poor sanitation, certain gut infections, and micronutrient deficiencies. Helicobacter pylori infection, small intestinal bacterial overgrowth (SIBO), abnormal gut microbiota, undernutrition, and toxins may all play a role. EED is usually asymptomatic, but it is important due to its association with stunting. Diagnosis is frequently by the dual sugar absorption test, although other biomarkers are emerging. EED may partly explain the reduced efficacy of oral vaccines in low- and middle-income countries and the increased risk of serious infection seen in children with undernutrition. CONCLUSIONS: Despite its potentially significant impacts, it is currently unclear exactly what causes EED and how it can be treated or prevented. Ongoing trials involve nutritional supplements, water and sanitation interventions, and immunomodulators. Further research is needed to better understand this condition, which is of likely crucial importance for child health and development in low- and middle-income settings.

Answer 65

**Pathogens associated with enteropathy and growth faltering** Colonisation with mucosal damage – rather than overt diarrhoea: * **• Campylobacter** * **• EAEC (enteroaggerative E. coli)** * **• Giardia** Kosek MN. Causal Pathways from Enteropathogens to Environmental Enteropathy: Findings from the MAL-ED Birth Cohort Study. EBioMedicine 2017;18:109-117.

Answer 66

Major types of malnutrition are – Stunting (chronic; 24% world’s children) – Wasting (acute; 7.5%) – Overweight / obesity (6%) – Plus micronutrient deficiency Undernutrition underlies 45% of all deaths; most occurring in mild/moderate undernutrition Multiple/interlinked underlying causes – but recent focus on effect of enteropathogens on gut health/function

Answer 67

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

Answer 68

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

Answer 69

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

Answer 70

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

Answer 71

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

Answer 72

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

Answer 73

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

Answer 74

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

Answer 75

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

Answer 76

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

Answer 77

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

Answer 78

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

Answer 79

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

Answer 80

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

Answer 81

* mortality 18% overall * 32% P. falciparum parasitemia of whom 21% died * 26% at least one virus of whom 33% died * mostly adenovirus; mumps, human herpes virus 6, rabies, cytomegalovirus, herpes simplex virus 1, and enterovirus were also important * 9% had both cerebral malaria and viral infection * A third of the children who met the case definition for cerebral malaria had viral infections, **including a quarter of the children who had the characteristic retinal changes** thought to be diagnostic of cerebral malaria. Although fewer patients had viral infection than parasitaemia, more children with viral infection died, even when patients with rabies—which is uniformly fatal—were excluded. Lancet Glob Health. 2013 Sep;1(3):e153-60. Viral CNS infections in children from a malaria-endemic area of Malawi: a prospective cohort study. Mallewa M, Vallely P, Faragher B, Banda D, Klapper P, Mukaka M, Khofi H, Pensulo P, Taylor T, Molyneux M, Solomon T. Abstract BACKGROUND: Fever with reduced consciousness is an important cause of hospital admission of children in sub-Saharan Africa, with high mortality. Cerebral malaria, diagnosed when acute Plasmodium falciparum infection and coma are recorded with no other apparent reason, is one important cause. We investigated whether viruses could also be an important cause of CNS infection in such patients, and examined the relative contribution of viral pathogens and malaria parasitaemia. METHODS: We did a prospective cohort study in Blantyre, Malawi. From March 1, 2002, to Aug 31, 2004, we enrolled children aged between 2 months and 15 years who were admitted to hospital with suspected non-bacterial CNS infections. Children with a cerebrospinal fluid (CSF) white cell count of less than 1000 cells per μL and negative bacterial microscopy and culture were deemed to have suspected viral CNS infection. Blood was examined for asexual forms of P falciparum. PCR was done on CSF or on post-mortem brain biopsy specimens to detect 15 viruses known to cause CNS infection. FINDINGS: Full outcome data were available for 513 children with suspected viral CNS infection, of whom 94 (18%) died. 163 children (32%) had P falciparum parasitaemia, of whom 34 (21%) died. At least one virus was detected in the CNS in 133 children (26%), of whom 43 (33%) died. 12 different viruses were detected; adenovirus was the most common, affecting 42 children; mumps, human herpes virus 6, rabies, cytomegalovirus, herpes simplex virus 1, and enterovirus were also important. 45 (9%) of the 513 children had both parasitaemia and viral infection, including 27 (35%) of 78 diagnosed clinically with cerebral malaria. Children with dual infection were more likely to have seizures than were those with parasitaemia alone, viral infection only, or neither (p\<0·0001). 17 (38%) of the 45 children with dual infection died, compared with 26 (30%) of 88 with viral infection only, 17 (14%) of 118 with parasitaemia only, and 34 (13%) of 262 with neither (p\<0·0001). Logistic regression showed children with a viral CNS infection had a significantly higher mortality than did those who did not have a viral CNS infection (p=0·001). INTERPRETATION: Viral CNS infections are an important cause of hospital admission and death in children in Malawi, including in children whose coma might be attributed solely to cerebral malaria. Interaction between viral infection and parasitaemia could increase disease severity.

Answer 82

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

Answer 83

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

Answer 84

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

Answer 85

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

Answer 86

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

Answer 87

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

Answer 88

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

Answer 89

Clinical features with good “red flag” value **• Globalassessment/behaviour** – Parental concern LR+ 14.4 – Clinician instinct LR+ 23 **• Temperature** – T \>=40C in low prevalence setting – In high prevalence setting, raised temperature no rule in value, and **absence of fever had good rule out value** • Circulatory & respiratory – Cyanosis LR+ 3 to 52 – Rapid breathing LR+ 1.3 to 10 – Shortness of breath LR+ 1.1 to 9 – Poor peripheral circulation LR+ 1.5 to 39 Clinical features with good “red flag” value Meningeal irritation LR+ 2.6 to 275 Petechial rash LR+ 6 to 84 Several clinical features need to be considered to r/o SBI Effective safeguards to ensure children w/o red flags are not missed (van den Bruel A, Lancet 2010)

Answer 90

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

Answer 91

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

Answer 92

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

Answer 93

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

Answer 94

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

Answer 95

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

Answer 96

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

Answer 97

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

Answer 98

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

Answer 99

* Really Sick Children Must Take No Exercise 1. Rubella (alt Varicella for Very for shingles) 2. Scarlet Fever 3. Chicken Pox 4. Measles 5. Typhus 6. Nothing 7. Enteric Fever (Typhoid, paratyphoid)

Answer 100

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

Answer 101

1. Mild Measles * small, frequent feeds * acetaminophen * saline gtts for blocked nos * oral hygeine for rinsing mouth * ocular hygeine * Vitamin A capsule (2 doses in 2 days) * 200,000 IU/day\>12m, 100,00 IU 6-12 m, 50,000 IU\<6m * oral rehydration solution * use oral antibiotic * Admit if signs or symptoms of severe measles 2. Severe measles * iv antibiotics * O₂for pneumonia * tx croup with nebulized adrenaline * diarrhea: oral rehydration and antibiotics if bloody stool * otitis media: antibiotics and regular aural hygeine * xeropthalmia: protective eye pad and aural hygeine * malnutrition. treat to SAM guidelines * encephalopathy 3. Prevention and f/u * adequate nutrition * watch for TB, often seen after measles * chronic persistent diarrhea * gammaglobulin (if available) for susceptible contacts if \<1 yr old * improve vaccination coverage

Answer 102

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

Answer 103

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

Answer 104

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

Answer 105

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

Answer 106

1. active screening for sore throat (not for assymptomatic carriers) and prompt treatment of pharyngitis with oral Abx 2. regular dosing with abx after RF * Rheumatic fever with carditis and residual heart disease (persistent valvular disease†) * 10 years or until age 40 years (whichever is longer); lifetime prophylaxis may be needed * Rheumatic fever with carditis but no residual heart disease (no valvular disease†) * 10 years or until age 21 years (whichever is longer) * Rheumatic fever without carditis 5 years or until age 21 years (whichever is longer)

Answer 107

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

Answer 108

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

Answer 109

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

Answer 110

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

Answer 111

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

Answer 112

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

Answer 113

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

Answer 114

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

Answer 115

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

Answer 116

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

Answer 117

* pH: 7.35 – 7.45 * pO2: 10 – 14kPa\* (75-105 mm Hg) * pCO2: 4.5 – 6kPa\* (34-45 mm Hg) * Base excess (BE): -2 – 2 mmol/l * HCO3: 22 – 26 mmol/l \*1kPa = 7.5mmHg. p stands for the ‘partial pressure of…’

Answer 118

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

Answer 119

Circumoral Pallor Scarlet Fever

Answer 120

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

Answer 121

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

Answer 122

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

Answer 123

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

Answer 124

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

Answer 125

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

Answer 126

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

Answer 127

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

Answer 128

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

Answer 129

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

Answer 130

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

Answer 131

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

Answer 132

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

Answer 133

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

Answer 134

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

Answer 135

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

Answer 136

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

Answer 137

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

Answer 138

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

Answer 139

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

Answer 140

* Measles * BCG * Yellow Fever * 6 hours

Answer 141

* DPT, DT, TT * i.e. Toxoids

Answer 142

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

Answer 143

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

Answer 144

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

Answer 145

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

Answer 146

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

Answer 147

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

Answer 148

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

Answer 149

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

Answer 150

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

Answer 151

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

Answer 152

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

Answer 153

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

Answer 154

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

Answer 155

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

Answer 156

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

Answer 157

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

Answer 158

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

Answer 159

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

Answer 160

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

Answer 161

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

Answer 162

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

Answer 163

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

Answer 164

* tool for reorganization

Maternal and Child Health Flashcards

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