Academic Courses
FACULTY OF CLINICAL MEDICINE AND SURGERY
Unit 1: Topic 1 Introduction to Paediatrics and Child Health 1
Learning outcomes
- By the end of this lesson, the learner should be able to:
- Define Paediatrics and child health terminologies
- Explain concepts and principles in Paediatrics and Child health
- Take
a comprehensive paediatric history
- Pediatrics is a •Is a
medical speciality that
is
concerned with
the health of infants, children, and adolescents;
•their growth and development; &•their opportunity to achieve full potential as adults.
Neonatology:
is a
medical specialty of care of newborn babies, sick babies and premature
babies
Neo-new
natal—birth
ology---science of
Preterm:- baby
born before 37 weeks gestation
A preterm can be an
(AGA)-
appropriate for gestational age
small for gestational age(SGA)
or LGA
–Large for gestational age
Very
low birth weight (VLBW) –Is a baby weighing 1.5kgs 0r less
Extremely low birth weight– is a baby weighing 1kg
or less
Incredibly low birth weight-- 750g
or less.
LGA=Birth
wt >
90th centile for gestational age.
SGA–
Birth wt <
10th centile for gestational age
Infant
mortality rate:-
number of deaths in the 1st 12months per a 1000 live
births
Neonatal mortality rate:-no. of deaths in the 1st 28 days per a thousand live
births
Perinatal mortality rate:- still births and neonatal deaths
up to 7 days per 1000 total births
Perinatal
mortality =includes all stillbirths
&neonatal deaths in the 1st wk of
life. It is any death or abortion > 500g or death at 24 wks and more
still birth – a
baby born after 24 weeks gestation of pregnancy and does not show at any time
signs of life (cardiopulmonary activity
Neonatal mortality accounts for 50% of infant
mortality in developing countries
A
normal newborn
is a baby born between 37—41wks
weighs 2.5kgs—4kgs
head circumference 33—37cm
APGAR score 7—10
length 50cm, no abnormalities & does not require resuscitation at
birth
UNIT 1: Topic 2 Paediatric History
Topic two:
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Topic name |
PAEDIATRIC HISTORY |
- History taking is the corner stone of clinical practice
- One needs to have the ability to distill the important information from history
- This builds up clinical skills, attitude towards patients knowledge about diseases and disorders
- Parents are acutely interested in and anxious about their children
- Parents usually can recognize clinicians who are empathic, demonstrate interest and concern
- Parents seek out clinicians who possess appropriate skills and attitudes towards their children
Child age is always a key feature, it determines
The nature and presentation of illness, development or behavioral problems
The way in which the history taking and examination are conducted
The way in which any subsequent management is organized
Never ignore parents, these are astute observers of their children
Make sure you have read any referral letter and scanned the notes before start of the interview
Welcome child and parents and address them by name
Introduce yourself
Determine relationship of adult to child
Establish eye contact and rapport with the family. Infants and toddlers are most secure in a parents arms or lap.
Young children may need some time to know you, don’t rush them
Ensure that the interview room is as welcoming and unthreatening as possible
Have toys available. Observe how the child separates, plays and interacts with other sibling available
Do not forget to address questions to the child when appropriate
Some occasions the parents would not like to be with the child or when the child should be seen alone
This is to avoid any embarrassment to the child e.g. teenage children
It is important to note that
Pediatrics is a specialty governed by age, the illnesses and the problems children encounter are highly age dependent. The child’s age will determine the questions to be asked on history taking, how to conduct the examination, the diagnosis and ddx and the management plan
Start with the patients identification data: name, age, occupation/ level of education residence, address, next of kin, inpatient number, ward, date of admission
Complains and duration (what brought the patient to hospital
History of presenting illness. History must be adapted to the age e.g. the age when a|
Make sure you have read any referral letter and scanned the notes before start of the interview Welcome child and parents and address them by name Introduce yourself Determine relationship of adult to child Establish eye contact and rapport with the family. Infants and toddlers are most secure in a parents arms or lap. Young children may need some time to know you, don’t rush them Ensure that the interview room is as welcoming and unthreatening as possible Have toys available. Observe how the child separates, plays and interacts with other sibling available Do not forget to address questions to the child when appropriate Some occasions the parents would not like to be with the child or when the child should be seen alone This is to avoid any embarrassment to the child e.g. teenage children It is important to note that Pediatrics is a specialty governed by age, the illnesses and the problems children encounter are highly age dependent. The child’s age will determine the questions to be asked on history taking, how to conduct the examination, the diagnosis and ddx and the management plan Start with the patients identification data: name, age, occupation/ level of education residence, address, next of kin, inpatient number, ward, date of admission Complains and duration (what brought the patient to hospital History of presenting illness. History must be adapted to the age e.g. the age when a child first walks is relevant when taking history of a toddler but irrelevant to a teenager with headaches. Full details of presenting problems are required. Let the parent and child recount the presenting problems in their own words and at their own pace. Note the parents words verbatim about the presenting complaint. Ensure that you ask about: Onset of the complaints Duration and previous episodes What relieves/aggravates symptoms What is the time course of the problem Is the problem getting worse and are there any associated symptoms Has the child’s or family lifestyle been affected? If so what has the family done Find out: What prompted referral to a doctor What is the fear that the parents have, this is an important factor
Past medical and surgical history What past illnesses has the child suffered from Any hospitalizations and operations (what was the reason, what age, what was the nature and were there any complications) Are there any allergies Are there any bleeding tendencies Any history of accidents and injuries Any past and present medications
Antenatal history How was the health of the mother during the pregnancy of this child Any relevant genetic history of parents Any history of infection during pregnancy Any abnormality detected in antenatal u/s History of amniocentesis Antenatal profile and results (HIV, VDRL, Urinalysis, BS for MPS, HB), ITN, SP, Folate, ferrous sulphate Any immunization e.g. TT
Natal history What was the kind of labour Type of delivery Birth weight Duration of labour How was first cry State of infant at birth Neonatal: APGAR score, color, respiratory distress, excessive salivation, abdominal distension, meconium passed or not.
Nutrition history Exclusive breast feeding Eating patterns History of vomiting after feeds Difficulty in swallowing Developmental Milestones (key developmental milestones) Neck support, sitting, standing, walking, speaking, schooling, Urinary continence Control of defeacation Unusual growth School grade Current milestone and whether upto date Immunization history KEPI schedule Comment on either up to date; fully immunized or defaulter Personal Social economic History Check Relevant information about the family and the community-parental occupation, economic status, housing, refuse disposal, water treatment, relationships, parental smoking, marital stresses, habits and hobbies. Is the child happy at home, Is the child happy at school many childhood illnesses or conditions are permeated by adult problems e.g. Alcohol and drug abuse Long term unemployment/poverty Poor, damp and crammed housing Parental psychiatric disorders Unstable partnership Family history Position of the patient in the family Should include information about illnesses in the family e.g. parents, siblings and grandparents Cause of death of close relatives (parents and siblings) Presence of any serious illnesses in the family (chronic familial disease (diabetes, asthma heart disease, hypertension, sickle cell). Systemic review Selected as appropriate Respiratory system – cough wheeze, breathing problems, throat infections, stridor (noisy breathing), snoring CVS – oedema , cyanosis, exercise intolerance, orthopnoea, dyspnoea GIT – vomitting, diarrhea/constipation, abdominal pain GUT – dysuria, frequency, wetting, toilet trained CNS – seizures, headaches, abnormal movements, paralysis Examination Approach Obtain child’s cooperation Make friends with the child, Be confident but gentle, Avoid dominating the child Do short mock examinations e.g. on the mother or teddy bear – this may allay a young child’s fears, Start examination from non-threatening areas e.g. hand or knee Explain to the child what you are about to do, what you want him/her to do, in a language they can understand. A smiling talking doctor appears less threatening, but this should not be overdone as it can interfere with ones relationship with the parents Leave unpleasant procedures until last Babies in the first few months are best examined on the couch with the parent next to them A toddler is best examined initially on the mother’s lap, or occasionally on the parents shoulder. Parents are reassuring to the child and can facilitate good examination if guided on what to do
Preschool children can in the beginning be examined as they play Older teenagers are often concerned of their privacy. A teenage girl should be examined in the presence of their mother, nurse or chaperone. Be aware of cultural sensitivities from different ethnic groups Undressing Children Be sensitive on children’s modesty It is easiest and kind to ask the parent to do the undressing The area to be examined should be inspected fully, but done in stages, redressing the child when each stage has been completed Warm clean hands: hands must be washed before and after examining a child. Warm smile, warm hands and warm stethoscope all help Requirements A well-lit room, Chair, Examination coach, Stethoscope, Touch, Sterile gloves, Tongue depressant
General examination Initial survey or Observations Careful observation is key to success in examining children. Look before touching the child Inspection will provide Severity of illness, Growth and nutrition, Behaviour and social responsiveness, Level of hygiene Is the child sick or well? If sick, how sick. For the acutely ill infant or child, perform the 60 sec rapid assessment Airway and breathing – respiration rate and effort, presence of stridor, wheeze, cyanosis etc Circulation – heart rate, pulse volume, peripheral temperature, pallor Disability – level of consciousness general state of health Dressing, grooming and personal hygiene height, weight, build, motor activity, facial expression, state of awareness or level of consciousness. The general morphological appearance may suggest chromosomal or dysmorphic syndrome In infants palpate the fontanelles and sutures Check the skin, head, face, eyes, nose and Check for clinical signs: Pallor, Jaundice, Cyanosis, Finger clubbing, Oedema, Dehydration, Lymphadenopathy Systemic examination Respiratory System Examination Inspection – Nose: is there any discharge, abnormality of the nose, flaring of alae nasae Mouth: cyanosis (central cyanosis) Harrison sulcus (indrawing of lower ribs, Rachitic rosary (rickets), Barrel chest/ pigeon chest (COAD), count the Respiratory rate, Chest movements . Signs of respiratory distress (nasal flaring, subcostal and intercostal recession, head nodding cyanosis, grunting) noisy breathing wheeze. Tachypnea: rate of respiration is usually age related Dyspnea: labored breathing. This is judged by nasal flaring, expiratory granting, use of accessory muscles of respiration, retraction of the chest wall from use of suprasternal, intercostal, and subcostal muscles Harrison sulcus (from diaphragmatic tug), this occurs from poorly controlled asthma Asymmetry of chest movements Respiratory Rates in Children Age normal Tarchypnea Neonate 30-50 >60 Infant 20-30 >50 Young child 20-30 >50 Older child 15-20 >40 Difficulty in speaking or feeding Chest shape, hyper-extension or barrel shape e.g. in asthma Pectus excavatum (hollow chest) or pectus carinatum (pegion shaped) Palpation – tracheal deviation, tenderness, swelling, chest expansion. Percussion Note any localized dullness – dullness suggests lung collapse, consolidation or fluid Auscultation (use ears and stethoscope)Note the quality and symmetry of breath sounds and added soundsHarsh breath sounds from the upper airway are transmitted to the upper chest in infants · Note hoarse void – refers to abnormality of the vocal cords Auscultation --normal vesicular sounds, bronchial breathing, ronchi, crepitations, air entry) · Stridor – is a harsh, low pitched, mainly inspiratory sound from upper airways obstruction · Note the breath sounds – normal breath sounds are vesicular, · Bronchial breathing is high pitched and the lengths of inspiration and expiration are equal · Wheeze is high pitched, expiratory sound from distal airway obstruction · Crackles – discontinuous moist sounds from the opening of bronchial · Chest abnormalities in children · Bronchiolitis – labored breathing, hyperinflated chest, chest reccession, hyper-resonant, fine crackles in all zones, wheeze may or may not be present · Pneumonia – reduced breath sounds on the affected side on chest movement, rapid, shallow breaths, bronchial breathing on auscultation, crackles
Cardiovascular system Use the inverted J Hand- pallor, cyanosis, oslers nodes, finger clubbing, splinter haemorhages, janeways lesions, Radial pulse, (Pulse- check for the rate, rhythm – sinus arrhythmia (variation of pulse rate with respiration) is normal. Check volume of pulse – is feeble in circulatory failure/insufficiency or aortic stenosis. It is increased in high output states e.g. stress, anemia. It is collapsing in patent ductus arteriosus Blood pressure , Jugular Venous Pressure Palpate the precordium- apex beat (4th ics) thrills, heaves Auscultation – S1, S2, aortic area, pulmonary area, mitral area, tricuspid area. Heart rate and rhythm, Added Heart sounds, Murmurs, Additional sounds – pericardial rub Murmurs check for Site, Timing, Intensity, Character /pitch, Radiation, Relation to respiration, posture and exercises Fixed splitting of second heart sound is heard in atrial septal defect Third heart sound in mitral area is normal in young children Murmurs – when you ausculate a murmur, check for Timing – is it systolic, diastolic or continuous What is the duration – mid systolic (ejection), pansystolic How loud is it – systolic murmurs are graded as: Grade 1 – 2: soft, difficult to hear Grade 3: audible, no thrill Grade 4-6: loud with thrill Check for the area of maximum intensity – mitral, pulmonary, aortic or tricuspid area Check where the murmur radiates to – to neck (aortic stenosis), to the back (coarctation of the aorta or pulmonary stenosis) Hepatomegally -- It’s a sign of heart failure in infants. An infants liver is palpable 1-2cm below the costal margin. Femoral pulses - In coarctation of the aorta, there will be decreased volume or may be impalpable in infants, there will be brachiafemoral delay in older children NB: heart diseases are common in children with other congenital abnormalities or syndromes e.g. downs syndrome or turners syndrome Femoral pulses In coarctation of the aorta, there will be decreased volume or may be impalpable in infants, there will be brachiafemoral delay in older children NB: heart diseases are common in children with other congenital abnormalities or syndromes e.g. downs syndrome or turners syndrome Normal resting pulse rate in children Age beats/min <1 year 110-160 2-5 years 95-140 5-12 years 80-120 <12 years 60-100 Pulse rate increases in children when there is stress, fever, arrhythmia, exercise Features suggesting a murmur is significant It is conducted all over the precordium Is loud There is a thrill (grade 4-6) Any diastolic murmur Is accompanied by other cardiac signs Features of heart failure in infants Poor feeding, failure to thrive Sweating |
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Features of heart failure in infants.. Tarchypnoea Tarchycardia Gallop rhythm Cardiomegally Hepatomegally
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Practical quiz: Explain the difference on auscultation of the following abnormal respiratory Conditions 1. Consolidation 2. Lung Collapse (atelectasis) 3. Pleural effusion 4. Pneumothorax
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Per abdominal examination This is performed in 3 major clinical setting ◦ During routine examination ◦ When there is an acute abdomen ◦ When there is abdominal distension or mass Associated signs in abdominal examinations ◦ Examine eyes for jaundice ◦ Examine tongue for coating and color ◦ Examine fingers for finger clubbing
Inspection Abdomen is protuberant in normal toddlers and young children Generalized abdominal distension is explained by the five f’s ◦ Fat ◦ Fluid (ascites – uncommon in children, commonly nephrotic syndrome) ◦ Faeces (constipation) ◦ Flatus (malabsorption, intestinal obstruction) ◦ Fetus (remember this when female child is in puberty)
Occasionally abdominal distension is caused by a grossly enlarged liver and or spleen or muscle hypotonia) Causes of localized abdominal distension are · Upper abdomen: gastric dilatation from pyloric stenosis, hepatosplenomegaly · Lower abdomen: distended bladder or masses · Other signs to be inspected are dilated veins and abdominal striae Inspect for operative scars Inspect for peristalsis – from pyloric stenosis, intestinal obstruction Inspect buttocks if well rounded or wasted as in malabsorption as in coeliac disease or malnutrition Palpation Use warm hands, explain, relax the child and keep the parent close at hand. Ask if it hurts Palpate in systematic fashion – liver, spleen, kidneys, bladder through the four abdominal quadrants
Ask about any tenderness. Watch the child’s face for any grimacing as you palpate NB: a young child may be cooperative if you first start palpating with his hand or putting your hand on top of his Tenderness Is localized in appendicitis, hepatitis, pyelonephritis, generalized mesenteric adenitis, peritonitis Guarding: often not impressive on direct palpation in children. However pain on coughing, on moving about, on walking, bumps during a car journey suggests peritoneal irritation. Back bent on walking maybe be from psoas inflammation in appendicitis Hepatomegally Palpate from right illiac fossa Locate edge with tips or side of finger Edge maybe soft or firm One is unable to get above it Hepatomegally… Moves with respiration Measure (in cm) extension below costal margin in mid clavicular line. Liver tenderness is likely to be inflammation from hepatitis Spleenomegally Palpate from left illiac fossa Edge is usually soft Unable to get above it Spleenomegally.. It moves with respiration Measure size below costal margin (in cm) in mid clavicular line If uncertain whether it palpable or not Use bimanual approach Turn child onto right side A palpable spleen is at least twice its normal size A hyperextended chest in bronchiolitis or asthma may displace liver and spleen downwards mimicking hepatosplenomegaly Causes of Spleenomegally Congenital Infections, Infectious mononucleosis Hepatitis, Malaria, Parasitic infections, Haematological, -Sickle cell anemia, Thallasemia Causes of Hepatomegally Liver disease, Chronic active hepatitis, Portal hypertension, Polycystic disease, Malignancy- Leukemia Lymphoma, Neuroblastoma, Wilms tumor, Hepatocellular carcinoma Metabolic - Glycogen and lipid storage disorders, Mucopolysaccharidosis Cardiovascular- Heart failure
Kidneys Not usually palpable beyond neonatal period unless enlarged or the abdominal muscles are hypotonic On exam ◦ Palapate by balloting bimanually ◦ They move on respiration ◦ One can get above them Tenderness implies inflammation Abdominal masses – these could be: Wilms tumor – these are renal masses, sometimes are visible and does not cross the midline Neuroblastoma – these are irregular firm masses, may cross the midline, the child is usually very unwell Faecal mass – these are mobile, non tender, indentable Intussusception – child becomes acutely unwell, mass may be palpable and most often in the right quandrant. Percussion Liver – dullness delineate upper and lower border, record the span Spleen – dullness delineate the lower border Ascites – shifting dullness. Percus from most resonant spot to most dull point Auscultation Not very useful in routine examination, but important in acute abdomen Auscultation.. Increased bowel sounds – intestinal obstruction, acute diarrhea Reduced or absent bowel sounds – paralytic ileus, peritonitis
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Genital examination Check for inguinal hernia or perineal rash In males check for: ◦ The size of the penis ◦ Development of scrotum ◦ Are the testes palpable? Place one hand on the inguinal area, palpate with the other hand. Record if the testes is descended, retractile or impalpable In males… ◦ Is there any scrotal swelling (it could either be hernia or hydrocele) In females: Examine the external genitalia, comment whether it looks normal. Does the anus look normal? Any evidence of fissure?
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Rectal examination This is not part of routine exam It is unpleasant and disliked by children It’s usefulness in acute abdomen (e.g. appendicitis) is debatable in children as they have a thin abdominal wall and so tenderness and masses can be identified on palpation of the abdomen If intussusception is suspected, the mass maybe palpable and stools looking like redcurrent jam maybe revealed on rectal exam
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CNS - Neurological screen Conduct a quick neurological and development overview Avoid unnecessary examination Adapt it to the child’s age Take into account the parents account of the developmental milestones Watch child draw or write, assess manipulative skills, language, speech, social interactions as appropriate, vision and hearing (are they normal) In infants Assess first by observation…what does one assess? ◦ Posture and movement of limbs ◦ When picking child note the muscle tone. The body or limbs may feel normal or floppy or stiff. Head control maybe poor, with abnormal head lag on pulling to sitting NB: Most children are neurologically intact and do not require formal neurological examination of reflexes, tone etc. Detailed neurological exam is performed only if indicated Detailed Neurological Exam
Observe walking or running q Normal walking heel – toe: a toe – heal walking suggests pyramidal tracts (cortico-spinal) dysfunction particularly hemiplagia or diplagia q A foot drop – suggests superficial peroneal nerve lesion q A tight tendo achilles as in muscular disorder q A broad based gait – immature gait or secondary to cerebellar disorder Patterns of Movement… q Standing from lying down supine – observe children from 36 months of age will turn prone in order to stand because of poor pelvic muscle fixation. But if beyond this age it suggests neuromuscular weakness (duchennes muscular dystrophy) 2. Coordination Assess this by q Asking child to build one brick upon another
Coordination… q Ask child to stretch his arms out straight, close their eyes and observe for tremors or drift q Finger nose testing (use teddy’s nose to reach out and touch if necessary) q Rapid alternating movements of hands and fingers q Touching tip of each finger in turn with thumb q Ask the child to walk heel-toe, jump and hop
Inspection of Limbs Muscle bulk Wasting maybe secondary to cerebral palsy, meningomyelocele, or a muscle disorder or from previous poliomyelitis Increased bulk of calf muscles may indicate duchennes muscular dystrophy 4. Muscle Tone Best assessed by taking the weight of a whole limb and then bending and extending it around a single joint ◦ Testing is easiest at the knee and ankle joints. Assess for the range of movement as well as the general feel of it Increased tone at adductors and internal rotators of the hips, clonus at the ankles or increased tone on pronation of forearms at rest is due to pyramidal dysfunction Scissors of legs in posture of limbs with pronated forearms result from increased tone 5. Truncal Tone In pyramidal tract disorders, the trunk and head tend to arch backwards (extensor posturing) In muscle disease and some central brain disorders, trunk maybe hypotonic. Child feels floppy to handle and cannot support the trunk Head lag: best tested by pulling the child up by the arms from a supine position 6. Power Difficult to test in babies Watch for anti-gravity movements and note motor function From 6 months onwards; watch pattern of mobility and gait From age 4 years, power can be tested formally 6. Reflexes Test with the child in a relaxed position Brisk reflexes may reflect anxiety in the child or due to pyramidal disorder Absent reflexes may be due to neuromuscular lesion or within spinal cord or may be due to poor technique Plantar responses: equivocal. With over reaction. Its unpopular in children as it is unpleasant ◦ Its unreliable in children under 1 year, however upgoing plantar responses provides additional evidence of pyramidal dysfunction 8. Sensation You test the ability to tickle Loss of sensation is likely in meningomyelocele. In this instance do a more detailed sensory testing Cranial Nerves CN 1-These can usually be tested formally from 4 years of age No need to test during routine practice. Can be done by recognizing smell of a hidden mint sweet CN 2- Visual acuity: determined according to age. It refers to clarity of vision, determine smallest letter they can read. Direct and consensual pupillary response tested to light and accommodation CN 3,4,5 – full eye movement through horizontal and vertical planes. Check the presence of squint Check presence of nystagmus – avoid extreme lateral gaze as it can induce nystagmus in normal children CN 6 – clench teeth and waggle jaw from side to side against resistance CN 7 – close eyes tight, smile and show teeth CN 8 – hearing: ask parents, although unilateral deafness may be missed this way CN 9 – levator palate…let them say aagh CN 10 – Recurrent laryngeal nerve – listen for hoarseness or stridor CN 11 – Trapezius and sternomastoid muscles are responsible for power – shrug shoulders and turn head against resistance CN 12 – let them put out tongue and waggle it from side to side
Bones and Joints Presentation of bone and joint disorders include Limb pain, Unwillingness to use limb, Limb, joint or muscle pain Joint swelling, Muscle wasting Inspection Swelling could be due to joint effusion (there will be loss of joint outline) Inspection… Swelling may also be due to synovial thickening (there will be redness, pain on movement) Palpation Palpate for heat, comparing both joints, tenderness, fluctuation or effusion Movements – passive before active in order not to hurt the child. Explain movements in child friendly words. If necessary show with your own limbs the movements you want to test. Record joint movement in degrees Scoliosis – inspect spine especially in older children/adolescents. Ask them to stand straight as a soldier and note the shape of spine Neck Examination Thyroid Inspect for swelling, it is uncommon in childhood, occasionally at puberty Palpate behind and front for swelling, nodule or thrill Auscultate if enlarged Look for sign of hypo/hyper thyroidism
Examination of Lymphnode Examine symmetrically – check the occiput, cervical, inguinal, axillary. Note the size, number and consistency of the nodes felt Nodes can be small, discrete, pea sized, mobile in the neck, groin and axilla. This is common in normal children especially if thin Nodes can be small, multiple nodes in the neck. This is common in URTI which is either viral/bacterial Multiple lymph nodes of variable size in child with extensive eczema Lymph nodes can be large, hot, tender sometimes fluctuant usually on the neck. This can be due to infection or abscess Nodes can be of variable size and shape Nodes can be caused by Infections e.g. viral (infectious mononucleosis), or bacterial (TB) Rare causes e.g. malignancy (usually non tender), kawaski disease, cat scratch
Indications for taking a blood pressure Critically ill child, Child with renal or cardiac disease, Diabetes mellitus, If receiving drugs such as cortico-steroids causing hypertension Technique Measured by use of sphygmomanometer Show child the ballon in the cuff and demonstrate how it is blown up Use a cuff that fits comfortably, covering atleast 2/3rds of the upper arm The child must be calm, relaxed and not crying Systolic pressure is easiest to determine in young children and clinically the most useful Diastolic pressure is when the sounds become muffled Normal: use the available charts related to age. An abnormally high reading must be repeated, with the child relaxed
Examination of the eye Inspect eyes, pupil, iris and sclera Are eye movements full and symmetrical? Is nystagmus detectable? If present, may have cerebellar or occular cause Are pupils equal and central? Is there a squint? Ophthalmoscopy In infants the red reflex is seen from a distance of 20-30cm, absence of red reflex occurs in corneal clouding, cataract or retinoblastoma Fundoscopy Is difficult to conduct, it requires experience and cooperation from the child. Myriadrics are needed in young children Check for the condition of fundi of the eye Retinopathy of prematurity Retinopathy of congenital infections Choriodo-retinal haemorrhages Retinal haemorrhages maybe seen in the shaken baby syndrome (non accidental injury) Exam usually left till last, as it can be unpleasant Explain the procedure Show the parent how to hold and gently restrain a younger child to ensure success and avoid possible injury Throat: Look at the uvula, tonsils, pharynx, and posterior palate Older children, 5 years plus will open their mouths wide open as possible to avoid spatula Look for redness, swelling pus or palatal petechiae, teeth, dental caries and gross abnormality Ear Examine the ear canals and drums gently, trying not to hurt the child Look for anatomical landmarks on the ear drum and for swelling, redness, perforation, dullness and fluid.
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Topic summary
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By the end of this topic you should be able to take a comprehensive paediatric history and perform general and systemic examination. A good history helps establish relevant facts, it is a source of diagnostic information · It helps elicit all relevant clinical findings, · It helps collate the findings from the history and examination. It helps formulate a working diagnosis or differential diagnosis on the basis of logical deduction · It helps to assemble a problem list and management · At the end of history and examination: Summarize the key problems (in physical, emotional, social and family terms if relevant). · List the diagnosis and differential diagnoses Draw up a management plan to address the problem, both short and long term. This could be reassurance, period of observation, performing investigations or therapeutic interventions Provide explanation to the parent and child, if old enough provide further written information Ensure your notes are well written, dated and signed.
Quiz In summary you should be able to answer the following questions. · Outline the schema for history taking in children · Why is biodata important· Why should we always weigh the children· What is contained in the following:-· Complains and duration· History of presenting illness· Past medical and surgical history· Birth history.(antenatal, natal, post -natal)· Diet history· Immunization history· Developmental milestones
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Unit 1: Topic 3 Neonatal conditions
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Topic name |
RESUSCITATION OF THE NEWBORN |
Topic outcome
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By the end of this lesson the learner should be able to assess and resuscitate a newborn |
Topic objectives
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Define neonatal resuscitation Explain the steps in neonatal resuscitation 3. Define birth asphyxia 4. Outline the causes 5. Manage birth asphyxia 6. Interpret an APGAR score |
What is neonatal resuscitation –Resuscitation of the new born infant is the intervention after birth, to help the baby breathe and to help its heart beat.(Lorr R.Frankel et al 2007). Transition from placental gas exchange in a liquid-filled intrauterine environment to spontaneous breathing of air requires dramatic physiological changes in the infant within the first minutes to hours after birth. Passage through the birth canal is a hypoxic experience for the fetus, since significant respiratory exchange at the placenta is prevented for the 50-75 s duration of the average contraction. Though most babies tolerate this well, the few that do not may require help to establish normal breathing at delivery. Newborn resuscitation is intended to provide this help which comprises the following elements:
· Drying and covering the newborn baby to conserve heat;
· Assessing the need for any intervention;
· Opening the airway;
· aerating the lung;
· rescue breathing;
· chest compression;
Administration of drugs (rarely)
Common causes of neonatal deaths
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18 % |
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Other causes |
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09 % |
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Malformation |
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29 % |
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Perinatal hypoxia |
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17 % |
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Infection |
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27 % |
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Prematurity |
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Deaths (n = 1800) |
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Cause |
Perinatal asphyxia
· A range of disorders that occur subsequent to oxygen deprivation of a fetus/newborn during the two weeks surrounding delivery
· The main syndrome usually involves the brain but many other organs can be involved.
Pathophysiology –molecular Accumulation of intracellular calcium
· Increase of excitatory amino acids in the damaged cells
· Elaboration and increased liberation of reactive oxygen species (free radicals)
Etiology
· Prenatal: Placental insufficiency syndromes
· Labor/Delivery: Prolonged / obstructed labor
· Cord accidents/ Ante partum hemorrhage
· Post Natal: Ineffective resuscitation at birth
· Severe respiratory diseases
Pathophysiology –Gross
· Reduction of oxygen supply to the body organs (hypoxia)
· progressive reduction of systemic blood flow (ischemia)
· eventual decrease of cerebral & coronary blood flow (loss of autoregulation).
· Hypoxic/Ischaemic cell death
APGAR scoring ·
This signifies presence of Central Nervous system
depression ·
Presence
of encephalopathy: Suggesting actual
neurological damage § 0 1 2 ·
Appearance
Pale/blue peripheral
cyanosis pink ·
PULSE 0 <100 >100 ·
Grimace
None Weak Strong ·
Activity
None Weak Strong ·
Respiration None
Shallow Lusty Performed at 1&5 minutes. If abnormal repeated at 10 & 20 minutes APGAR Interpretation ·
1
minute score identifies those needing resuscitation ·
5
minute score defines asphyxia as: ·
Mild 6&7 ·
Moderate 4&5 ·
Severe 0-3 ·
Extended scores estimate or predict later outcomes Hypoxic Ischaemic
Encephalopathy (complication of severe birth asphyxia) ·
Grade 1; MILD ·
Hyperactive
and jittery, no convulsions ·
Grade 2;
MODERATE ·
Dull and
lethargic but awake or arousable ·
Convulsions
frequent ·
Grade 3; SEVERE ·
Stuporous/comatose with intractable fits ·
Other organ involvement, decorticate or decerebrate posture Laboratory evaluation ·
Cerebral ultra sound ·
Electro encephalography ·
CT Scan ·
MRI Principles of management ·
Effective resuscitation at birth ·
Active maintenance of normal homeostasis during the acute phase ·
Appropriate management of convulsions and other complications
NORMAL NEWBORN
Outcomes
1. Describe a normal newborn
2. Perform a systematic examination of the newbornA normal newborn
A normal new born infant is any baby with all of the following:-
· Is a baby born between 37—41weeks gestation,
· Weighs 2.5kgs—4kgs,
· Head circumference 33—37cm,
· APGAR score 7—10,
· length 50cm,
· no abnormalities & does not require resuscitation at birth.
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Note: A complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal function. Look for any signs of illness or birth defects. Physical examination of a newborn often includes assessment of the following: · Vital signs: o Temperature. Able to maintain stable body temperature 98.6 degrees F (36.50 c to 37.40c) in normal room environment o Pulse. Normally 100 to 140 beats per minute for infants, 80—120 older child. o Breathing rate. Normally 30 to 60 breaths per minute o Blood pressure: 80/50 to 115/80 (100-140 systolic /60—90 diastolic · General appearance. Physical activity, tone, posture, and level of consciousness · Skin. Color, texture, nails, presence of rash |
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Systematic 'Head-to-Toe' Examination· This should be done carefully after washing and rubbing hands, in good light and warmth (under a radiant warmer/Resuscitaire) to detect abnormalities and prevent hypothermia. · Head: · Shape, presence of fontanelle and whether normal, sunken or bulging · Measure and record head circumference on growth chart · Assess facial appearance and eye position · Look for any asymmetry or abnormality of facial form · Eyes: · Normal shape and appearance? · Check for presence of red reflex · Look for obvious cataracts or signs of ophthalmic infection · Ears: · Shape and size · Are they set at the normal level or 'low set'? · Check patency of external auditory meatus · Mouth: · Colour of mucous membrane, observe the palate · Check sucking reflex by inserting a clean little finger gently inside baby's mouth · Arms and hands: · Are they of normal shape and moving normally? · Look for evidence of traction birth injury (eg Erb's palsy) by checking neck, shoulders and clavicles · Count fingers and observe their shape – is there any evidence of Clinodactyly (incurving of fingers) or polydactyly · Check palmar creases – are they multiple or single? A single palmar crease may be normal, but can also be a sign of Down's syndrome, look for other signs (low set ears, thick epicanthic fold, flat facies, and flat nasal bridge. · Check brachial, radial and femoral pulses for rate, rhythm and volume · A hyperdynamic pulse may suggest persistent ductus arteriosus · A weak pulse may occur with a congenital cardiac anomaly (impairing cardiac output and in conjunction with other signs from the examination) · Check for radio-femoral delay (aortic Coarctation) · Heart: · Check cardiac position by palpation and feel for any thrill or heave · Listen to the heart sounds carefully and for any added sounds or murmurs, Suspected abnormalities require further examination and often more expert opinion and investigation · Lungs: · Observe respiratory pattern, rate and depth for a few seconds · Look for any evidence of intercostal recession · Listen for stridor · Auscultate lung fields for added sounds · Abdomen: Look at abdominal girth and shape Carefully check the umbilical stump for infection or surrounding hernia Palpate gently for organs, masses or hernia It is common to be able to feel a tip of the liver and/or spleen in healthy new-borns. Check the external genitalia carefully R/O Ambiguous Genitalia Palpate for testicles in boys (Undescended testis (cryptorchidism) is common in premature boys). Inspect the anus (has meconium been passed?) · Back: Look carefully at skin over back and at spinal curvature/symmetry Is there any evidence of spina bifida occulta or pilonidal sinus hidden by flesh creases or dimples? Palpate the spine gently · Hips: Specifically test for congenital dislocation of the hip (a.k.a. congenital hip dysplasia) using combination of Barlow and Ortolani manoeuvres · Legs: Watch movements at each joint Check for any evidence of tallipes equinovarus Count toes and check shape · CNS: Observe tone, behaviour, movements and posture Elicit newborn reflexes (Rooting, sucking, Moro, stepping grasping Record findings of your examintion Common abnormalities detected in the newborn screening examination · Capillary or macular haemangioma: also known as stork mark/bites, or salmon patch; found around eyes and nape of neck in 30–50% babies. Those around eyes normally disappear in first year, commonly persist if on nape of neck · Blue-black pigmented area: Mongolian blue spots; seen at base of back and on buttocks. These are common in dark-skinned parents but can occur in Caucasian infants. They normally disappear over first year
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Unit 1: Topic 3 Neonatal conditions
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Topic name |
RESUSCITATION OF THE NEWBORN |
Topic outcome
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By the end of this lesson the learner should be able to assess and resuscitate a newborn |
Topic objectives
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Define neonatal resuscitation Explain the steps in neonatal resuscitation 3. Define birth asphyxia 4. Outline the causes 5. Manage birth asphyxia 6. Interpret an APGAR score |
What is neonatal resuscitation –Resuscitation of the new born infant is the intervention after birth, to help the baby breathe and to help its heart beat.(Lorr R.Frankel et al 2007). Transition from placental gas exchange in a liquid-filled intrauterine environment to spontaneous breathing of air requires dramatic physiological changes in the infant within the first minutes to hours after birth. Passage through the birth canal is a hypoxic experience for the fetus, since significant respiratory exchange at the placenta is prevented for the 50-75 s duration of the average contraction. Though most babies tolerate this well, the few that do not may require help to establish normal breathing at delivery. Newborn resuscitation is intended to provide this help which comprises the following elements:
· Drying and covering the newborn baby to conserve heat;
· Assessing the need for any intervention;
· Opening the airway;
· aerating the lung;
· rescue breathing;
· chest compression;
Administration of drugs (rarely)
Common causes of neonatal deaths
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18 % |
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Other causes |
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09 % |
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Malformation |
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29 % |
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Perinatal hypoxia |
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17 % |
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Infection |
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27 % |
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Prematurity |
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Deaths (n = 1800) |
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Cause |
Perinatal asphyxia
· A range of disorders that occur subsequent to oxygen deprivation of a fetus/newborn during the two weeks surrounding delivery
· The main syndrome usually involves the brain but many other organs can be involved.
Pathophysiology –molecular Accumulation of intracellular calcium
· Increase of excitatory amino acids in the damaged cells
· Elaboration and increased liberation of reactive oxygen species (free radicals)
Etiology
· Prenatal: Placental insufficiency syndromes
· Labor/Delivery: Prolonged / obstructed labor
· Cord accidents/ Ante partum hemorrhage
· Post Natal: Ineffective resuscitation at birth
· Severe respiratory diseases
Pathophysiology –Gross
· Reduction of oxygen supply to the body organs (hypoxia)
· progressive reduction of systemic blood flow (ischemia)
· eventual decrease of cerebral & coronary blood flow (loss of autoregulation).
· Hypoxic/Ischaemic cell death
APGAR scoring ·
This signifies presence of Central Nervous system
depression ·
Presence
of encephalopathy: Suggesting actual
neurological damage § 0 1 2 ·
Appearance
Pale/blue peripheral
cyanosis pink ·
PULSE 0 <100 >100 ·
Grimace
None Weak Strong ·
Activity
None Weak Strong ·
Respiration None
Shallow Lusty Performed at 1&5 minutes. If abnormal repeated at 10 & 20 minutes APGAR Interpretation ·
1
minute score identifies those needing resuscitation ·
5
minute score defines asphyxia as: ·
Mild 6&7 ·
Moderate 4&5 ·
Severe 0-3 ·
Extended scores estimate or predict later outcomes Hypoxic Ischaemic
Encephalopathy (complication of severe birth asphyxia) ·
Grade 1; MILD ·
Hyperactive
and jittery, no convulsions ·
Grade 2;
MODERATE ·
Dull and
lethargic but awake or arousable ·
Convulsions
frequent ·
Grade 3; SEVERE ·
Stuporous/comatose with intractable fits ·
Other organ involvement, decorticate or decerebrate posture Laboratory evaluation ·
Cerebral ultra sound ·
Electro encephalography ·
CT Scan ·
MRI Principles of management ·
Effective resuscitation at birth ·
Active maintenance of normal homeostasis during the acute phase ·
Appropriate management of convulsions and other complications
Congratulations - end of lesson reached
Well done!
NEONATAL CONDITIONS - BIRTH INJURIES
Learning outcome
By the end of the lesson the learn should be able to diagnose and manage common birth injuries
Topic objectives
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1. Define birth injury 2. Explain the causes 3. Outline common birth injuries 4. Manage specific birth injuries
Injuries to the infant resulting from
mechanical forces during birth (compression, traction) or Physical injury
sustained during the birth process. Can coexist with hypoxemic-ischemic
insult - may predispose to each other. This is sometimes called birth trauma or
birth injury. Primigravida Cephalopelvic disproportion Small maternal stature maternal pelvic anomalies Prolonged or rapid labor Arrest of descent of presenting fetal part Oligohydramnios Fetal anomalies Fetal neuromuscular disease HIE Resuscitation with CPR Abnormal presentation (breech/face) Use of forceps or vacuum extraction Versions VLBW infant or extreme prematurity Macrosomia Large fetal head Common
birth injuries include: Caput succedaneum,
Cephalohematoma, bruising/forceps marks, Subconjunctival hemorrhage, Facial
paralysis, Brachial palsy, Fracture, Facial Nerve Paralysis Intracranial Hemorrhage Injuries may be caused by a
combination of mechanical trauma and hypoxia. Birth injuries may be minor and
transient but they can produce serious and permanent effect as well as being
fatal. The majority of these are Erb's palsy
involving the upper part of the brachial plexus. The underlying problem is
usually injudicious traction when the anterior shoulder is trapped (shoulder
dystocia).[10][11]
Only 10% involve the whole brachial plexus.[12]
Associated injuries include: The position of the hand is said
to be reminiscent of a porter who is turning away but is holding out his hand
behind him for a tip. This is much less common than Erb's palsy in infants. Cranial nerve and spinal
cord injuries result from hyperextension, traction and overstretching with
simultaneous rotation. Neurapraxia will resolve swiftly but complete nerve or
cord transection is a much more serious matter. Factors within labour are complex,
but processes such as uteroplacental vascular disease, reduced uterine
perfusion, fetal sepsis, reduced fetal reserves and cord compression can be
involved alone or in combination producing fetal distress. Gestational and
antepartum factors modify the fetal response to them. |
UNIT 1: Topic 5: CONGENITAL ABNORMALITIES
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CONGENITAL ABNORMALITIES |
b) Learning outcome
By the end of this lesson the learner should be able to diagnose and manage congenital abnormalities
Topic objectives
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Define congenital abnormalities |
c) Topic Content
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Definition Congenital malformations are anatomical defects present at birth. Defects of the CNS and heart account for more than half of the total Significance 1—2% of all babies are born with serious congenital malformations. · Are major causes of Perinatal and infant death to the extent of increase in infant mortality rate · The incidence of serious defects and chromosomal anomalies amongst spontaneous abortions is very high. · Some of them are predisposing factors to diseases e.g UTI in congenital obstruction of the urinary tract
Life threatening abnormalities CHOANAL ATRESIA; Presents with;- respiratory distress in the delivery room. Apnoea, inability to pass a nasogastric tube through the nares Suspect CHARGE Syndrome · C—Coloboma of the eyes · H—Heart anormaly · A—Atresia of the choana · R—Retardation · G—Genital anomaly · E—Ear anomaly 2. PIERRE ROBIN SYNDROME;-- Micrognathia, cleft palate, air way obstruction 3. DIAPHRAGMATIC HERNIA Scaphoid abdomen, bowel sounds present in the chest Respiratory distress 4. TRACHEOESOPHAGEAL FISTULA. Polyhydramnious , aspiration pneumonia, excessive salivation, Inability to pass a NGT in to the stomach Suspect VATER Syndrome · V=Vertebral defects · A=anal may be imperforate · T-E= Tracheo -Esophageal fistula · R=Radial and Renal dysplasia Intestinal obstruction;- Polyhydramnious , bile stained emesis, abdominal distension -Volvulus, duodenal atresia ileal atresia;-- suspect trisomy 21 cystic fibrosis Gastroschisis, omphalocele;-- Polyhydramnious, intestinal obstruction Renal agenesis, potter syndrome—oligohydromnious, anuria , pulmonary hypoplasia PneumothoraxNeural tube defects;-- Encephalocele, meningomyelocele=
Ductal- dependant congenital heart disease;- present with cyanosis, hypotension, murmurs Aetiology § Environmental and genetic factors § -Idiopathic accounts for 50% § -single gene defects § -Chromosomal anomalies e.g Down syndrome § Infections e.g rubella syndrome [ consist of cataract , deafness ,cardiac abnormalities] § Teratogenic drugs e.g thalidomide causes phocomelia § Social economic factors e.g an ence phaly, and spina bifida is high in low socio-economic status. § Parental age e.g § Maternal age dependant trisomy 21 > 35yrs § Paternal age dependant - achondroplasia § Seasonal:- some are more common in winter than summer § Regional incidence:—an encephaly is highest in highlands e.g Liverpool in England § Congenital dislocation of the hip is high in Finland § Sex : Congenital pyloric stenosis § M : F ratio is 5 : 1. § Dislocation of the hip :- F: M ratio is 6:1. § Birth order -first borns have high incidences of malformation § Ionizing radiation § Mechanical factors e.g tallipes equino varus, CDH, § Parity of the mother § Multiple factors
DIAGNOSIS, Is by history, Physical examination, Relevant investigations SPINA BIFIDA Is the most common neural- tube defect, most frequently occurring Permanent disabling birth defect. Results from failure of the spine to close during the first month of pregnancy. May cause paralysis leading to bowel and bladder complications A large percentage also has hydrocephalus It can cause profound defects on the childs motional and social development LOW FOLIC ACID Status before conception and during the first week of pregnancy increases the risk TYPES 1. Spina - bifida occulta; Features;- a dimple, Tuft of hair, Lipoma 2. Spina bifida cystica: Observe a cyst or sarc on the back, May be covered with a thin layer of skin, May be a Meningocoele, Contains meninges and CSF or a Meningomyelocele; Contains tissue, CSF, nerves, and part of spinal cord. 3. Encephalocele [cranial bifida); The bones of the skull fail to develop properly. May contain brain tissue, CSF with or without part of the brain. Examine lower limbs for paralysis and head circumference to rule out hydrocephalus. 4. An – encephaly: Complete absence of peripheral hemisphere and overlying skull. 90% are female, common in first borns. High incidence in low socio economic class. Is associated with hydramnious due to inability of the fetus to swallow. 5. Umbilical hernia Two types :- True umbilical hernia and Supra umbilical hernia. Natural cure is expected. Spontaneous closure at one year. Surgery if there are symptoms or at 5years if it persists. CONGENITAL URETHRAL VALVES: May cause recurrent UTI , Reflux hydronephrosis, obstructive uropathy Micturating cysto urethrogram (M C U) is a must Treatment is surgery.
HYPOSPADIA The urethral opening is on the ventral surface of the gland or shaft Epispadia, hypospadia with chordate, penile, or coronal. Avoid circumcision - skin is used to repair. Repair is advised at the age of 4—5yrs UNDESCENDED TESTIS [CRYPTORCHIDISM] 33% of premature male develop cryptorchidism. 3% of term infants. May descend in the first few months after birth. Surgical correction is best at 2years BUT MUST be done by 7-9yrs. Infertility results if bilaterally undescended past puberty. May be cancerous if remains for a long time. Treatment is orchidopexy. Congenital dislocation of the hip It is Common in girls, Girl : boy ratio is 6: 1; Ortolani,s test is positive. Treatment is Reduction and immobilize in POP for 3 months. CONGENITAL HYPERTROPHIC PYLORIC STENOSIS Features include projectile vomiting from the second to third week of life, never bile stained, Common in first borns. More common in males than females. There is marked weight loss and dehydration. There is visible peristalsis left to right after feeds and before vomiting. Investigations Blood for urea and electrolytes - reduced sodium (Na+) Potassium (k+), chloride (Cl) Increased PH. It leads to Hypochloraemic alkalosis. Barium meal is mandatory. Treatment Correct the electrolyte imbalance and dehydration with IV fluid. Definitive treatment is by surgery [pyloromyotomy].
CONGENITAL TALLIPES EQUINO VARUS [CTEV] / CLUB FOOT] Common in boys, Majority are mechanical in origin Defects. Equinus- plantar flexion. Varus -- displacement towards the midline together with medial rotation of tibia. And fore feet adduction Treatment: Starts from first day of life. Dennis brown splint is applied for 3 months 33 % are fully corrected.
DOWNS SYNDROME /MONGOLISM /TRYSOMY 21 Is the commonest form of mental retardation with a prevalence of 1: 700 live birth. The frequency is related to maternal age i.e >35 years Chromosomal anomalies associated with Downs syndrome 1. Full trysomy 21 - 95% of cases [non dysfunction]
Clinical features Slanting palpebral fissures, Marked epicanthic folds Small mouth with a protruding tongue, Hypotonia, Poor moro reflex, Hyperflexibility of joints Excess nuchal skin, Flat facial profile, Delayed dentition, Delayed closure of fontanels, Single palmar crease [simian crease] Dysplasia of the pelvis, Wide gap between first and second finger and toes, Low set ears. Have a good temperament - are quiet most of the time with a lot of interest in music, Are short statured Complications · 40% have a congenital heart defect [ AVSD , PDA , VSD] · IQ range =25—50 · Hypothyroidism 5% · Leukaemia 1: 95 · Atlanto axial instability 12—20 % usually asymptomatic · Mean age for survival =65 years
Diagnosis: Chromosomal analysis
ACHONDROPLASIA
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Discussion A 3weeks old baby is brought to you with a 1/52 history of vomiting after feeds. the reports that the child does not look sick at all. He feels hungry after feeding and wants to breastfeed again. On examination you observe projectile non -bilious vomiting, dehydrated babay. You suspect a congenital anomaly. What is your impression How will you confirm your diagnosis Manage this baby. |
Topic 7: PREMATURITY
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PREMATURITY |
Learning outcome
By the end of this topic the learner should be able to diagnose and manage prematurity
Topic Outcomes
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l Define premature newborn l Outline the causes l State the features l Explain LBW, SGA,LGA l Discuss the complications l Describe the management |
a) Topic Content
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POST MATURE BABY They have marked loss of s/c fat The skin is dry, cracked, ringled, peeling & may be meconium stained with absence of vernix caseosa, Are hungry & they feed well, Unusual alertness, Wide eyed look Common complications of an SGA l Hypoglycaemia l Hypothermia l Massive pulmonary haemorhage l Skin infections l Meconium aspiration is evident in post mature |
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b) Topic Summary
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Prematurity is not synonymous with LBW It can be assessed by gestational dates, and physical features at birth Management and care depends on the birth weight and the level of prematurity Important to note in the care is · Thermoregulation · Fluid electrolyte balance · Feeding |
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n Define neonatal jaundice n Explain bilirubin metabolism n Outline the causes according to age of onset n State the predisposing factors n Outline the diagnosis n Explain the modes of Rx n List complications n Define kernicterus
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Topic Content
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n DEFINITION Increased neonatal serum bilirubin levels sufficient enough to result in jaundice. This can be physiological or pathological. n BILIRUBIN METABOLISM Bilirubin is made from breakdown of RBCs. Myoglobin,and other heame containing substances in the body.The heame is metabolised to bilirubin:- n HEAME→BILIVERDIN→BILIRUBIN ↑ ↑ heame biliverdin oxygenase. Reductase. n Uncojugated energy depen conjugat Bilirubin → liver metab →bilirubin transferase enz In serum, unconjugated bilirubin is bound to albumin.↓serum albumin leads to ↑free bilirubin.This is fat soluble and crosses the blood / brain barrier to cause kernicterus if the levels are high. Some factors displace bilirubin from the albumin binding sites. Acidosis, drugs esp. sulphonamides n METABOLISM contd n Conjugated water excreted via Bilirubin → soluble → urine/stool Conjugation is an energy dependant activity that can be disrupted by various factors
Causes according to age of onset n First 24—48 hours n ABO & Rhesus incompatibility n 3rd –4th day n Physiological jaundice ( it does not mean its harmless; it depends on the level) n It is due to fetal RBC break down n They lack bacterial flora n The liver conjugation system is immature 7th day onset n It is due to infections (acquired or congenital) n Prolonged jaundice (>1/52) n Caused by; n Congenital billiary atresia, n Neonatal hepatitis – hepatitis B, syphilis, CMV n Hypothyroidism – thyroid hormone enhances the efficiency of conjugation system Congenital hemolytic anemias n G6PD deficiency n Congenital spherocytosis n Pyruvate kinase deficiency n Hereditary spherocytosis Others n Haematoma - cephalohaematoma n Breast milk jaundice- 4th –10th day- pregnanediol substance in milk inhibit the fxn of glucuronil transferase in some newborns n PHYSIOLOGICAL JAUNDICE n Serum bili increases after birth to a peak at around day 3-4 of life. n This is due to breakdown of fetal RBCs in the face of inadequate liver metabolism. n The level starts to reduce around day 6. n The peak may result in jaundice. n 6-7% of full term infants are affected. physiological jaundice Is that jaundice that occurs in a full term infant around day 3-4 of life and no pathological cause can be found. n A diagnosis of exclusion JAUNDICE OF PREMATURITY n Jaundice occurring in a preterm infant. n Usually caused by;- ↑RBC mass. immature liver metabolism prone to hypo-glycemia, anoxia acidosis. p/s premature infants can also have pathological jaundice described ahead n PATHOLOGICAL JAUNDICE n DUE TO:- (a) Overproduction of bilirubin Such as increased RBC destruction. (b) Reduced metab/excretion Such as enzymatic defficiencies c) Overproduction of bilirubin n HEMOLYTIC DISEASE OF THE NEWBORN (HDN);- ABO incompatibility…..mother O+ve baby is either A,B or AB. Can occur with 1st baby Can be very severe. common in our country. n HDN n Rhesus incompatibility.. mother rh-ve while baby is rh+ve occurs in subsequent deliveries after the 1st because the mother has to be sensitised by prior exposure to rh+ve stimuli. Less common than ABO in our setup but is frequent. n HDN n Minor blood group incompatibilities. Not routinely tested for e.g Kell, Duffy and others that may be restricted to regions RBC membrane defects e.g congenital spherocytosis RBC enzymatic defects e.g G6PD defficiency n OVERPRODUCTION n POLYCYTHEMIA…infants of diabetic mothers, intra-uterine growth retardation(SGA),etc n Collections of free blood e.g cephalohematoma. n Traumatic birth that destroys myoglobin and injures the cytochrome system n REDUCED EXCRETION n Either by interfering with metabolism, excretion or both. n Asphyxia,hypoglycemia,infections….all interfere with liver cell function hence its ability to metabolize bilirubin. n Enzyme deffeciencies….lack of the transeferase enzyme---Criggler Najar type 1 and 2, …..lack of ligand proteins x and y---roto syndrome. n REDUCED EXCRETION n Biliary atresia…..intra or extra hepatic. Conjugated bilirubin cant be excreted via bile as the ducts are atretic within or outside the liver. n Intestinal obstruction….conjugated bilirubin gets to the gut but due to obstruction,there is stasis allowing the enzyme –glucuronidase--to deconjugate it with re-absorbtion of unconjugated bilirubin (enterohepatic circulation) n BREASTMILK JAUNDICE n Juandice associated with breastfeeding. n For some mothers ,their breastmilk contains factors that interfere with bilirubin metabolism.(glucuronidase) Exclusively breastfed infants have a higher peak of bilirubin that results in jaundice. May be due to dehydration resulting from initial low milk output.=breastfeeding jaundice. n RX stoppage of breastfeeding for 24hrs resolves the jaundice! n HYPERBILI clinical features n Jaundice on the skin,sclera of eyes,under the tongue , and palms and soles of feet. n Generally jaundice occurring on 1st or 2nd day of life is pathological. n Jaundice on the 3rd or 4th day may be physiological and if physiological it should last less than 2 weeks. n Jaundice appearing after day 4 is also most likely pathological. n CLINICAL FEATURES n HISTORY----any history of previously affected sibling. --mothers blood group if known. --suggestive pre-desposing factors to sepsis.
n CLINICAL FEATURES n EXAMINATION…jaundice,pallor n ,hepatomegally,vomiting,lethargy, n poor feeding. With onset of kernicterus,there is high pitched cry,hypertonicity,jitteriness convulsions, bulging fontanelles, opisthotonus posturing. n DIAGNOSTIC EVALUATION n HISTORY and CLINICAL FINDINGS n LABORATORY WORKUP (a)Total bili and differential..serially to monitor effectiveness of treatment. (b) Heamogram…HB and reticulocyte count. (c) Blood group….mother and baby n LABORATORY INV n (d) Coombs test to identify case of HDN that may not involve ABO or RH factors. n (e) Peripheral blood film….may show features of infection or hemolysis. n (f) Total protein and albumin to determine albumin binding capacity. n MANAGEMENT n PREVENTION:- use of anti-d to prevent maternal rhesus sensitisation if she is rh-ve and has:- (a) blood tx of inco. Blood (b) fetal loss i.e abortion (c) delivers rh+ve baby n MANAGEMENT n SUPPORTIVE:- n (a) maintain hydration (b) ensure nutrition or adequate caloric intake to avoid hypoglycemia. (c) correct acidosis and hypoxia. n MANAGEMENT n SPECIFIC:-(1) Phototherapy Works by a process of photo-isomerization so that isomers are produced which are water soluble and do not require liver for excretion. n PHOTOTHERAPY n Light of 420-470 nm wavelength is most effective. Blue light is most appropriate. n Distance from light source to the baby should be not more than 15-20 cm n Turn baby frequently or use photo-optic blanket. n May cause loose stools, n skin rashes, dehydration,retinal damage,overheating. n MANAGEMENT n EXCHANGE TRANSFUSION.(EX TX) (a) removes xs bilirubin. (b) removes sensitized RBCs. (c) improves HB level. n EXCHANGE TRANSFUSION n INDICATIONS: (1) Very rapid rise of bilirubin 8-17 umol/dl/hr. (2) Rapid fall in HB.(hemolysis) (3) ill child—sepsis/meningitis (4) Prematurity (5) Previously severe dx in sibs (6) Reticulocyte count > 15 % EXCHANGE TRANSFUSION PROCEDURE: · Use fresh blood preferably heparinized. Blood group O-ve most suitable. Can use babies ABO type but RH-ve cross matched against mothers serum. · Warm blood to 35-37°c · Continuously mix the blood to avoid sedimentation. · Empty infants stomach with NGT and leave it in situ. · Aseptically cannulate infants umbilical vein (up to 7cm for full term baby) · Take pre exchange sample for HB and Bilirubin baseline. · Exchange over 45-60 minutes using 5-20ml aliquotes depending on baby size and condition. Monitor HR, RR by a continuous monitor if possible otherwise use observation and stethoscope strapped on infants precordium. n Take post exchange sample for HB and Bilirubin at end of procedure. n Continue phototherapy and serial bilirubin monitoring at end of procedure. In exchange transfusion , use double volume transfusion Assumes baby blood vol. of 85 mls /kg body weight. (2 x 85) wt in kg= vol of blood required. n HYPERBILIRUBINEMIA COMPLICATIONS 1. KERNICTERUS Unconjugated bilirubin crosses the blood/brain barrier and if very high can lead to kernicterus. High unconjugated bilirubin crosses the blood brian barrier and interferes with oxygen uptake of the brain cells. n It is deposited in the basal ganglia giving them a yellow colouration. n Some pre-desposing factors increase the chance of kernicterus Pre-disposing factors: (a) Low serum albumin. (b) Prematurity. (c) Sepsis esp. with meningitis. (d) Asphyxia. (e) Acidosis. (f) Intra-ventricular hemorrhage Features of Kernicterus n Lethargy, poor suck, loss of Moro response, reduced tendon reflexes. n Respiratory distress, bulging fontanels, shrill high pitched cry, convulsions and spasms eventually develops opisthotonic posturing. n 75% mortality while survivors have various degrees of brain injury including athetotic cerebral palsy. |
Topic Summary
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Summary Quiz · Discuss neonatal jaundice under the following subheadings A) Definition B) Causes C) Management D) Kernicterus · What are the indications for exchange transfusion · What are the side effects of phototherapy
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NEONATAL SEIZURES
Learning outcome By
the end of this lesson the learner should be able to diagnose and manage
anaemia in children Topic objectives ·
Define anaemia ·
Classify anaemia according to the causes ·
State the investigations ·
Outline the management Topic Content Definitions Anemia
is when the Central venous hemoglobin < 13 g/dL or capillary hemoglobin
< 14.5 g/dL in infant > 34 weeks and 0-28 days old Average
value for central venous hemoglobin at birth for > 34 weeks GA is 17 g/dL Reticulocyte
count in cord blood 3-7% Average
mean corpuscular volume 107 fL Physiological anemia of infancy In
healthy term infants, hemoglobin levels begin to decline around the third
week of life Reach 11
g/dL at 8-12 weeks Differences
in premature infants At birth
they have slightly lower hemoglobin levels, and higher MCV and retic counts Average level is 7-9 g/dL and is reached at 4-8 weeks of
age. Related to a combination of decreased RBC mass at birth, increased
iatrogenic losses from lab draws, shorter RBC life span, inadequate
erythropoietin production, and rapid body growth Pathophysiology Anemia
in the newborn results from three processes • Loss of RBCs: hemorrhagic anemia (Most
common cause) • Increased destruction: hemolytic
anemia • Underproduction of RBCs:
hypoplastic anemia Hemorrhagic anemia Antepartum
period (1/1000 live births) • Loss of placental integrity • Abruption, previa, • traumatic amniocentesis • Anomalies of the umbilical cord or
placental vessels • abnormal insertion of the cord in
twins, communicating vessels, • cord hematoma, entanglement of the
cord • Twin-twin transfusion syndrome • Only in monozygotic multiple
births • 13-33% of twin pregnancies have
TTTS • Difference in hemoglobin usually
> 5 g/dL • Congestive heart disease common in
anemic twin and hyperviscosity common in plethoric twin Hemorrhagic
anemia Intrapartum
period • Feto-maternal hemorrhage (30-50%
of pregnancies) • Increased risk with
preeclampsia-eclampsia, need for instrumentation, and c-section • C-section: anemia increased in
emergency c-section • Traumatic rupture of the cord • Failure of placental transfusion
due to cord occlusion (nuchal or prolapsed cord) • Obstetric trauma causing occult
visceral or intracranial hemorrhage Hemorrhagic anemia Neonatal
period ·
Enclosed
hemorrhage: suggests obstetric trauma or severe perinatal distress, cephalohematoma, ·
Intracranial
hemorrhage, visceral hemorrhage, Defects in hemostasis, Congenital
coagulation factor deficiency, Consumption coagulopathy: DIC, sepsis, Vitamin
K dependent factor deficiency. ·
Failure
to give vit K causes bleeding at 3-4 days of age ·
Thrombocytopenia:
immune, or congenital ·
Iatrogenic
blood loss due to blood draws Hemolytic anemia ·
Immune hemolysis: Rh incompatibility or autoimmune
hemolysis ·
Nonimmune: sepsis, TORCH infection ·
Congenital erythrocyte defect: G6PD, thalassemia, unstable
hemoglobins, membrane defects (hereditary spherocytosis, elliptocytosis) ·
Systemic diseases: galactosemia, osteopetrosis Nutritional
deficiency: vitamin E presents later Hypoplastic anemia Congenital
causes • Diamond-Blackfan syndrome, • congenital leukemia, • sideroblastic anemia Acquired • Infection: Rubella and syphilis
are the most common • Aplastic crisis, • aplastic anemia Clinical
presentation Determine
the following factors • Age at presentation • Associated clinical features • Hemodynamic status of the infant • Presence or absence of
compensatory reticulocytosis Presentation of hemorrhagic anemia Acute
hemorrhagic anemia, ·
Pallor
without jaundice or cyanosis and unrelieved by oxygen, ·
Tachypnea
or gasping respirations ·
Decreased
perfusion progressing to hypovolemic shock ·
Decreased
central venous pressure ·
Normocytic
or normochromic RBC ·
Reticulocytosis
within 2-3 days of event Presentation of hemorrhagic anemia Chronic
haemorhagic anaemia •
Pallor
without jaundice or cyanosis and unrelieved by oxygen •
Minimal
signs of respiratory distress •
Central
venous pressure normal •
Microcytic
or hypochromic RBC indices •
Compensatory
reticulocytosis •
Enlarge
liver d/t extramedullary erythropoiesis • Hydrops fetalis or stillbirth may
occur Presentation of hemolytic anemia •
Jaundice
is usually the first symptom, Compensatory reticulocytosis •
Pallor
presents after 48 hours of age •
Unconjugated
hyperbilirubinemia of > 10-12 mg/dL •
Tachypnea
and hepatosplenomegaly may be present Presentation of hypoplastic anemia •
Uncommon •
Presents
after 48 hours of age •
Absence
of jaundice •
Reticulocytopenia Presentation of other forms Twin-twin
transfusion • Growth failure in the anemic twin,
often > 20% Occult
internal hemorrhage • Intracranial: bulging anterior
fontanelle and neurologic signs (altered mental status, apnea, seizures) • Visceral hemorrhage: most often
liver is damaged and leads to abdominal mass. Pulmonary hemorrhage:
radiographic opacification of a hemithorax with bloody tracheal secretions Diagnosis Initial
studies • Hemoglobin • RBC indices • Microcytic or hypochromic suggest
feto-maternal or twin-twin hemorrhage, or a-thalassemia • Normocytic or normochromic suggest
acute hemorrhage, systemic disease, intrinsic RBC defect, or hypoplastic
anemia • Reticulocyte count elevation suggests antecedent
hemorrhage or hemolytic anemia while low count is seen with hypoplastic
anemia Diagnosis Initial
studies continued • Blood smear looking for • spherocytes (ABO incompatibility
or hereditary spherocytosis) • elliptocytes (hereditary
elliptocytosis) • pyknocytes (G6PD) • schistocytes
(consumption coagulopathy). Direct Coombs test: positive in isoimmune or
autoimmune hemolysis Other diagnostic studies Blood type and Rh in isoimmune
hemolysis Kleihauer-Betke test on maternal
blood looking for fetomaternal hemorrhage CXR for pulmonary hemorrhage Bone marrow aspiration for
congenital hypoplastic or aplastic anemia TORCH: bone films, IgM levels,
serologies, urine for CMV DIC panel, platelets count Occult hemorrhage: placental exam,
cranial or abdominal ultrasound Intrinsic RBC defects: enzyme
studies, globin chain ratios, membrane studies Management Simple
replacement transfusion Indications: acute hemorrhage Use 10-15 ml/kg O, RH- packed RBCs
or blood cross-matched to mom and adjust hct to 50% Give via low UVC or central UVC if
time permits Draw diagnostic studies before
transfusion ongoing deficit replacement maintenance of effective
oxygen-carrying capacity Haematocrit < 35% in severe cardiopulmonary disease Haematocrit < 30% in
mild-moderate cardiopulmonary disease, apnea, symptomatic anemia, need for
surgery Haematocrit < 21% Management Exchange
transfusion • Indications • Chronic hemolytic anemia or
hemorrhagic anemia with increased central venous pressure • Severe isoimmune hemolytic anemia • Consumption coagulopathy Nutritional
replacement: iron, folate, vitamin E Prophylactic management Erythropoietin • Increased erythropoiesis without
significant side effects • Decreases need for late
transfusions • Will not compensate for anemia due
to labs • Need to have restrictive policy
for blood sampling and micro methods in the lab Nutritional
supplementation: iron, folate, vitamin E NEONATAL ANAEMIA Learning outcome By the end of this lesson the learner should be able to diagnose and manage anaemia in children Topic objectives · Define anaemia · Classify anaemia according to the causes · State the investigations · Outline the management Topic Content Definitions Anemia is when the Central venous hemoglobin < 13 g/dL or capillary hemoglobin < 14.5 g/dL in infant > 34 weeks and 0-28 days old Average value for central venous hemoglobin at birth for > 34 weeks GA is 17 g/dL Reticulocyte count in cord blood 3-7% Average mean corpuscular volume 107 fL Physiological anemia of infancy In healthy term infants, hemoglobin levels begin to decline around the third week of life Reach 11 g/dL at 8-12 weeks Differences in premature infants At birth they have slightly lower hemoglobin levels, and higher MCV and retic counts Average level is 7-9 g/dL and is reached at 4-8 weeks of age. Related to a combination of decreased RBC mass at birth, increased iatrogenic losses from lab draws, shorter RBC life span, inadequate erythropoietin production, and rapid body growth Pathophysiology Anemia in the newborn results from three processes • Loss of RBCs: hemorrhagic anemia (Most common cause) • Increased destruction: hemolytic anemia • Underproduction of RBCs: hypoplastic anemia Hemorrhagic anemia Antepartum period (1/1000 live births) • Loss of placental integrity • Abruption, previa, • traumatic amniocentesis • Anomalies of the umbilical cord or placental vessels • abnormal insertion of the cord in twins, communicating vessels, • cord hematoma, entanglement of the cord • Twin-twin transfusion syndrome • Only in monozygotic multiple births • 13-33% of twin pregnancies have TTTS • Difference in hemoglobin usually > 5 g/dL • Congestive heart disease common in anemic twin and hyperviscosity common in plethoric twin Hemorrhagic anemia Intrapartum period • Feto-maternal hemorrhage (30-50% of pregnancies) • Increased risk with preeclampsia-eclampsia, need for instrumentation, and c-section • C-section: anemia increased in emergency c-section • Traumatic rupture of the cord • Failure of placental transfusion due to cord occlusion (nuchal or prolapsed cord) • Obstetric trauma causing occult visceral or intracranial hemorrhage Hemorrhagic anemia Neonatal period · Enclosed hemorrhage: suggests obstetric trauma or severe perinatal distress, cephalohematoma, · Intracranial hemorrhage, visceral hemorrhage, Defects in hemostasis, Congenital coagulation factor deficiency, Consumption coagulopathy: DIC, sepsis, Vitamin K dependent factor deficiency. · Failure to give vit K causes bleeding at 3-4 days of age · Thrombocytopenia: immune, or congenital · Iatrogenic blood loss due to blood draws Hemolytic anemia · Immune hemolysis: Rh incompatibility or autoimmune hemolysis · Nonimmune: sepsis, TORCH infection · Congenital erythrocyte defect: G6PD, thalassemia, unstable hemoglobins, membrane defects (hereditary spherocytosis, elliptocytosis) · Systemic diseases: galactosemia, osteopetrosis Nutritional deficiency: vitamin E presents later Hypoplastic anemia Congenital causes • Diamond-Blackfan syndrome, • congenital leukemia, • sideroblastic anemia Acquired • Infection: Rubella and syphilis are the most common • Aplastic crisis, • aplastic anemia Clinical presentation Determine the following factors • Age at presentation • Associated clinical features • Hemodynamic status of the infant • Presence or absence of compensatory reticulocytosis Presentation of hemorrhagic anemia Acute hemorrhagic anemia, · Pallor without jaundice or cyanosis and unrelieved by oxygen, · Tachypnea or gasping respirations · Decreased perfusion progressing to hypovolemic shock · Decreased central venous pressure · Normocytic or normochromic RBC · Reticulocytosis within 2-3 days of event Presentation of hemorrhagic anemia Chronic haemorhagic anaemia • Pallor without jaundice or cyanosis and unrelieved by oxygen • Minimal signs of respiratory distress • Central venous pressure normal • Microcytic or hypochromic RBC indices • Compensatory reticulocytosis • Enlarge liver d/t extramedullary erythropoiesis • Hydrops fetalis or stillbirth may occur Presentation of hemolytic anemia • Jaundice is usually the first symptom, Compensatory reticulocytosis • Pallor presents after 48 hours of age • Unconjugated hyperbilirubinemia of > 10-12 mg/dL • Tachypnea and hepatosplenomegaly may be present Presentation of hypoplastic anemia • Uncommon • Presents after 48 hours of age • Absence of jaundice • Reticulocytopenia Presentation of other forms Twin-twin transfusion • Growth failure in the anemic twin, often > 20% Occult internal hemorrhage • Intracranial: bulging anterior fontanelle and neurologic signs (altered mental status, apnea, seizures) • Visceral hemorrhage: most often liver is damaged and leads to abdominal mass. Pulmonary hemorrhage: radiographic opacification of a hemithorax with bloody tracheal secretions Diagnosis Initial studies • Hemoglobin • RBC indices • Microcytic or hypochromic suggest feto-maternal or twin-twin hemorrhage, or a-thalassemia • Normocytic or normochromic suggest acute hemorrhage, systemic disease, intrinsic RBC defect, or hypoplastic anemia • Reticulocyte count elevation suggests antecedent hemorrhage or hemolytic anemia while low count is seen with hypoplastic anemia Diagnosis Initial studies continued • Blood smear looking for • spherocytes (ABO incompatibility or hereditary spherocytosis) • elliptocytes (hereditary elliptocytosis) • pyknocytes (G6PD) • schistocytes (consumption coagulopathy). Direct Coombs test: positive in isoimmune or autoimmune hemolysis Other diagnostic studies Blood type and Rh in isoimmune hemolysis Kleihauer-Betke test on maternal blood looking for fetomaternal hemorrhage CXR for pulmonary hemorrhage Bone marrow aspiration for congenital hypoplastic or aplastic anemia TORCH: bone films, IgM levels, serologies, urine for CMV DIC panel, platelets count Occult hemorrhage: placental exam, cranial or abdominal ultrasound Intrinsic RBC defects: enzyme studies, globin chain ratios, membrane studies Management Simple replacement transfusion Indications: acute hemorrhage Use 10-15 ml/kg O, RH- packed RBCs or blood cross-matched to mom and adjust hct to 50% Give via low UVC or central UVC if time permits Draw diagnostic studies before transfusion ongoing deficit replacement maintenance of effective oxygen-carrying capacity Haematocrit < 35% in severe cardiopulmonary disease Haematocrit < 30% in mild-moderate cardiopulmonary disease, apnea, symptomatic anemia, need for surgery Haematocrit < 21% Management Exchange transfusion • Indications • Chronic hemolytic anemia or hemorrhagic anemia with increased central venous pressure • Severe isoimmune hemolytic anemia • Consumption coagulopathy Nutritional replacement: iron, folate, vitamin E Prophylactic management Erythropoietin • Increased erythropoiesis without significant side effects • Decreases need for late transfusions • Will not compensate for anemia due to labs • Need to have restrictive policy for blood sampling and micro methods in the lab Nutritional supplementation: iron, folate, vitamin E Unit Two Unit Name GROWTH AND DEVELOPMENT a)
Unit Outcome By the end of this unit the learner should be able to Assess growth & development in a child Apply principles and concepts of growth and
development in diagnosis and management of childhood illnesses and conditions. Unit objectives ·
Explain the importance of growth
and development. ·
Define growth and development. ·
State the principles of growth
& development. ·
List factors affecting growth
& development. ·
Outline
types of growth & development. ·
Describe
the stages of development. a)
Unit Learning
Requirements To
proficiently complete this unit, you ought to make sure you spend quality
time and purpose to; a)
Topic objective By the end of this lesson you should be able to Describe terms used in growth and development in a
child Growth §
Growth refers to an increase in physical size of the
whole/part of body §
It is simply a
quantitative change §
The physical
changes include: Height,
Weight, Vital signs, Vocabulary §
It can be measured in Kg, pounds, meters, inches, Development Increase in capability /complexity or
function: • Milestones (sitting, walking, talking) • Communication • Motor skills • Emotions • It is a qualitative change in the child’s functioning. It
can be measured through observation. Maturation •
Increase in child’s competence and
adaptability. •
It is describing the qualitative
change in a structure. •
The level of maturation depends on
child’s heredity. Importance of knowing growth & development •
Knowing what to expect of a
particular child at any given age. •
Gaining better understanding of the
reasons behind illnesses. •
Helping in formulating the plan of
care. Periods of development ·
Prenatal period: from conception to
birth ·
Infancy and toddlerhood: birth to 2
yrs ·
Early childhood: 2-6 years old ·
Middle childhood: 6-12 years old ·
Adolescence: 12-19 years old Principles of growth and development •
Continuous process •
Predictable Sequence •
Don’t progress at the same rate (↑
periods of GR in early childhood and adolescents & ↓ periods of GR in
middle childhood. Not all body parts grow in the same rate at the same time. •
Each child grows in his/her own
unique way. Each stage of G&D is affected by the preceding types of
development •
G & D proceed in regular related
directions :
Cephalo-caudal(head
down to toes)
Proximodistal
(center of the body to the
peripheral) General to specific Growth pattern
The child’s pattern of growth is in
a head-to-toe direction, or cephalocaudal, and in an inward to outward pattern
called proximodistal. Factors affecting G & D •
Hereditary •
Environmental factors Pre-natal environment 1-Factors related to mothers during
pregnancy: - Nutritional deficiencies - Diabetic mother - Exposure to radiation - Infections - Smoking - Use of drugs •
Factors
related to fetus •
Mal-position in uterus •
Faulty placental implantation Post-Natal Environment External environment: - socio-economic status of the family - child’s nutrition - climate and season - child’s ordinal position in the
family - Number of siblings in the family - Family structure (single parent or
extended Internal environment •
Child’s intelligence •
Hormonal influences •
Emotions TYPES OF
GROWTH AND DEVELOPMENT Types of
growth: - Physical growth (Ht, Wt, head &
chest circumference) - Physiological growth (vital signs …) Types of
development: - Motor development - Cognitive development - Emotional development Social development •
Prenatal
- Embryonic (conception- 8 w) - Fetal stage (8-40 or 42 w) •
Infancy -
Neonate:
Birth to end of 1 month -
Infancy:
1 month to end of 1 year •
Early
Childhood -
Toddler:
1-3 years -
Preschool:
3-6 years •
Middle
Childhood -
School
age: 6 to 12 years •
Late
Childhood -
Adolescent:
13 years to approximately 18 years n Neonatal stage Neonatal stage is the first 4
weeks or first month of life. It is a transitional period from intrauterine
life to extra uterine environment Normal newborn growth Physical growth - Weight = 2.500 – 4 kg - Wt loss 5% -10% by 3-4 days after birth - Wt gain by 10th days of life - Gain ¾ kg by the end of the 1st
month Weight They loose 5 % to 10 % of weight by 3-4 days after birth as
result of : Height •
Boys average Ht = 50 cm •
Girls average Ht = 49 cm •
Normal range for both (47.5- 53.75
cm) Head circumference 33-35 cm Head is ¼ total body length Skull has 2 fontanels (anterior
& posterior) n Anterior fontanel •
Diamond in shape •
The junction of the sagittal,
corneal and frontal sutures forms it •
Between 2 frontal & 2 parietal
bones •
3-4 cm in length and 2-3 cm width •
It closes at 12-18 months of age APGAR Score Skull has 2 fontanels (anterior
& posterior) n Anterior fontanel •
Diamond in shape •
The junction of the sagittal,
corneal and frontal sutures forms it •
Between 2 frontal & 2 parietal
bones •
3-4 cm in length and 2-3 cm width •
It closes at 12-18 months of age Normal skull of a newborn
•
The Posterior fontanel is Triangular
Located between occipital & 2 parietal bones •
Closes by the end of the 1st
month of age n Chest circumference: It
is 30.5 to 33cm (usually 2–3cm less than head circumference). Newborn senses Senses -
Touch -
Vision -
Hearing -
Taste -
Smell n Touch •
It is the most highly developed
sense. •
It is mostly at lips, tongue, ears,
and forehead. •
The newborn is usually comfortable
with touch. n Vision •
Pupils react to light •
Bright lights appear to be
unpleasant to newborn infant. •
Follow objects in line of vision n Hearing •
The newborn infant usually makes
some response to sound from birth. •
Ordinary sounds are heard well
before 10 days of life. •
The newborn infant responds to
sounds with either cry or eye movement, cessation of activity and / or startle
reaction. n Taste Well developed as bitter and sour
fluids are resisted while sweet fluids are accepted. Smell Only evidence in newborn infant’s
search for the nipple, as he smell breast milk. Motor development The newborn's movement are random, diffuse and
uncoordinated. Reflexes carry out bodily functions and responses to external
stimuli. n Fine motor development •
Holds hand in fist •
When crying, he draws arms and legs
to body n Reflexes •
Sucking •
Stepping •
Moro •
Rooting •
Grasp •
Tonic-neck Ø Sucking – place finger in mouth; infant sucks Ø Moro – [“startle reflex”] elicit by loud noise; infant
extends arms & legs suddenly. Ø Rooting – touch cheek; turns head in direction of touch. Ø Babinski – stroke
sole of foot from top to bottom; toes fan out. Ø Grasping – place
finger in newborn’s hand; grabs & hold. Ø Stepping – hold
infant upright w. feet on surface; stepping movements Reflexes cont. Sucking – place finger in mouth; infant sucks Ø Moro – [“startle reflex”] elicit by loud noise; infant
extends arms & legs suddenly. Ø Rooting – touch cheek; turns head in direction of touch. Ø Babinski – stroke
sole of foot from top to bottom; toes fan out. Ø Grasping – place
finger in newborn’s hand; grabs & hold. Ø Stepping – hold
infant upright w. feet on surface; stepping movements Cognitive Development The cognitive development of newborn infant is difficult to
understand or observe it. Emotional development The newborn infant expresses his emotion just through cry
for hunger, pain or discomfort sensation Physical growth of a normal infant Weight : the infant gains :
Birth to 4 months → ¾ kg /month
5 to 8 months → ½ kg / month
9 to 12 months → ¼ kg /month The infant will double his birth wt
by 6 months and triple it by 12 months of age n Calculating the weight Infants from 3 to 12 months Weight = Age in months + 9 2 Weight of 7 months old infant = 7+9 = 16/2 = 8 kg 2 n Height •
Length increases about 3 cm /month
during the 1st 3 months of age, •
then it increases 2 cm /month at age
of 4-6 months, •
Then, at 7 – 12 months, it increases
1 ½ cm per month n Head circumference •
It increases about 2 cm /month
during the 1st 3 months, •
Then, ½ cm/month during the 2nd
9 months of age. •
Posterior fontanel closes by 6-8 w
of age. •
Anterior fontanel closes by 12-18
months of age. n Chest circumference By the end of the 1st
year, it will be equal to head circumference. Physiological growth of infants:- •
Pulse 110-150 b/min •
Resp
35 ± 10 c/min •
Breath through nose. •
Blood pressure 80/50 ± 20/10 mmHg Eruption of teeth starts by 5–6 months of age. It is called
"Milky teeth" or "Deciduous teeth" or "Temporary teeth Motor development •
At 2
months •
Hold head erects in mid-position. •
Turn from side back. •
At 3
months, the infant can •
Hold head erects and steady. •
Open or close hand loosely. •
Hold object put in hand •
Head control At 4
months •
Sit with
adequate support. •
Roll over from front to back. •
Hold head erect and steady while in
sitting position. •
Bring hands together in midline and
plays with fingers. •
Grasp objects with both hands. •
Balance head well when sitting. •
Sit with
slight support. •
Pull feet up to mouth when supine. •
Grasp objects with whole hand (Rt.
or Lt.). •
Hold one object while looking at
another 6months
Turn completely over ( abdomen to abdomen ). •
Lift chest and upper abdomen when
prone. •
Hold own bottle. 8 months •
Sits alone
steadily. •
Drinks from cup with assistance. •
Eat finger food that can be held in
one hand n 9 months •
Rise to sitting position alone. •
Crawl (i.e., pull body while in prone position). •
Hold one bottle with good hand-mouth
coordination n 10 months •
Creep well
(use hands and legs). •
Walk but with help. •
Bring the hands together. At 11 months •
Walk holding on furniture. •
Stand erect with minimal support n 12 months •
Stand-alone for variable length of
time. •
Site down from standing position
alone. •
Walk in few steps with help or alone
(hands held at shoulder height for balance). •
Pick up small bits of food and
transfers them to his mouth n Motor
growth •
9 month old: crawl •
10 month old: creep •
1 year: stand independently from a
crawl & creep position
•
13 month old: walk and toddle
quickly •
15 month old: can run n Emotional development •
His emotions are instable, where it
is rapidly changes from crying to laughter. •
His affection for or love family
members appears. •
By 10
months, he expresses several beginning
recognizable emotions, such as anger, sadness, pleasure, jealousy, anxiety and
affection. •
By 12
months of age, these emotions are clearly
distinguishable. Motor growth •
9 month old: crawl •
10 month old: creep •
13 month old: walk and toddle
quickly •
15 month old: can run n Emotional development •
His emotions are instable, where it
is rapidly changes from crying to laughter. •
His affection for or love family
members appears. •
By 10
months, he expresses several beginning
recognizable emotions, such as anger, sadness, pleasure, jealousy, anxiety and
affection. •
By 12
months of age, these emotions are clearly
distinguishable. n Social
development •
He learns that crying brings
attention. •
The infant smiles in response to
smile of others. •
He responds socially to his name. According to Erikson, the
infant develops sense of trust. Through the infant's
interaction with caregiver (mainly the mother), especially during feeding, he
learns to trust others through the relief of basic needs Red flags in development •
Unable to sit alone by age 9 months •
Unable to transfer objects from hand
to hand by age 1 year •
Abnormal pincer grip or grasp by age
15 months •
Unable to walk alone by 18 months •
Failure to speak recognizable words
by 2 years. n Toddler stage is between 1 to 3 years of age. During this
period, growth slows considerably The toddler's average weight gain is
1.8 to 2.7 kg/year. Formula to calculate normal weight
of children over 1 year of age is Age
in years X 2+8 = ….. kg. e.g., The weight of a child aged 4
years = 4 X 2 + 8 = 16 kgs n Height •
During 1–2 years, the child's height
increases by 1cm/month. The toddler's height increases about
10 to 12.5cm/year. Height = Age in years X 5 + 80 = cm. e.g. the length of 2 years old child
= 2 X 5 + 80 = 90cm n Teething •
By 2 years of age, the toddler has
16 temporary teeth. •
By the age of 30 months (2.5 years),
the toddler has 20 teeth Physiological growth Pulse: 80–130 beats/min
(average 110/min). Respiration: 20–30C/min. Bowel and bladder control: Daytime
control of bladder and bowel control by 24–30 months •
1 year old: transfer objects from
hand to hand •
2 year old: can hold a crayon and
color vertical strokes •
Turn the page of a book •
Build a tower of six blocks •
3 year old: copy a circle and a
cross – build using small blocks n Height •
During
1–2 years, the child's height increases by 1cm/month. The toddler's height increases
about 10 to 12.5cm/year. Height = Age in
years X 5 + 80 = cm. e.g. the length of 2 years old
child = 2 X 5 + 80 = 90cm n Teething •
By 2
years of age, the toddler has 16 temporary teeth. •
By the
age of 30 months (2.5 years), the toddler has 20 teeth Physiological growth Pulse: 80–130 beats/min
(average 110/min). Respiration: 20–30C/min. Bowel
and bladder control: Daytime
control of bladder and bowel control by 24–30 months •
1 year
old: transfer objects from hand to hand •
2 year
old: can hold a crayon and color vertical strokes •
Turn the
page of a book •
Build a
tower of six blocks •
3 year
old: copy a circle and a cross – build
using small blocks n Fine
motor development At 15
months, the toddler can: •
Walk
alone. •
Creep
upstairs. •
Assume
standing position without falling. •
Hold a
cup with all fingers grasped around it. At 18
months: •
Hold cup
with both hands. •
Transfer
objects hand-to hand at will. n At 24
months •
Go up
and down stairs alone with two feet on each step •
Hold a cup with one hand. •
Remove
most of own clothes. •
Drink
well from a small glass held in one hand. n 30
months •
Jump
with both feet. •
Jump
from chair or step. •
Walk up
and downstairs, one foot on a step. •
Drink
without assistance. n Parenting
& emotional development •
Stranger
anxiety – should dissipate by age 2 ½ to 3 years •
Temper
tantrums: occur weekly in 50 to 80% of children – peak incidence 18 months –
most disappear by age 3 •
Sibling
rivalry: aggressive behavior towards new infant: peak between 1 to 2 years
but may be prolonged indefinitely •
Thumb
sucking, Toilet Training n Cognitive
development •
Up to 2
years, the toddler uses his senses and motor development to different self
from objects. •
The
toddler from 2 to 3 years will be in the pre-conceptual phase of
cognitive development (2-4 years), where he is still egocentric and
can not take the point of view of other people.
n Preschoolar It
is 3 to 6 years of age. The growth is relatively slow. Weight
=1.8kg/year. Height: He
doubles birth length by 4–5y •
Pulse:
80–120 beat/min. (average
100/min).Respiration: 20–30C/min. •
Blood
Pressure: 100/67+24/25. n Fine motor •
3 year
old: copy a circle and a cross – build using small blocks •
4 year
old: use scissors, color within the borders •
5 year
old: write some letters and draw a person with body parts Fine motor & cognitive abilities •
Buttoning
clothing •
Holding
a pencil •
Building
with small blocks •
Using
scissors •
Playing
a board game •
Have
child draw picture of himself n School age period School-age: 6 to 12 years. The
child's growth and development is characterized by gradual growth Weight: child gains about 3.8kg/year. •
Boys
tend to gain slightly more weight through 12 years. •
Weight
Formula for 7 - 12 yrs = (age in
yrs x 7 )– 5 2 n Height •
The
child gains about 5cm/year. •
Body
proportion during this period: Both boys and girls are long-legged. Dentition: •
Permanent
teeth erupt during school-age period, starting
from 6 years, usually in the same order in which primary teeth are lost. •
The
child acquires permanent molars, medial and lateral incisors. n Physiological
growth •
Pulse: 90+15 beats/min •
Respiration:
21+3C/min (18–24). •
Blood
Pressure: 100/60+16/10 •
Writing
skills improve, Fine motor is refined •
Fine
motor with more focus •
Building: models – logos, Sewing, Musical instrument,
Painting, Typing skills •
Technology:
computers At 6–8
years, the school–age child: •
Rides a
bicycle. •
Runs
Jumps, climbs and hops. •
Has
improved eye-hand coordination. •
Prints
word and learn cursive writing. •
Can
brush and comb hair. At 8–10
years, the school–age child: •
Throws
balls skillfully. •
Uses to
participate in organized sports. •
Uses
both hands independently. •
Handles
eating utensils (spoon, fork, knife) skillfully. At 10–12 years, the school–age child: •
Enjoy
all physical activities. •
Continues
to improve his motor coordination. n School Age: cognitive development At 7-11
years, the child now is in the
concrete operational stage of cognitive development. He is able to
function on a higher level in his mental ability. Greater ability to concentrate and
participate in self-initiating quiet activities that challenge cognitive
skills, such as reading, playing computer and board games. n Red flags •
School
failure •
Lack of
friends •
Social
isolation •
Aggressive
behavior: fights, fire setting, animal abuse n Adolescence Adolescence is a transition period
from childhood to adulthood. Its is
based on childhood experiences and accomplishments. It begins with the appearance of secondary sex
characteristics and ends when somatic growth is completed and the individual is
psychological mature. n Physical growth Weight: Growth spurt begins earlier in girls (10–14 years, boys
12–16 in boys). •
Males gains 7 to 30kg, while female
gains 7 to 25kg. Height: By 13, the adolescent triples his birth length. •
Males gains 10 to 30cm in height. •
Females gains less height than males
as they gain 5 to 20cm. Growth in height ceases at 16 or 17 years in females
and 18 to 20in males n Physiological growth Pulse: Reaches adult value 60–80 beats/min. Respiration: 16–20C/minute. NB: The sebaceous
glands of face, neck and chest become more active. When their secretion
accumulates under the skin in face, acne will appear. n 2° sex characteristics in girls •
Increase in transverse diameter of
the pelvis. •
Development of the breasts. •
Change in the vaginal secretions. •
Growth of pubic and axillary hair. •
Menstruation (menarche) which occurs
between 12 to 13 years). n 2° sex
characteristics in boys •
Increase in size of genitalia. •
Swelling of the breast. •
Growth of pubic, axillary, facial
and chest hair. •
Change in voice. •
Rapid growth of shoulder breadth. •
Production of spermatozoa (which is
sign of puberty). •
As teenagers gain independence they
begin to challenge values •
Critical of adult authority •
Relies on peer relationship •
Mood swings especially in early
adolescents Adolescence behavioral problems Anorexia,Attention
deficit, Anger issues, Suicide, Relationships, Sexuality
– STD’s / AIDS, Substance use and abuse, Gang
activity, Driving,Access to
weapons Unit Two: Summary Growth and development is Continuous process •
Predictable
Sequence •
Don’t
progress at the same rate (↑ periods of GR in early childhood and adolescents
& ↓ periods of GR in middle childhood. Not all body parts grow in the
same rate at the same time. •
Each
child grows in his/her own unique way. Each stage of G&D is affected by
the preceding types of development •
G &
D proceed in regular related directions •
It is
influenced by – both hereditary and environmental factors Reference Material Nelsons text book of Paediatrics Oxford Hand Book of Paediatrics b)
Topic objective By
the end of this lesson the learner should be able to Describe terms used in
growth and development in a child c)
Topic Content Growth § Growth
refers to an increase in physical size of the whole/part of body § It is simply a quantitative change § The physical changes include: Height, Weight, Vital signs,
Vocabulary § It can
be measured in Kg, pounds, meters, inches, Development Increase in capability /complexity or
function: • Milestones (sitting, walking,
talking) • Communication • Motor skills • Emotions • It is a qualitative change in the
child’s functioning. It can be measured through observation. Maturation •
Increase
in child’s competence and adaptability. •
It
is describing the qualitative change in a structure. •
The
level of maturation depends on child’s heredity. Importance of knowing growth &
development •
Knowing
what to expect of a particular child at any given age. •
Gaining
better understanding of the reasons behind illnesses. •
Helping
in formulating the plan of care. •
Helping
in parents’ education in order to achieve optimal growth & development at
each stage. Periods of development ·
Prenatal
period: from conception to birth ·
Infancy
and toddlerhood: birth to 2 yrs ·
Early
childhood: 2-6 years old ·
Middle
childhood: 6-12 years old ·
Adolescence:
12-19 years old Principles of growth and development •
Continuous
process •
Predictable
Sequence •
Don’t
progress at the same rate (↑ periods of GR in early childhood and adolescents
& ↓ periods of GR in middle childhood. Not all body parts grow in the same
rate at the same time. •
Each
child grows in his/her own unique way. Each stage of G&D is affected by the
preceding types of development •
G
& D proceed in regular related directions : Cephalo-caudal(head
down to toes) Proximodistal (center
of the body to the
peripheral) General to specific Growth pattern The
child’s pattern of growth is in a head-to-toe direction, or cephalocaudal, and
in an inward to outward pattern called proximodistal
Infant feeding - Refers to feeds given to babies in
the first year of life Methods ◦
Breast
feeding ◦
Bottle
feeding ◦
Tube
feeding (too ill / immature NGT Gastrostomy (if required long term) Silastic naso-jejunal tube (severe
GOR, Aspiration, recurrent apneas) When to
initiate Feeding should be initiated as soon
after birth as possible, depending on the infant's ability to tolerate enteral
nutrition. This helps maintain normal
metabolism during the transition from fetal to extra uterine life and also promotes bonding between the mother and
infant. Most infants can start
breast-feeding immediately after birth, almost always within 1–4 hr. (should be
within 30min) Advantages of breast feeding • Reduces maternal postpartum
haemorhage • Mild maternal contraceptive effect • Enhance bonding • Reduces maternal breast cancer risk • Reduces infant mortality • Reduces GI and respiratory infection • Reduces later autoimmune disease
incidence e.g type 1 DM • Increases later IQ • Breast milk is
cheap Is the natural food for full-term
infants & is the appropriate milk for infants It is always available at the proper temp.
& requires no preparation time. It is fresh and free from
contamination reducing the chances of GI disturbances. Has protective effects against
enteric and other pathogens result in less morbidity. is associated with fewer feeding difficulties Reduced allergy and/or intolerance.
i.e diarrhea, GI bleeding, occult melena, “spitting up,” colic, & atopic
eczema. It
contains bacterial & viral antibodies + secretory immunoglobulin A, that
prevent microorganisms from adhering to the intestinal mucosa. It also contains substances that
inhibit the growth of many common viruses as well as specific antibodies that
are thought to provide local gastrointestinal immunity. These
factors probably account, at least partially, for the lower prevalence of
diarrhea, otitis media, pneumonia, bacteremia, and meningitis during the 1st
year of life in infants who are breast-fed exclusively compared with those who
are formula-fed for the 1st 4 months Macrophages
in human milk may synthesize complement, lysozyme, and lactoferrin. In
addition, breast milk contains lactoferrin, an iron-binding whey protein that
is normally approximately ⅓ saturated with iron and has an inhibitory effect on
the growth of Escherichia coli in the intestine. The
lower pH of the stool of breast-fed infants is thought to contribute to the
favorable intestinal flora (more bifidobacteria and lactobacilli; Fewer Escherichia coli), and
this helps protect against infections caused by some species of E. coli.
Human milk also contains bile
salt-stimulated lipase, which kills Giardia lamblia &E.
histolytica There is passive transfer of T-cell
immunity. Milk from the mother whose diet is
sufficient and properly balanced will supply all the necessary nutrients. The vitamin K content of human milk
is low may contribute to hemorrhagic
disease of the newborn. Parenteral administration of 1 mg of vitamin K1
at birth is recommended
psychological advantages for both & infant • The mother is personally involved in
nurturing of her infant, and this results in both a feeling of being essential
and a sense of accomplishment. • At the same time, the infant
develops a close and comfortable physical relationship with the mother Disadvantages Transmission of HIV - 15% if safe alternatives are available, HIV
infected mothers can avoid B/F in many developing countries, breast-feeding
may be crucial for infant survival; the risk of HIV transmission by
breast-feeding may be less than the risk of other feeding methods. The WHO recommends that
breast-feeding be continued, even in areas of high endemic rates of HIV
infection, unless safe infant formula is readily available Cytomegalovirus
(CMV), human T-cell lymphotropic virus type 1, rubella virus, hepatitis B
virus, and herpes simplex
virus have also been demonstrated in breast milk Contraindications Positive maternal HIV status (dev. Countries Certain maternal medications
(amiodarone) Maternal herpes zoster over the
breast Infantile galactoceamia or PKU
(Phenylketonuria) Primary lactose intolerance Factors conducive for breast feeding Factors that are conducive to
successful breast-feeding include good nutritional health, a proper balance of rest and
exercise, freedom from worry, early and sufficient treatment of
any intercurrent disease, and adequate nutrition. Retracted and/or inverted
nipples are detractions but not contraindications to breast-feeding. Retracted nipples usually benefit
from daily manual breast-pump suction during the latter weeks of pregnancy, and
truly inverted nipples may be helped by the use of milk cups, starting as early
as the 3rd month of pregnancy. Check for good
attatchment & correct positioning in breast feeding Is
the infant able to attach? To check for attachment look for: -Chin touching the breast -Mouth wide open -lower lip turned outward -More areola seen above than below
the mouth The 4 signs of good
attachment must be present for one to decide the infant has good attachment correct
positioning Is the infant correctly positioned?
Positioning refers to how the baby is placed during a breastfeed. To check for
correct positioning, look for: - Infant’s head and body straight - Infant facing the mother with the
nose opposite the nipple -infant’s body close to the mother’s
body -mother supporting infant’s whole
body and not just neck and shoulders. Expressed
breast milk EBM Useful when Mother & baby are separated Mothers’s nipples are sore Tube feeds are reguired Breast engorgement N/B
– Once expressed, refrigerate and use within 24-48hrs; freeze up to 3mo Formular milk Volume reguired 150mls/kg /day Advantages Less freguent feeds Parternal involvement Milk intake determined Problems Constipation, oral thrush, milk
bezoars, hypernatraemic dehydration Infant feeding - Refers to feeds given to babies in
the first year of life Methods ◦
Breast
feeding ◦
Bottle
feeding ◦
Tube
feeding (too ill / immature NGT Gastrostomy (if required long term) Silastic naso-jejunal tube (severe
GOR, Aspiration, recurrent apneas) When to
initiate Feeding should be initiated as soon
after birth as possible, depending on the infant's ability to tolerate enteral
nutrition. This helps maintain normal
metabolism during the transition from fetal to extra uterine life and also promotes bonding between the mother and
infant. Most infants can start
breast-feeding immediately after birth, almost always within 1–4 hr. (should be
within 30min) Advantages of breast feeding • Reduces maternal postpartum
haemorhage • Mild maternal contraceptive effect • Enhance bonding • Reduces maternal breast cancer risk • Reduces infant mortality • Reduces GI and respiratory infection • Reduces later autoimmune disease
incidence e.g type 1 DM • Increases later IQ • Breast milk is
cheap Is the natural food for full-term
infants & is the appropriate milk for infants It is always available at the proper temp.
& requires no preparation time. It is fresh and free from
contamination reducing the chances of GI disturbances. Has protective effects against
enteric and other pathogens result in less morbidity. is associated with fewer feeding difficulties Reduced allergy and/or intolerance.
i.e diarrhea, GI bleeding, occult melena, “spitting up,” colic, & atopic
eczema. It
contains bacterial & viral antibodies + secretory immunoglobulin A, that
prevent microorganisms from adhering to the intestinal mucosa. It also contains substances that
inhibit the growth of many common viruses as well as specific antibodies that
are thought to provide local gastrointestinal immunity. These
factors probably account, at least partially, for the lower prevalence of
diarrhea, otitis media, pneumonia, bacteremia, and meningitis during the 1st
year of life in infants who are breast-fed exclusively compared with those who
are formula-fed for the 1st 4 months Macrophages
in human milk may synthesize complement, lysozyme, and lactoferrin. In
addition, breast milk contains lactoferrin, an iron-binding whey protein that
is normally approximately ⅓ saturated with iron and has an inhibitory effect on
the growth of Escherichia coli in the intestine. The
lower pH of the stool of breast-fed infants is thought to contribute to the
favorable intestinal flora (more bifidobacteria and lactobacilli; Fewer Escherichia coli), and
this helps protect against infections caused by some species of E. coli.
Human milk also contains bile
salt-stimulated lipase, which kills Giardia lamblia &E.
histolytica There is passive transfer of T-cell
immunity. Milk from the mother whose diet is
sufficient and properly balanced will supply all the necessary nutrients. The vitamin K content of human milk
is low may contribute to hemorrhagic
disease of the newborn. Parenteral administration of 1 mg of vitamin K1
at birth is recommended
psychological advantages for both & infant • The mother is personally involved in
nurturing of her infant, and this results in both a feeling of being essential
and a sense of accomplishment. • At the same time, the infant
develops a close and comfortable physical relationship with the mother Complimentary feeding Begin
after 6
months The volume and frequency of breast-feeding ↓ Complimentary
feeding can be initiated when desired by the mother and infant by substituting
formula by cup for part and, subsequently, all of a breast-feeding. Breast-feeding
is eventually replaced with formula-feeding, at which time the infant is weaned
completely. Important principles for complimentary feeding Begin at ≈
6 mo of age Avoid
foods with high allergenic potential (cow's milk, eggs, fish, nuts, soybeans).
Encourage
a cup rather than a bottle. Introduce 1 food at a time. Energy
density should exceed that of breast milk. Iron-containing foods (meat, iron-supplemented
cereals) are required. Zinc
intake should be encouraged with foods such as meat, dairy products, wheat, and
rice. Phytate
intake should be low to enhance mineral absorption. Breast
milk should continue to 12 mo; formula or cow's milk is then substituted. Give no more than 4–6 oz/day of fruit juices.
No soda. Cereals, a good source of iron, are
usually introduced 1st, followed by vegetables and fruits, then meats, and
finally, eggs. However, the order in which these
foods are introduced is not crucial, but only 1 new food should be introduced
at a time and additional new foods should be spaced by at least 3–4 days to allow
detection of any adverse reaction(s) to each newly introduced food. This
is particularly important if there is a family history of food and/or other
allergies. Feeding
problems Underfeeding. Underfeeding is suggested by
restlessness and crying as well as by failure to gain weight adequately. It may also result from the infant's
failure to take a sufficient quantity of food, even when offered. In these cases, the frequency of
feedings, the mechanics of feeding, possibility of abnormal mother-infant
“bonding,” and possible systemic disease in the infant should be considered. S+S Constipation, failure to sleep,
irritability, and excessive crying are to be expected. Weight gain may be slow, or there
may be an actual loss of weight. In the latter case, the skin becomes
dry and wrinkled, S/C tissue disappears, & the
infant assumes the appearance of an “old man.” Deficiencies of vitamins A, B, C,
and D as well as of iron and protein may be responsible for the C’C
manifestation Treatment of
underfeeding Increasing nutrient intake, correcting any deficiencies of
vitamins and/or minerals, and instructing the caregiver in the art
and practice of infant feeding. If an underlying systemic disease,
child abuse or neglect, or a psychologic problem is responsible, specific
management of that disorder is necessary 2. Overfeeding Most
frequent symptoms: postprandial
discomfort. Regurgitation, vomiting. Diets
that are too high in fat delay gastric emptying, cause abdominal distention and
discomfort, and may cause excessive weight ↑↑ carbohydrate diet cause undue
fermentation in the intestine, resulting in distention, flatulence & more rapid weight gain than desirable. Because neither breast milk nor
formula contains either excessive fat or excessive carbohydrate, excessive
intakes usually result from supplementation. This practice also tends to dilute
the protein, vitamin, and mineral contents of formula and, hence, should be
avoided Regurgitation & vomiting Regurgitation refers to the return of small
amounts of swallowed food during or shortly after eating. Vomiting, on the other hand, is the
more complete emptying of the stomach, often occurring sometime after feeding. Within limits, regurgitation is a
natural occurrence, especially during the 1st several months of life. It can be reduced to a negligible
amount by adequate eructation of swallowed air during and after eating, Loose or
diarrhoel stools The stool of the breast-fed infant
is naturally softer than that of the formula-fed infant. From 4th to the 6th day, the stools
of the breast-fed infant go through a transitional stage of being loose,
greenish-yellow in color and containing mucus to the typical “milk stool.” The use of laxatives or the
ingestion of certain foods by the mother may be temporarily responsible for a
breast-fed infant's loose stools. Excessive intake of breast milk may
also increase the frequency and water content of the stool. Actual diarrhea from overfeeding,
however, is unusual; thus, diarrhea should be considered infectious until
proven otherwise. Constipation Constipation
in breast-fed infants is uncommon, rare in formula-fed infants
receiving an adequate intake. The
consistency of the stool, not its frequency, is the basis for diagnosis. Most
infants have 1 or more stools daily, but some occasionally have a stool of
normal consistency at intervals of up to 36–48 hr. Whenever
constipation or obstipation is present from birth or shortly after birth, a
rectal examination should be performed Colic Colic is a
symptom complex of paroxysmal abdominal pain, presumably of intestinal origin,
and severe crying It usually occurs in infants younger than 3 mo
of age. The attack usually begins suddenly, with a
loud, sometimes continuous cry. The
paroxysms may persist for several hours. The
infant's face may be flushed, or there may be circumoral pallor. The abdomen is
usually distended and tense. The legs may be extended for short periods, but
are usually drawn up on the abdomen. The feet are often cold, and the hands are
usually clenched. The attack
may not terminate until the infant is completely exhausted. Sometimes, however,
the passage of feces or flatus appears to provide relief. Holding
the infant upright or prone across the lap or on a hot water bottle or heating
pad occasionally helps. Passage of
flatus or fecal material spontaneously or with expulsion of a suppository or
enema sometimes affords relief Causes of
constipation Insufficient amount of food Diets that are too high in protein
or deficient in bulk. Simply increasing the amount of
fluid or sugar in the formula may be corrective during the 1st few months of
life. Infant feeding - Refers to feeds given to babies in
the first year of life Methods ◦
Breast
feeding ◦
Bottle
feeding ◦
Tube
feeding (too ill / immature NGT Gastrostomy (if required long term) Silastic naso-jejunal tube (severe
GOR, Aspiration, recurrent apneas) When to
initiate Feeding should be initiated as soon
after birth as possible, depending on the infant's ability to tolerate enteral
nutrition. This helps maintain normal
metabolism during the transition from fetal to extra uterine life and also promotes bonding between the mother and
infant. Most infants can start
breast-feeding immediately after birth, almost always within 1–4 hr. (should be
within 30min) Advantages of breast feeding • Reduces maternal postpartum
haemorhage • Mild maternal contraceptive effect • Enhance bonding • Reduces maternal breast cancer risk • Reduces infant mortality • Reduces GI and respiratory infection • Reduces later autoimmune disease
incidence e.g type 1 DM • Increases later IQ • Breast milk is
cheap Is the natural food for full-term
infants & is the appropriate milk for infants It is always available at the proper temp.
& requires no preparation time. It is fresh and free from
contamination reducing the chances of GI disturbances. Has protective effects against
enteric and other pathogens result in less morbidity. is associated with fewer feeding difficulties Reduced allergy and/or intolerance.
i.e diarrhea, GI bleeding, occult melena, “spitting up,” colic, & atopic
eczema. It
contains bacterial & viral antibodies + secretory immunoglobulin A, that
prevent microorganisms from adhering to the intestinal mucosa. It also contains substances that
inhibit the growth of many common viruses as well as specific antibodies that
are thought to provide local gastrointestinal immunity. These
factors probably account, at least partially, for the lower prevalence of
diarrhea, otitis media, pneumonia, bacteremia, and meningitis during the 1st
year of life in infants who are breast-fed exclusively compared with those who
are formula-fed for the 1st 4 months Macrophages
in human milk may synthesize complement, lysozyme, and lactoferrin. In
addition, breast milk contains lactoferrin, an iron-binding whey protein that
is normally approximately ⅓ saturated with iron and has an inhibitory effect on
the growth of Escherichia coli in the intestine. The
lower pH of the stool of breast-fed infants is thought to contribute to the
favorable intestinal flora (more bifidobacteria and lactobacilli; Fewer Escherichia coli), and
this helps protect against infections caused by some species of E. coli.
Human milk also contains bile
salt-stimulated lipase, which kills Giardia lamblia &E.
histolytica There is passive transfer of T-cell
immunity. Milk from the mother whose diet is
sufficient and properly balanced will supply all the necessary nutrients. The vitamin K content of human milk
is low may contribute to hemorrhagic
disease of the newborn. Parenteral administration of 1 mg of vitamin K1
at birth is recommended
psychological advantages for both & infant • The mother is personally involved in
nurturing of her infant, and this results in both a feeling of being essential
and a sense of accomplishment. • At the same time, the infant
develops a close and comfortable physical relationship with the mother Topic
name Malnutrition in children a)
Topic objectives Topic Content What is malnutrition Definition Malnutrition is the insufficient, excessive or imbalanced consumption of
nutrients. Several nutritional disorders may develop ·
It can complicate measles, pneumonia & diarrhoea or
it may cause the above ·
It is measured in weight for height (BMI), Or height for age, Mid upper arm circumferance Classification of malnutrition. ·
Underweight: weight for age < 80% expected ·
Marasmus: weight for age < 60% expected ·
Kwashiorkor: weight for age < 80% + edema ·
Marasmic kwashiorkor: wt/age <60% + edema ·
Wasting: weight for height ·
Stunting: height for age ·
WHO CLASSIFICATION (severe,
moderate, acute/chronic) ·
SAM: severe acute malnutrition; MAM, Chronic
malnutrition PEM Protein-energy malnutrition (PEM) is manifested
primarily by inadequate dietary intakes of protein and energy, either because
the dietary intakes of these 2 nutrients are less than required for normal
growth or because the needs for growth are greater than can be supplied.
However, PEM is almost always accompanied by deficiencies of other nutrients.
For this reason, the term severe malnutrition which more accurately
describes the condition, is preferred. Clinical
manifestation ·
Marasmus is C’C by
failure to gain weight and irritability, weight loss and listlessness until emaciation. ·
skin loses turgor & s/c
fat & becomes wrinkled ·
Infant's face
may be shrunken and wizened. ·
Infants are often constipated, starvation diarrhea,
with frequent, small stools containing mucus. ·
The abdomen may be distended or flat, with the
intestinal pattern readily visible. muscle atrophy and resultant hypotonia. ·
As the condition progresses, the temperature usually
becomes subnormal and the pulse slows. Kwashiorkor
May
initially present as vague manifestations that include lethargy, apathy, and/or
irritability. When advanced, there is lack of growth, lack of stamina, loss of
muscle tissue, increased susceptibility to infections, vomiting, diarrhea,
anorexia, flabby subcutaneous tissues, and edema. ·
The edema usually develops early and may mask the
failure to gain weight. It is often present in internal organs before it is
recognized in the face and limbs. ·
Liver enlargement may occur early or late in the
course of disease. Dermatitis is common, with darkening of the skin in
irritated areas, but in contrast to pellagra, ·
Depigmentation may occur after desquamation in these
areas, ·
The hair is sparse and thin, and in dark-haired
children, it may become streaky red or gray. Eventually, there is stupor, coma,
and death. Cold chain is
the process by which vaccines are maintained at the right temperature from the
manufacturer to the recepient. It ensures
vaccines are kept at 0-8℃ from manufacturers to recepient and also ensures
potency at 4 levels -central
stores, Regional stores, District H/C & dispensries Requirements
for cold chain Cold rooms Refrigerators, Cold box Vaccine carriers Thermometers Find out the types of
fridges used Fridge
arrangement Coldest part - polio, measles, BCG
Middle part - pentavalent
Lower part - ice packs Problems
affecting the cold chain Electricity
failure Transport
problems Less than
optimal coverage Side effects *Very sick child
not immunized Standards
Availability of vaccines: - Ø vaccine services should be readily available Ø vaccines are integrated with other h/c
services Ø barriers to immun. are identified and
minimized Ø patients cost is minimized ( free in Kenya) Assessment of vaccine
status Ø Health care
professionals review the vaccination & health status of patients at every encounter to
determine which vaccines are indicated. Ø H/C professionals follow only medically accepted
contraindications Effective communication about vaccine benefits & risks Ø Health education
in a culturally accepted manner & in the lanquage the community understands
Proper storage, adminstration of
vaccines & documentation Ø H/C workers follow appropriate procedures Ø Up- to- date
written vaccination protocol at all lacations
where vaccines are adminstered Ø H/W who adminster
vaccines receive continuous education Ø Report adverse
events following vaccine promptly Implementation of strategies to improve vaccination Ø Community based
approaches health education on immunization. Reminder system a)
Topic objectives By
the end of this lesson the learner should be able to Define terms
used in immunization State the EPI
schedule in Kenya Outline the
cold chain Diagnose and
manage children with
immunizable diseases Definition Immunization -Is the process of
inducing immunity against a specific disease. Immunity – ability of the host to protect itself against
invading microbes. It can be passively through adminstration of antibody
containing preparations or naturally
thro’ transplacental. Actively by administering a vaccine or toxoid to stimulate the immune system to
produce a prolonged humoral or cellular
immune response Immunization is
one of the most beneficial and cost-effective disease prevention measure Vaccines are
medications that boost our ability to fight off certain diseases. Many of the
vaccine-preventable diseases are highly contagious and even fatal As a result of effective and safe vaccines :-small pox has been eradicated,
Polio is close to world wide eradication Measles and rubella are no longer
endemic in most countries. The incidence of most other vaccine preventable diseases of childhood have
been reduced by > 90% from the annual morbidity. Passive immunity Is achieved by
adminstration of preformed antibodies to
induce transcient protection against an infectious agent. It can also
be induced naturally through
transplacental transfer of antibodies during gestation. Maternally
derived antibodies can provide protection during an infant’s first months of
life & may persist for a year Indications
for passive immunity To provide
protection to:- Immunodeficient
children with B-lymphocytes defects
(have difficulties making antibodies) Persons exposed
to infectious d’ses or at risk Persons with
infectious d’se as part of specific therapy for that d’se. Immune
globulin (IG) Is a sterile
antibody containing solution, usually derived through cold ethanol
fractionation of large pools of human plasma. There are 5
immunoglobulin isotypes:-IgM, IgG, IgA, IgD & IgE IgG & IgM
are the most important immunoglobulins in the blood & body fluids. IgM is confined
to to the intravascular compartment IgG is present
in all internal body fluids IgA is a major
protective of external secretions in GIT, RS & GUT IgE is found in
both internal and external body fluids, has a major role in host defense
against parasites IgG crosses the placenta. Protects the baby
against gram positives All others do
not. That is why newborns are vulnerable to gram –ve organisms Active immunization Is when a
vaccine against a disease is given to protect a person from a specific disease Vaccines are part or whole of microorganisms adminstered to prevent infectious
diseases. Vaccines can
consist of whole inactivated microorganism e.g polio, hepatitis A or parts of the organism e.g Heb B, pneumococcal,
Hib Live attenuated microorganisms e.g measles, mumps rubella, varicella Toxoids -are modified bacteria toxin that is made non
toxin, but is still able to induce an active immune response against the toxin. Immunization may be natural or artificial Natural immunization occurs without
vaccines; when a baby gets Abs from the mother and when a person gets an infection and produces his own antibodies. Artificial immunization refers to when a person
is given a vaccine (antigen). Or by passively immunizing him with antibodies. In Kenya , children are immunized routinely against the following diseases Tuberculosis, Polio,
Diphtheria , pertusis, Tetanus, H. Influenza ,
hepatitis B, Measles, Yellow fever, rot virus, malaria The above are targeted by primary H/C because they cause severe d’ses and
mortality Other immunizable diseases not in KEPI Hepatitis A, mumps, Rubella, rota virus, varicella, meningococcal, plaque, rabies, typhoid fever,
cholera.Some vaccines are given only in outbreaks Primary h/c strategy is to improve coverage through:-Outreach, Fixed
facilities, Mass campaigns (NIDs) a)
Topic objectives o
State the epidemiology o
Explain the pathogenesis o
Outline the clinical manifestation o
List the differential diagnosis o
State the Diagnosis o
Outline the treat ment Diphtheria is a bacterial infection caused by corynebacterium diphtheriae Epidemiology
·
Corynebacterium diphtheriae are 4 biotypes; Gravis, mitis, intermedius & belfanti. ·
Are differentiated by colonial morphology, haemolysis
& fermented reactions. ·
Grow in selective media. Colonies are grey black in color ·
Are aerobic nonencapsulated non-spore forming ·
Mostly motile gram +ve bacilli ·
Spread by airborne, direct contact with respiratory
secretions or exudates from skin ·
Has carrier states in resp tract ·
Produces exotoxins ·
Has low endemicity in the world ·
Mainly a tropical dse . ·
Forms black grey membrane called desert sore Factors affecting spread Socio economic, Hygiene, Immunization Pathogenesis Both toxigenic & nontoxigenic cause disease occasionally; Incubation is 2-4 days Organisms remain in superficial layers of the skin & mm of resp tract. It inhibits protein
synthesis leading to tissue necrosis .C’C by a grey brown pseudomembrane of
resp tract, pharynx, tonsils. Bleeds on touch. Causes inflammation, local paralysis of the palate. Thick grey coating over the back of the throat-
may lead to suffocation . The toxins may affect kidney tubules & heart
causing cardiomyopathy, Nerves –
demyelination. Bone marrow-
thrombocytopenia leading to immediate
effects or 6 weeks later Clinical
features Low grade fever,
sore throat, dysphagia, hoarseness of voice, malaise, headache, erosive
rhinitis, membrane formation Tonsils &
pharynx may be unilateral or bilateral. Membranes form deeper in the surrounding, leading to
bullneck appearance, Regional lymphadenopathy, Soft tissue swelling, Upper airway
obstruction, Needs mechanical
intubation and tracheostomy DDX Streptococcal
pharyngitis Epstein bur
virus Wilson angina Phlembitis Thrombosis of
jugular vein Severe LTB Cutaneous
diphtheria Non progressive infection of the skin Takes time to heal Its covered by grey brown membrane, Impetigo, Cardiomyopathy
Is one of
the killers. Toxic cardiomyopathy occurs in ¼ of patients with resp diphtheria C’c by
tarchycardia, low grade fever, CCF, arrhythmias Toxic
neuropathy Hyperaesthesia, Paralysis, Weakness of structures on neck- dysphagia,
aspiration, Cranial nerve
palsy, Facial asymmetry, Polyneuropathy -- LMNL DDX Guillain barre
syndrome Paralysis of
phrenic nerve – leads to sudden death Autonomic nerves Sweating Ear – otitis
media Eyes –
conjunctivitis GUT DIAGNOSIS S+S High index of
suspicion Swabs in resp
tract for gram stain culture & sensitivity Treatment
Passive
immunization – antiserum antitoxin neutralizes free toxins Antibiotics –
erythromycin 50mg/kg/day x 2wks Or rifampicin,
clindamycin, X-pen Throat swab
before stopping drugs Bed rest Isolate the
patient Immunize the
staff, house hold or contacts with a booster vaccine Unimmunized
house hold contacts should be given benzathine penicillin Prognosis
Depends on 1. virulence of the organism 2. Age – very
young & very old 3. Site of
infection 4. antitoxins 5. well
immunized a. Definition of change To change something implies altering it, varying or modifying it in some way. It is also the process of moving from one system to another. It is also the process of making something different from what it was. Also change is any shift in status from an undesirable current status to a desirable future status. b. Types of change c. The change process (planned change) Change is a continual unfolding process rather than an event. The process begins with the present state, moves through a transition period then comes to a desired state once the desired state has been reached the process begins again. The change process is very similar to the problem solving process and involves :- d. Change theories There are several theories that have been developed concerning the change process. These theories are In this session we are going to review the Lewins’ force field model while you can read about the other theories Overcoming Resistance to Change Steps of change according to Lewin Unfreezing the existing equilibrium: Refers to the awareness of an opportunity, need or problem for which some action is necessary. To unfreeze a status quo, a change agent must increase driving forces or decreases restraining forces in the situation. According to Lewin it involves motivating the participants by getting them ready for change, building trust and recognition for the need to change To their attitudes, actively involve the participants in identifying problems and generating solutions. Move the target system to a new level of equilibrium (moving)/change This is done by getting the participants to agree that the status quo is not beneficial to them, encouraging them to view the problem from a new perspective and helping them scan the environment to search for relevant information Refreeze the system at the new level of equilibrium: This involves reinforcing the new patterns of behavior (e.g. rewarding for desired behavior or research on new system).Reinforcement can also be done through formal and informal mechanism (e.g. formulating policies, establishing communication channels To implement the above process the following approaches will be necessary:- Resistance to change Reasons why people resist change There are several reasons why people resist change. Among them are the following Measures of dealing with resistance to change BCG –Bacille Calmate
Guerin Protects against
Tuberculosis, It is given at
birth; It is live attenuated Dose o.1 mls; Route -
intradermal; Site upper outer
left fore arm or right deltoid BCG can be
freeze dried ( +2 to -10℃ ) Reconstitute
using chilled diluent Must be used
within 2-3 hours BCG is sensitive
to light, it loses potency just after 3-5minutes Inject o.1ml to
form a weal 5mm diameter A successful
vaccination results in a small red nodule forming during the 1st week 2-6weeks it
becomes an ulcer A scar forms by
12weeks Side
effect – BCG infection Contra
indication- symptomatic HIV or serious immune d’ses
A child with severe deformity due to polio Oral
polio vaccine Oral (Sabin) vaccine contains live attenuated virus from all the three
types of polio Brunhilde 1, Lancing II, & Leon III. It can be frozen ( active life is upto 2yrs) but
outside the fridge 2 days.
Dose
– 1 drop depending on the instructions on the label. Route : oral, 4th dose at 14 weeks is
Im.Frequency. At birth, 6wks, 10wks, 14wks NOTE: at 14 weeks (IPV). Successful immunization of infants guarantees 5-6yr immunity. Then
naturally acquired immunity takes overwhen the artificial immunity fades. Contraindication to OPV A child with
diarhea and vomiting ( OPV competes with other enteroviruses in the GIT) No complications
or reactions identified A child with
neonatal tetanus Diphtheria: a child with bull neck Pertusis
(whooping cough) This child has broken blood
vessels in his eyes and bruising on his face because of coughing from pertussis Hepatitis B Haemophilus influenzaetype b Pentavalent
Has 5 antigens Diphtheria, Pertusis, Tetanus, Haemophilus influenza type B, Hepatitis B. Diphtheria
- toxoid Tetanus
- toxoid Pertusis
is a dead bacterial antigen Hepatitis
B – killed hep B virus H ib
– killed bacteria. Dose – o.5mls 3 doses 4wks apart Route -
intramuscular Site - thigh Age - 6 wks, 10
wks, 14wks Contra indication – high fever Pneumococcal vaccine pneumococcal meningitis with purulence in the brain surface Is made up of
coating of many types of pneumococcal
bacteria. (23) Dose 0.5mls IM Age 6wks, 10wks,
14wks Measles Measles vaccine is live a attenuated freeze dried vaccine Storage - 2℃ to
-10℃ It is diluted
with a special diulent when ready to use. Can last for 5-6 hours after
dilution. Dose 0.5ml IM. Is sensitive to light ,give at Age: 9months given at 6months in HIV. Rota vaccine Is for protection against rota virus infection Given orally for 2 doses at 6 and 10 weeks. Malaria vaccine Topic name Immunizable diseases - Tuberculosis Introduction
This topic entails tuberculosis as
an Immunizable disease. It has been discussed under definition, cause, risk
factors, clinical manifestation, diagnosis, treatment and complications Learning Outcome; By the end of this topic the learner should be
able to Diagnose and manage a child with tuberculosis a)
Topic objectives Ø Define
tuberculosis Ø State the
epidemiology Ø State the risk
factors Ø Outline the
pathophysiology of TB Ø Describe the signs and symptoms Ø Diagnose &
treat TB in children Ø State the complications Define Tuberculosis Tuberculosis is an infectious disease caused by
mycobacterium tuberculosis. The tubercle
bacilli are non-spore forming, non motile,pleomorphic weakly gram-positive
curved rods 2-4μm long.Beaded or clumped in a culture media. Is an acid fast bacilli. Grow slowly 12-24hrs generation time Epidemiology TB occurs in 2 clinical forms: ¤ PTB- lungs, ¤ Extra PTB-
outside the lungs Latent tuberculosis infection occurs after inhalation of infective droplet with myc.TB Reactive tuberculin skin test and absence of
clinical and radiographic manifestation are the hall mark of this stage. 40% of LTBI develop tuberculosis A positive TB skin test indicates infection, but a negative TST does
not exclude the possibility of TB infection Risk factors for
tuberculosis infection Incidence
of infectious TB in the population Average
duration of infectiousness of cases Number
of cases/ contact interactions over time. Population
density Family
size Poverty Overcrowding. Children
exposed to high risk adults Foreign-born persons
from high-prevalence countries Poor persons,
especially in large cities Homeless, Drug addicts Present and former
residents or employees of correctional institutions, homeless shelters, and
nursing homes H/W caring for high-risk patients Risk factors
for progression of latent tuberculosis infection to TB disease Infants and
children ≤4 yr of age, esp those <2 yr of age Adolescents and young adults Persons co-infected with HIV Persons with skin
test conversion in the past 1–2 yr Persons who are
immunocompromised, e.g. malignancy,
solid organ transplantation, immunosuppressive medical treatments diabetes mellitus, chronic renal failure,
silicosis, and malnutrition Transmission: Person to person
by airborne, mucus droplet that contain
mycobacterium tuberculosis. Smear positive sputum increases chances of
transmission Risk factors to transmission ¨ Infectiousness of the person with TB d’se ¨ Susceptibility of the exposed child (contact) ¨ Environmental factors ¨ Proximity frequency & duration of
exposure to the infectious person pathogenesis ¨ Infection with TB occurs after exposure to
infectious bacilli & they reach the alveoli. They are ingested by alveolar
macrophages which destroy them ¨ A few bacilli may survive, multiply in the
macrophages & are released when the macrophages die. This process induces
an immune response. ¨ The immune cells in the alveoli may form an
immune capsule called a granuloma (ghorn focus) ¨ There are no S+ S (Latent TB infection) ¨ The primary complex of tuberculosis includes
local infection at the portal of entry and the regional lymph nodes that drain
the area ¨ The
lung is the portal of entry in >98% of cases. ¨ The tubercle bacilli multiply initially
within alveoli and alveolar ducts. ¨ Most of the bacilli are killed, but some
survive within nonactivated macrophages, which carry them through lymphatic
vessels to the regional lymph nodes. ¨ When the primary infection is in the lung,
the hilar lymph nodes usually are involved, although an upper lobe focus
may drain into paratracheal nodes. ¨ The tissue reaction in the lung parenchyma
and LN intensifies over the next 2–12 wk as the organisms grow in number and
tissue hypersensitivity develops. encapsulation. ¨ The parenchymal portion of the primary
complex often heals completely by fibrosis or calcification after
undergoing caseous necrosis and Occasionally, this portion continues to
enlarge, resulting in focal pneumonitis and pleuritis. ¨ If
caseation is intense, the center of the lesion liquefies and empties into the
associated bronchus, leaving a residual cavity. ¨ The foci of infection in the regional lymph
nodes develop some fibrosis and encapsulation, but healing is usually less
complete than in the parenchymal lesion. ¨ Viable M. tuberculosis can persist for
decades within these foci. ¨ In
most cases of initial tuberculosis infection the lymph nodes remain normal in
size. ¨ However, hilar and paratracheal lymph nodes
that enlarge significantly as part of the host inflammatory reaction may
encroach on a regional bronchus ¨ Partial obstruction of the bronchus caused by
external compression may cause hyperinflation in the distal lung segment. ¨ Complete obstruction results in atelectasis.
Inflamed caseous nodes can attach to the bronchial wall and erode through it,
causing endobronchial tuberculosis or a fistula tract. ¨ The caseum causes complete obstruction of the
bronchus. The resulting lesion, a combination of pneumonitis and
atelectasis, is called a
collapse-consolidation or segmental lesion Ghorn complex ¨ There is
haematogenous spread of tubercle to to
the tissues like the lung apices, the brain, kidneys and bones. ¨ Dissemited
tuberculosis – occurs if a no. Of circulating bacilli is large & the host
cellular immune response is inadequate ¨ Time btn initial
infection &clinically apparent disease is variable. ¨ Menengeal TB –
2-6months of acquisition ¨ Lymphnode or
endobronchial TB -3-9months ¨ Bones and joints
– years ¨ 25- 35% of
children with tuberculosis develop extra
pulmonary manifestations ¨ PTB that occurs
˃1year after 1˚ infection. Is usually
caused by endogenous regrowth of bacilli
in partially encapsulated lesions ¨ Risk of
dissemination of m.TB is high in HIV Classification of tuberculosis Presumptive TB- presents with suggestive s +
s Bacteriologically confirmed TB (Smear +ve
& gene xpert Clinically diagnosed TB Case May also be classified according to: Anatomical site,
history of previous treatment, drug
resistance, HIV status Pregnancy & newborn Pulmonary & extrapulmonary except
lymphadenitis in preg. Is associated with increased risk of prematurity, growth
retardation, LBW, perinatal mortality Congenital TB is rare; because GUT TB in female causes infertility. Congenital
TB may occur when there is placental lesion thro’ the umbilical vein 1° infection of mother just before or during preg.
Is more likely to cause congenital infection than reactivate a previous
infection Mantoux tuberculin skin
test § Is the
intradermal injection of 0.1 mL containing 5 tuberculin units of purified
protein derivative (PPD).stabilized with Tween 80. T cells sensitized by prior
infection are recruited to the skin where they release lymphokines that induce
induration through local vasodilatation, edema, fibrin deposition, and
recruitment of other inflammatory cells to the area. Definition
of postive tuberculin test Induration ≥ 5mm Children
suspected to have TB d’se Abnormal x-ray
consistent with active /previously TB Clinical
evidence of TB Children on
immunosuppressive therapy/ conditions Induration
≥ 10mm Children at ↑sed
risk of disseminated TB d’se < 4yrs of age Patient with
other medical conditions (lymphomas, DM, renal failure, malnutrition) Children with
↑sed risk of TB d’se Born in high
prevalence Those exposed to
adults, HIV ⁺ve , homeless Drug addicts Induration ≥ 15mm Children ≥ 4years without any risk factors Clinical manifestation Majority have no S+ S Occ. Low grade fever Mild cough Rarely high fever, cough, flu X-ray – hilar lymphadenopathy, focal hyperinflation, then
atelectasis May have lobar pneumonia Milliary pattern ¨ Progressive 1° pulmonary d’se High fever,
cough, with sputum production, wt loss, night sweats O/E ↓sed breath sounds, rales, dullness over the
cavity Prognosis – slow recovery , is exellent with
appropriate therapy May lead to Reactivated TB for >7yrs Pleural effusion Pericardial d’se TB meningitis Cutaneous d’se Bone & joint d’se
mostly the vatebrae Spondylitis , potts d’se Abdominal & gastrointestinal d’se Genital urinary d’se –rare in children ¨ Diagnosis ¨ 1. History = contact with a TB pt,
cough > 2/52, Fever x 2/52, lethargy, weight loss, lack of weight gain
(failure to thrive) ¨ 2. Physical examination= R/R,
Respiratory distress, ¨ Percussion may be normal, dull or stony
dullness (pleural effusion) ¨ Auscultation = wheeze, crackles, bronchial
breathing ¨ Features of severe pneumonia (fast breathing,
chest in drawing Diagnosis ¨ Gene X-pert is diagnostic ¨ Tuberculin skin test ( montoux test) – indicates infection, not
necessarily disease ¨ Mantoux is Positive if ¤ > 10MM in a well –nourished, HIV –VE ¤ > 15mm in a malnourished or HIV infected A negative mantoux does not rule out TB CXR – Persistent
lung opacification, hilar lymphadenopathy, diffuse micro nodular infiltrates
(miliary), Pleural effusions Diagnosis ¨ It is difficult
to diagnose TB in children because:- ¨ It is difficult
to obtain sputum ¨ Gastric lavage –
ZN staining –demonstrates swallowed bacteria ¨ CXR- may not
show much ¨ Dx is therefore
by history, S+S, Tuberculin test Paediatric
TB score chart ¨ Positive sputum
smear ........................5 ¨ Tuberculin test
result 10mm/ more.......3 ¨ Enlarged
painless LN sinus present........3 ¨ Night sweat, unexplained
fever .............2 ¨ Malnutrition not
improved after 4wks rx.....3 ¨ Angle deformity
of spine..............................4 ¨ Firm, non fluid
non traumatic jt swelling.......3 ¨ Un explained
abdominal swelling / ascites...3 ¨ Change in
temperament, fits or coma..........3 ¨ Interpretation ¨ 2– TB unlikely ¨ 3—4 TB possible
requires further investigations ¨ 6- TB probable
may justify therapy ¨ > 7 = treat for TB ¨ Clinical TB diagnosis ¨ Presence of 2 or more of the following ¨ Cough > 2wks ¨ Weight loss or poor weight gain ¨ Persistent fever or night sweats > 2wks ¨ Fatigue, reduced playfulness, less active Presence of 2
or more of the following o
Positive
contact history
Respiratory
signs
CXR
suggestive of TB ( where available)
Positive
mantoux test ( where available) ANY 2 ABOVE + 2
= TB IS LIKELY, TREATMENT IS
JUSTIFIED ALOGARITHM FOR TB
DX
TB Suspected Sputum for bacteriology Smear positive or +ve gene
Xpert Treat for TB treat for TB +VE contact, resp
sign, CXR suggestive, +ve mantoux ¨ If the child has < 2, is not very sick, treat with antibiotics then
review after a 1-2 wks ¨ If very sick admit for further management –
discharge if the child improves and review after a month ¨ If no improvement, re- evaluate for TB ( CXR,
Mantoux test, Gene expert) if TB suspected start Rx. Ct regular follow up and
complete the Rx. Sputum sample = 1st sample: On the spot, in the
hospital, 2nd sample – in the morning when the patient wakes up Laboratory diagnosis Sputum, gastric
aspirate, or bronchial specimens forAFB Microscopy, ZN staining Gene Xpert. (prefered 1st
test in children) TB Culture (all specimens from children under 5years) Histopathology (FNAs /biopsies) Extra-pulmonary TB (EPTB), FNA, Lymphnode, pleural aspirate Indications of Gene Xpert Gene X pert – a
Molecular TB diagnostic tool that also identifies resistance to Rifampicin o
MDR TB o
All
previously treated TB patients; relapses,
loss to F/up, treatment failure
Contacts
of drug resistant TB,
H/C
workers with symptoms of TB
Refugees
with symptoms of TB
Patient
who develops TB while on IPT DDX in a child with chronic
cough ¨ Asthma – recurrent wheeze, responds to bronchodilators, associated with other
allergies – eczema, rhinitis ¨ URTI ¨ Adenoid hypertrophy ¨ FB – sudden persistent cough + choking ¨ GERD – recurrent cough/wheeze, onset early infancy, +/- hoarse voice ¨ Bronchiectasis – severe persistent cough, much sputum
green yellow in colour, finger clubbing, CXR – honey comb pattern ¨ CHD – easy fatiquability, breathlessness,
onset in infancy ¨ Acquired heart diseases – older child,
palpitations, Dyspnoea oedema ¨ Congenital respiratory disorders – onset
early infancy, commonly premature baby, noisy
breathing during inspiration WHO recommended TB treatment
regime ALL forms of TB except TB meningitis, joint
and bone 2RHZE + 4RH TB Meningitis, bone and joint TB 2RHZE + 10RH Previously treated TB 3RHZE + 5RHE DRUG Resistant TB refer to DRTB N/B Streptomycin is no longer used for previously treated TB in
children. Note: Ethambutol
is now recommended as a fourth drug in intensive phase. The risk of toxicity is
negligible for any age. The dosages
should not exceed 25mg/kg/day i.e (20mg/kg. The risk of toxicity is dose
related & related to duration of therapy (the main risk is optic neuritis = blindness) DRUG ADVERSE EFFECTS Isoniazid Peripheral neuropathy Hepatitis Rifampicin Hepatitis , red colored body fluids Drug interactions
with ARVs Warfarin, insulin, oral contraceptives Pyrazinamide Hepatitis Arthralgia Ethambutol Optic neuritis Additional management decisions ¨ Treat the following as in patients (ADMIT) ¨ Severe forms of PTB & EPTB ¨ TB Meningitis ¨ Severe malnutrition for nutritional
rehabilitation ¨ Signs of severe pneumonia ¨ Other co-morbidities e.g Severe anaemia ¨ Social or logistic reasons to ensure
adherence ¨ Severe adverse reactions such as
hepatotoxicity Steroid therapy,
Given in:- TB Meningitis, PTB with respiratory distress, PTB with airway
obstruction by hilar nodes, Severe miliary TB, Pericardial Effusion Dose 2mg/kg once
daily x 4wks then taper off over 2wks (1mg/kg x 7/7 then 0.5mg for 7 days For HIV infected - Start Cotrimoxazole once
daily. Commence ARVs 2—8 wks of starting anti-TB therapy Immune
re-constitution inflammatory syndrome
(IRIS). This is paradoxical deterioration after initial improvement following
treatment initiation.It is seen during initial weeks of TB Rx commonly seen in
severely immunocompromised TB/HIV Co-infected children after initiating ARVs Management =
Continue anti TB therapy: give
non-steroidal anti-inflammatory drugs or /and prednisone until severe symptoms
subside Consider Referral of children with TB if ¨ Child has a severe d’se ¨ Diagnosis is uncertain ¨ Necessity for HIV – related care e.g commence
ART ¨ Failure to respond to treatment despite good
adherence Pyridoxine Give pyridoxine to
ALL children on TB treatment. This is to reduce the risk of these children developing
peripheral neuropathy due to isoniazid. The dose is 12.5mg/day for all
children. Follow- up of a child on anti-TB therapy. Patients visit the health
facility weekly during intensive phase and every 2 weeks during continuation
phase. During the visit assess the child for: Adherence, Drug toxicity, Weight
gain, Symptom assessment a)
Topic objectives Define poliomyelitis State the
epidemiology Explain the
pathology State the
clinical manifestation Diagnose and
treat poliomyelitis Outline the
differential diagnosis List the
complications State the
prognosis Definition It is an acute communicable
disease caused by polio virus It is a disease
that paralyses There are 3 strains: o
Leon 1 o
Brunhilde 11 o
Lansing 111 Epidemiology
Man &
Jipanzee are the only known reservior It spreads thro
droplets through the nasopharynx Endemic polio occurs where polio virus circulate abundantly, poor
enviromental sanitation. All children are
exposed to the 3 strains by the time they are 4yrs Most of the
infections are asymptomatic Epidemic
polio Occur in good
hygiene Age of exposure
shifts from infancy to childhood The delay in
exposure results to accumulation of susceptible hosts to high numbers
sufficient to support a wide range
spread of virus = epidemics Type 1 is asso
with epidemics Post vaccination
polio It is excreted
by vaccinees in large numbers infecting the unvaccinated contacts Pathology
Infection is not
synonmus with disease Majority (90%)
are asymptomatic 5-10 % develop
afebrile illness without paralysis Incubation
period 7-14 days Infectivity is
3-4 days before end of incubation.
And
1week after onset of symptoms After ingestion
of polio virus, it gains access to mucosal lining of pharynx then to the GIT Multiply within
the gut & the body produces IGA to provide local immunity. Majority of
cases, the disease is arrested at this stage In few cases the
virus gains access to regional LN later blood stream= v The virus
reaches the anterior horn of the spinal cord or
basal ganglia of the brain stem.In both it affects the motor neurones
leading to paralysis Neuropathy of poliomyelitis is pathognomonic. Neuronal damage is due to viral multiplication. Occ.
Injury to nerves is reversible, and restoration of fxn may occur 3-4weeks after
onset of disease Considerable
destruction of neurones may occur without clinical disability Regions of
damage Spinal cord –
anterior horn cells Medulla –
vestibular nuclei Cerebellum –
affects the root of nuclei, vital organs Cerbellum –
affects the root of nuclei Midbrain – grey
matter & substancia nigra, thalamus and hypothalamus Cerebral cortex
– motor cortex It spares the following: Non motor –
cerebral cortex White matter of
spinal cord Extra neural
pathology Bronchopulmonary changes - Aspiration
pneumonia,Atelectasis,Purulent bronchitisImpaired cough reflex CVS: Hypotension, CCF, Pulmonary oedema, renal failure,
hypertension Probems that arise from RX UTI 2°
catheterization Decubitus ulcers Psychotic
disturbance Stress ulcers ( vagus nerve) Infectious diseases
may be ¨ Genetic ¨ Biological ¨ Physical ¨ Chemical Infectious Disease Agents Most infectious
agents that cause disease are microscopic in size and thus, are called microbes
or microorganisms. Different groups of
agents that cause disease are: ¤ Bacteria ¤ Viruses ¤ Protozoa
(Protists) ¤ Fungi ¤ Helminths
(Animals) How Infectious Agents Cause Disease ·
Production of poisons, such as toxins and enzymes,
that destroy cells and tissues. ·
Direct invasion and destruction of host cells. ·
Triggering responses from the host’s immune system
leading to disease signs and symptoms. Phases of Infectious Disease time between
infection and the appearance of signs and symptoms. mild, nonspecific symptoms that signal onset
of some diseases. a person experiences typical signs and
symptoms of disease. subsidence of
symptoms. symptoms
have disappeared, tissues heal, and the body regains strength. Classification of
Infectious Disease ¨ By duration ·
Acute –
develops and runs its course quickly. ·
Chronic –
develops more slowly and is usually less severe, but may persist for a long,
indefinite period of time. ·
Latent –
characterized by periods of no symptoms between outbreaks of illness. ¨ By location ·
Local –
confined to a specific area of the body. ·
Systemic – a
generalized illness that infects most of the body with pathogens distributed
widely in tissues. ¨ By timing ·
Primary – initial
infection in a previously healthy person. ·
Secondary –
infection that occurs in a person weakened by a primary infection. Influenza Example of an Infectious Disease – Flu. Acute contagious disease caused by the
influenza virus. Respiratory
tract infection, but symptoms felt throughout entire body. Epidemics occur seasonally with low fatality; more
deadly pandemics occur several times each century. Highly changeable virus that can infect multiple
species, including humans, pigs, and birds. ¨ Concern
exists that current avian flu will lead to a new pandemic. ¨ Transmission
of Infectious Diseases ¨ Agents
that cause infectious diseases can be transmitted in many ways. ·
Through the air ·
Through contaminated food or water ·
Through body fluids ·
By direct contact with contaminated objects ·
By animal vectors such as insects, birds, bats, etc. Related Terms ¨ Endemic/Enzootic: The constant presence of a disease or infectious agent
within a given geographic area. ¨ Epidemic/Epizootic: The occurrence in an area of a disease or
illness in excess of what may be expected on the basis of past experience for a
given population (in the case of a new disease, such as AIDS, any occurrence
may be considered "epidemic"). ¨ Pandemic/Panzootic: A worldwide epidemic affecting an exceptionally
high proportion of the global population. ¨ Example of
an Infectious Disease - AIDS ¨ AIDS
(Acquired Immune Deficiency Syndrome) is the disease caused by the virus called
HIV (human immunodeficiency virus). HIV attacks cells of
the immune system and destroys their ability to fight infection by other
agents. HIV is
spread through the direct exchange of body fluids. There is a long
period of time from HIV infection to the onset of AIDS. Anti-HIV drugs
prolong the length and quality of life, but there is no vaccine or cure for
AIDS. Other infectious
diseases ·
Severe acute respiratory diseases (avian flu) SARS ·
EBOLA ·
COVID 19 (Corona virus Refer to latest
guidelines Reducing the Spread
of Infectious Diseases ·
Vaccines ·
Antimicrobial drugs ·
Good personal hygiene and sanitation ·
Protection against mosquitoes ·
Quarantine Infectious Diseases as a Cause of Death ¨ Infectious
diseases are responsible for a quarter to a third of all deaths worldwide. ¨ Infectious
diseases account for more than half of all deaths in children under the age of
5 ¨ Of the top
ten causes of death compiled by the World Health Organization, five are due to
infectious diseases. ¨ The top
single agent killers are HIV/AIDS, malaria and tuberculosis. The other top
killers are lower respiratory infections and diarrheal diseases, which are
caused by a variety of agents. Emerging Infectious Diseases ¨ Emerging
diseases are those that have recently appeared within a population, or whose
incidence or geographic range is increasing rapidly. Diseases can emerge or re-emerge due to: ¤ appearance
of a previously unknown agent. ¤ evolution
of a new infectious agent. ¤ spread of
an infectious agent to a new host. ¤ spread of
an infectious agent to new locations. ¤ acquisition
of resistance to anti-microbial drugs. ¤ deliberate
introduction into a population. Re-emerging
and Emerging Infectious Disease ·
Climate Change ·
A New Factor in Infectious Disease ·
Barriers to Treatment ·
Political leadership ·
Socio-cultural factors a)
Topic Summary Infectious diseases spread from
one person to the other through air, contact, contaminated food, vector,
sexual or transplcental. They are caused by various agents Bacteria, Viruses, Protozoa (Protists), Fungi, Helminths (Animals) Can be prevented by immunization,
antimicrobials and hygiene. ETAT (Emergency
Triage, assessment &Treatment ) Triage is the sorting of patients into
priority groups according to their need and the resources available Definition
Triage is the process of rapidly
examining all sick children when they first arrive in hospital in order to
place them in one of the following categories: Those with EMERGENCY SIGNS who require
immediate emergency treatment. If you find any emergency signs, do the
following immediately: -
give appropriate emergency treatment. - Call a senior health worker and other
health workers to help. - Carry out emergency laboratory
investigations.. Those with PRIORITY SIGNS, indicating
that they should be given priority in the queue, so that they can rapidly be
assessed and treated without delay. Those who have no emergency or priority signs and
therefore are NONURGENT cases. These children can wait their turn in the queue
forassessment and treatment.1 E - Emergency P - Priority Q - Queue
(non-urgent) Categories after triage
& Action required EMERGENCY CASES - emergency treatment PRIORITY CASES Need assessment and rapid
attention NON-URGENT CASES Can wait their turn in
the queue Emergency
The ABCD concept Triage of patients involves looking for
signs of serious illness or injury. It is easily remembered as: ·
A Airway ·
B Breathing ·
C Circulation ◦
Coma ◦
Convulsion ·
Dehydration
(severe) Priority
signs A child with priority signs, needs prompt, but not emergency assessment.
These signs can be remembered with the symbols 3 TPR - MOB: Tiny baby: any sick child aged under two
months Temperature: child is very hot Trauma or other urgent surgical
condition Pallor (severe) Poisoning Pain (severe) Respiratory distress Restless, continuously irritable, or
lethargic Referral
(urgent) Malnutrition: Visible severe wasting Oedema of both feet Burns WHO
SHOULD TRIAGE? All clinical staff involved in the care
of sick children should be prepared to carry out rapid assessment in order to identify
the few who are severely ill and require emergency treatment. If possible, all
such staff should be able to give initial emergency treatment, HOW
TO TRIAGE Keep in mind the ABCD steps: Airway,
Breathing, Circulation, Coma, Convulsion, and Dehydration. To assess if the child has airway or
breathing problems you need to know: Is
the child breathing? Is
the airway obstructed? Is
the child blue (centrally cyanosed)? Circulation To assess if the child has circulation
problems you need to know: ? Does the child have warm
hands? ? If not, is the capillary
refill time longer than 3 seconds? ? And is the pulse weak and
fast? In the older child the radial pulse may
be used; however, in the infant, the brachial or femoral pulses may need to be
felt. Consciousness
To assess for coma you need to
know: A rapid assessment of conscious level can
be made by assigning the patient to one of the AVPU categories: A Alert V responds
to Voice P responds
to Pain U Unresponsive Dehydration To assess for dehydration you need
to know: If
the child is lethargic or unconscious If
the child has sunken eyes If
the skin pinch goes back very slowly If the child has no emergency signs,
check for priority signs. After the examination for priority signs has been completed,
the child will be assigned to one of: Priority
(P): the child should be put at the front of the queue Queue
(Q): if the child has no emergency or priority signs Once appropriate emergency treatments
have been initiated: call for a senior health worker; draw blood for emergency laboratory
investigations such as blood glucose, haemoglobin and malaria smear; ask about head or neck trauma before providing
treatment; take careful note if the child is severely malnourished, because
this will affect the treatment of shock and dehydration caused by diarrhoea 1. Define “triage”. 2. When and where should triage take
place? 3. Who should do triaging? 4. What do the letters A, B, C and D in
"ABCD" stand for? 5. List the priority signs: Put the actions in the right chronological
order: what will you do first, what next, Ask about head or neck trauma Call a senior health worker to see any
emergency Have blood specimens taken for laboratory
analysis Look for any priority signs Look for emergency signs Move on to the next patient Place priority patients at the front of
the queue Start treatment of any emergency signs
you find What should you do if the child has a
priority sign? A B =AIRWAY
AND BREATHING Not
breathing, Central
cyanosis, or Severe
respiratory distress If yes, is the breathing obstructed Manage airway: Give oxygen Make sure the child is
warm; Manage airway of a
choking child Management of young infant. Lay the infant on your arm or thigh in a head
down position Give 5 blows to the infant’s back with heel of
hand If
obstruction persists, turn infant over and give 5 chest thrusts with 2 fingers,
one finger breadth below nipple level in midline If
obstruction persists, check infant’s mouth for any obstruction which can be
removed If
necessary, repeat sequence with back slaps again Child: Give 5 blows to the child’s back with
heel of hand with child sitting, kneeling or lying If the obstruction persists,
go behind the child and pass your arms around the child’s body; form a fist
with one hand immediately below the child’s sternum; place the other hand over
the fist and pull upwards into the abdomen; repeat this Heimlich manoeuvre 5
times If
the obstruction persists, check the child’s mouth for any obstruction which can
be removed If
necessary, repeat this sequence with back slaps again C - CIRCULATION Cold hand with: Capillary refill longer
than 3 seconds, and Weak and fast pulse Stop any bleeding Give oxygen Make sure the child is warm IF NO SEVERE MALNUTRITION: Insert IV and begin giving fluids rapidly. If not able to insert peripheral IV,
insert an external jugular or intraosseous line IF SEVERE MALNUTRITION: Give IV glucose Proceed immediately to full assessment and treatment Shock
Insert an intravenous line (and draw
blood for emergency
laboratory investigations). Fix the cannula and immobilize the
extremity with a splint. Attach Ringer’s lactate or normal saline
- make sure the infusion is running well. Infuse 20 ml/kg as rapidly as possible. The circulation should be reassessed as
described before. Improvement:
warmer hands, pulse slows and
capillary refill faster. If severe Malnutrition Avoid IV, find out if the child can drink
or use a nasogastric
tube (NGT). Weigh the child. Insert an intravenous line
(and draw blood for emergency laboratory investigations). Fix the cannula and immobilize the extremity
with a
splint. Give ReSoMal rehydration fluid orally or by NGT: - 5 ml/kg every 30 min
for 2 hours, then 5-10 ml/kg/hour for
4-10 hours, or - give half-strength normal saline (or
half strength Darrows
with 5% glucose) with 5% glucose at 15 ml/kg over 1 hour If there is NO
improvement: Give maintenance IV fluid 4ml/kg/hour while waiting for blood. Transfuse fresh whole blood at 10ml/kg/hour slowly over 3 hours
(use packed cells if in cardiac
failure). Maintenance: Continue ReSoMal
5-10ml/kg/hour for
the next 4-10 hours. If no severe malnutrition – maintenance Give 70 ml/kg of Ringer's lactate
solution (or, if not available, normal saline) over 5 hours in infants (aged
<12months); Over 2½ hours in children (aged 12 months to 5 years). Reassess the child every 1-2 hours. If
the condition is not improving, give the IV fluids more rapidly. Also give ORS solution (about 5 ml/kg/
hour) as soon as the child can drink; this is usually: after 3-4 hours (in infants); after 1-2 hours (in
children). Coma or Convulsing (now), Manage the airway, Give oxygen If
convulsing, give diazepam rectally Position the child (if head or neck trauma is
suspected, stabilize the neck first) Give IV glucose COMA If the child is unconscious you should: ? Manage the airway ? Position the child (if there
is a history of trauma, stabilize neck first) ? Check the blood sugar ? Give IV glucose CONVULSION If the child is convulsing now, you must: ·
Manage the airway ·
Position the child ·
Check blood sugar ·
Give IV glucose ·
Give anticonvulsant When the blood glucose cannot be
measured, hypoglycaemia
should be assumed to be present in all children in coma or having
a convulsion
AND should be treated Insert an IV line and draw blood for
emergency laboratory investigations. Give 5 ml/kg of 10% glucose solution rapidly
by IV injection
Recheck the blood glucose in 30 minutes. If it is still low, repeat 5 ml/kg of 10%
glucose solution. Feed the child as soon as conscious. If the child is not able to feed without
danger of aspiration, give:
IV fluid containing 5-10% glucose (dextrose), or Milk or sugar solution
via nasogastric tube. To make sugar solution, dissolve four
level teaspoons of sugar (20
grams) in a 200-ml cup of clean water. Topic
name IMNCI -Integrated management of neonatal and
childhood illness a)
Topic objective By the end of this lesson the learner
should be able to Describes
the steps of assessing and classifying the sick child 2 months up to 5 years Identifying
treatment and treating the child Counseling
the caregiver Assessing
and classifying the sick young infant Follow
up care INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD
ILLNESS (IMNCI) IMNCI case
management For
management purposes, children are placed into
age groups Age
up to 2 months Age
2 months up to 5 years Up to implies that the child has not
attained that age e.g. up to 5 years means the child has not as yet celebrated
the 5th birthday The IMCI chart booklet ·
Summarizes the case management process ·
Describes the steps of assessing and
classifying the sick child 2 months up to 5 years ·
Identifying treatment and treating the
child ·
Counseling the caregiver ·
Assessing and classifying the sick young
infant ·
Follow
up care ASSESSING AND CLASSIFYING A SICK CHILD AGED 2
MONTHS UPTO 5 YEARS ·
Check for the 5 General Danger signs ·
Assess for the 4 main symptoms ·
Check for malnutrition and anaemia ·
Check for the suspected symptomatic HIV infection ·
Check for immunization and Vitamin A supplementation
status ·
Assess if the child has any other problems General Danger signs ·
Child not able to drink or breastfeed ·
Vomits everything ·
History of convulsions in the current illness ·
Lethargic or unconscious ·
Convulsing now Child with any General Danger sign needs URGENT. attention: complete assessment and any pre referral treatment immediately so
referral is not delayed. Not able to
drink or breastfeed: Vomiting everything: KEY POINTS “Vomiting everything” means that: The
child is not able to hold anything down at all. What goes down comes back up. CONVULSIONS: is any
involuntary movement in any part of the body . A child can have this danger
sign if there is history of convulsions or convulsing during the visit A history of
convulsions only counts as a danger sign if the convulsions happened during the
present illness. Use words for
convulsions that caregivers understand. Eg fits or spasms Lethargic or unconscious: “Lethargic or unconscious" means that: the
child is not awake and alert when he should be, He is drowsy and does not show
interest in what is happening around him.; the child may stare blankly and
appears not to notice what is going on around him.; or Unconscious
child cannot be awakened. He does not respond when touched, shaken or spoken to 4 main symptoms MUST ask about all the four main
symptoms below. ·
Cough or difficult breathing ·
Diarrhoea ·
Fever ·
Ear problem When
a symptom is present, assess further on that symptom. Cough or
difficult breathing: Pneumonia is
an acute respiratory infection that affects the lungs. The infection causes the
alveoli to fill with secretions and compromise breathing. The small airway in
infants makes them more susceptible to severe infection Causative
organisms include; Viral, bacterial, fungal The most common causative organisms
are; 1.Bacterial-
Strep Pneumonia and H. Influenza type B 2.
Viral- Respiratory Syncytial virus 3.
Fungal-Pneumocystis Jirovecii in children with HIV infection Pneumonia is among the leading causes of death
in children under five years;Most children with cough or difficult breathing
have only a cough or a cold; A few children with cough or difficult breathing
may also have pneumonia. Assess and classify cough or difficulty in breathing Pulse
Oximetry can be used to; 1.
Detect hypoxemia 2.
Monitor hypoxemia 3.
Make efficient use of Oxygen supply 4.
Improve the monitoring of patient out comes •
Severe Pneumonia; Admit Oxygen Penicillin and Gentamycin •
Pneumonia; Oral Amoxycillin Counsel on danger signs and when to return •
No Pneumonia; Sooth the throat and relieve the cough
with a safe remedy Treat a Wheeze
with Salbutamol Topic
name IMNCI -Integrated management of neonatal and
childhood illness a)
Topic objective By the end of this lesson the learner
should be able to Describes
the steps of assessing and classifying the sick child 2 months up to 5 years Identifying
treatment and treating the child Counseling
the caregiver Assessing
and classifying the sick young infant Follow
up care INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD
ILLNESS (IMNCI) IMNCI case
management For
management purposes, children are placed into
age groups Age
up to 2 months Age
2 months up to 5 years Up to implies that the child has not
attained that age e.g. up to 5 years means the child has not as yet celebrated
the 5th birthday The IMCI chart booklet ·
Summarizes the case management process ·
Describes the steps of assessing and
classifying the sick child 2 months up to 5 years ·
Identifying treatment and treating the
child ·
Counseling the caregiver ·
Assessing and classifying the sick young
infant ·
Follow
up care ASSESSING AND CLASSIFYING A SICK CHILD AGED 2
MONTHS UPTO 5 YEARS ·
Check for the 5 General Danger signs ·
Assess for the 4 main symptoms ·
Check for malnutrition and anaemia ·
Check for the suspected symptomatic HIV infection ·
Check for immunization and Vitamin A supplementation
status ·
Assess if the child has any other problems General Danger signs ·
Child not able to drink or breastfeed ·
Vomits everything ·
History of convulsions in the current illness ·
Lethargic or unconscious ·
Convulsing now Child with any General Danger sign needs URGENT. attention: complete assessment and any pre referral treatment immediately so
referral is not delayed. Not able to
drink or breastfeed: Vomiting everything: KEY POINTS “Vomiting everything” means that: The
child is not able to hold anything down at all. What goes down comes back up. CONVULSIONS: is any
involuntary movement in any part of the body . A child can have this danger
sign if there is history of convulsions or convulsing during the visit A history of
convulsions only counts as a danger sign if the convulsions happened during the
present illness. Use words for
convulsions that caregivers understand. Eg fits or spasms Lethargic or unconscious: “Lethargic or unconscious" means that: the
child is not awake and alert when he should be, He is drowsy and does not show
interest in what is happening around him.; the child may stare blankly and
appears not to notice what is going on around him.; or Unconscious
child cannot be awakened. He does not respond when touched, shaken or spoken to Objectives Frequent
passage of normal stool is not diarrhoea to assess ask: For how long? Is there
blood in the stool?
LOOK AND FEEL Look at the
child’s general condition -Lethargic or
unconscious? Restless or
irritable? Look for
sunken eyes -Drinking
eagerly, thirsty? Pinch the
skin of the abdomen. Does it go back; Very slowly
(longer than 2 seconds, slowly
Classifying a child with diarrhoea; Children
with diarrhoea die as a result of dehydration.
ALL children with diarrhoea MUST first be classified for dehydration CLASSIFICATION
OF DEHYDRATION Severe
dehydration A
child with 2 of the following
Some
dehydration No
dehydration;-
Not enough signs to classify Sunken eyes Diarrhea lasting >14 days, with
dehydration Diarrhea lasting >14 days Blood in stool Diarrhoea management Extrapyramidal reactions reduces the number of episodes of vomiting but
increased the incidence of diarrhea Exercises Assessing
and classifying children with diarrhoea Blessing 12 Mo presents with H/o D + V
for 21 days. There was no blood in the stool
O/E sunken eyes, drinks eargerly, with a slow skin pinch. What is your classification Signs Classify As • Convulsions or • Not able to feed or
breastfeed or • Gasping or • Not breathing at all even
when stimulated or • Respiratory rate less
than 20 breaths per minute or • Fast breathing (60
breaths per minute or more) or • Severe chest indrawing or • Grunting or wheezing or • Nasal flaring or • Central cyanosis or • Bulging fontanelle or • Pus draining from the ear
or • Fever (37.5oC or
feels hot) or low body temperature (less than 35.5oC or
feels cold) or • Lethargic or unconscious or • No movement even when
stimulated VERY SEVERE DISEASE Signs Classify As • Red umbilicus or draining
pus or • Skin pustules LOCALBACTERIALINFECTION None of the signs of Very Severe Disease or local bacterial
infection NO VERY SEVERE DISEASE OR
LOCAL BACTERIAL INFECTION UNLIKELY Temperature 35.5oC –
36.4oC LOW BODY TEMPERATURE ¨ All sick
young infant must be checked for signs of very severe disease. ¨ In this
assessment, you are looking for signs of bacterial infection especially a
serious infection such as pneumonia, sepsis and meningitis. ¨ The young
infant must be calm and may be asleep while you assess the first four
signs namely; count breathing, look for
chest indrawing, nasal flaring and grunting. Objectives Define jaundice. Describe Types of jaundice. Describe causes of jaundice. Assess and Classify Jaundice Jaundice is defined as the yellow coloration of skin and mucous membranes due to high bilirubin levels in the serum § It’s the yellow colora\on of the skin, mucous membranes and or the eyes. § It may be physiological (normal) or pathological (abnormal). § More than 50% of normal newborns and 80% of preterm infants, have some jaundice. § It is visible in a neonate when serum bilirubin is more than 5mg/dl Yellow
discolouration of the skin is visible in a neonate when serum bilirubin is more
than 5mg/dl. Almost all
neonates may have physiological jaundice during the first week of life . Physiological
jaundice usually appears between 48 – 72 hours of age; maximum intensity on days 4 & 5 in term babies and day 7 in
pre-terms and disappears by day 14. Physiological
jaundice does not extend to palms and soles and does not need any
treatment. If jaundice appears on the
first day, persists for 14 days or more and extends to palms and soles it is
severe jaundice and requires urgent attention. Pathological jaundice Jaundice starts on the first 24 hours of life. • Jaundice lasts longer than 14 days in term baby, 21 days in preterm infants. • Jaundice accompanied with fever or other signs of illness. • Deep jaundice - palms and soles of the baby are deep yellow. • Look for the cause and treat accordingly. Physiological jaundice is due to normal physiological breakdown of large red blood cell mass. Causes of pathological jaundice Serious bacterial infection. § Haemolytic disease - blood group (Rhesus and ABO) incompatibility. § Congenital syphilis or other intrauterine infections. § Liver disease - hepatitis or biliary atresia. § Hypothyroidism. § Asphyxia. § Birth injuries. Check
for and classify jaundice Signs Classify As • Yellow palms and soles at any age or • Any jaundice if age less than 24 hours OR more than 14 days SEVERE JAUNDICE • No yellow palms and soles AND • Jaundice appearing between 24 hours and 14 days of age JAUNDICE • No signs to classify as severe jaundice or jaundice NO JAUNDICE Refer to IMNCI chart booklet for management of jaundice a)
Topic objectives By the end of this lesson the
learner should be able to 1.State the A & P
of the resp. system 2. Diagnose and manage common congenital respiratory
anomalies 3. State factors that influnce resp. illness b)
Topic Content a)
Topic objectives By
the end of the topic the learner should be able to diagnose and manage lower
respiratory tract infections in children Lower
respiratory tract infections in children Bronchitis. Brochiolities. Bronchial
asthma. Pneumonia T.B. Infection. History Cough & Duration H/o TB contact, HIV status Sudden onset of choking Paroxysms with whoop / vomiting/
cyanosis Immunization status = BCG,
Pentavalent H /o Asthma Examination Central cyanosis Apnoea, gasping, grunting, nasal
flaring Audible wheeze, stridor Head nodding Tachycardia Severe palmar pallor Chest
exam Respiratory rate , Chest indrawing ,
Hyperinflated chest, Trachea shift, apex beat displacement, raised JVP, Crepitations, reduced
air entry, bronchial breath
sounds or wheeze Percussion
signs of pleural effusion – stony dullness Pneumothorax
– hyper-resonance Investigations
Pulse oximetry to detect hypoxia Full blood count Chest x ray DDX
of cough Pneumonia Pleural effusion/ empyema Asthma Bronchiolitis Cardiac failure , CHD Pertussis TB F/B Croup, diphtheria
NEONATAL ANAEMIA
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unit II Topic 1: Growth and Development
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unit II: Topic 1: Normal Growth and development
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Topic 3: Periods of Growth and Development
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Topic 4: Types of Growth and Development
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Topic 4: Types of G & D cont.
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Topic 4: Types of G & D cont.
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Topic 4: G &D cont. physical growth
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Topic 1: Growth & Development - teeth eruption
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Topic 5: G & D Motor development
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Topic 6: G& D cont. Motor growth
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Topic 6: G & D Red flags in development
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Topic 6: G &D Cont. physiological growth
pre-school
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Topic 6: G &D Cont. Adolescence
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Unit Two: Summary
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Unit 2: Further Reading
TOPIC ONE: NORMAL GROWTH AND DEVELOPMENT
Unit Three: Topic one: Breast Feeding
Topic 0ne Breast Feeding cont.
Unit Three: Topic one: Breast Feeding
Topic One: Complimentary Feeding
Unit Three: Topic one: Breast Feeding
Topic two: Malnutrition in children
unit four: immunization and immunizable diseases
Topic 2: Cold Chain
unit four: immunization and immunizable diseases
Unit 4: Topic 1: Immunization and the immunization schedule
unit four: immunization and immunizable diseases
Topic 5: Diphtheria
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Topic 1: Change and Change Management [Cont'd]
Change is fundamental in order to guarantee long term success in the organization. Some organizations change in response to external circumstances (reactive change) and others change because they have decided to change (proactive change)Click here to access Unit Four Content..
Topic 1: Change and Change Management [Cont'd]
Topic 4: Immunizations
Topic 4: Immunizble diseases - Tuberculosis
Topic 4: Tuberculosis cont.
Topic 5: Poliomyelitis
Unit five: Topic one: Infectious diseases
Topic one: Summary
Unit six: ETAT (Emergency Triage, assessment &Treatment )
Topic two: ETAT cont.
Unit six: Topic two: IMNCI
KEY POINTSTopic three: IMNCI: The four main symptoms: Cough or difficulty breathing
Unit six: Topic two: IMNCI
KEY POINTSTopic four: IMNCI Main symptom: Diarrhoea
Topic 8: IMNCI - assessing the young infant
Topic 8: Jaundice
Unit 7: Respiratory tract Diseases and Conditions
Topic 4: Lower respiratory tract infections in children