Distance education courses child health course

Prevention

Remember that early diagnosis and treatment of this condition is very important to avoid complications. Such complications as deafness and blindness interfere with the growth and development of a child. You should also give health education on the dangers of sleeping in crowded, badly ventilated houses to reduce the transmission of meningitis. Remember to emphasize the importance of early reporting and treatment.

The Haemophilia influenzae meningitis is prevented by giving haemophilus influenzae vaccine to all children during immunization. Also, the pneumococcal and meningococcal vaccines are also available but are not yet being given routinely. You should report all cases of meningococcal meningitis to the district medical officer of health.

2: URINARY TRACT INFECTION

Urinary tract infection is the bacterial infection of the whole urinary tract from the urethra to the kidney. The infection of the urethra is called urethritis. The infection of the bladder is called cystitis. The infection of the pelvis and the kidney is called pyelonephritis. See these parts in Figure 2 below.

Untreated, urinary tract infection may cause renal destruction and death. Urinary tract infection is often present in children with protein energy malnutrition.



Figure 21.2: Structure of the urinary tract system

Causes

Urinary tract infection is caused by bacteria from the intestines and from the blood. The bacteria from the intestines include: E. coli, klebsiella, proteus, pseudomonas, enterococci and staphylococci. These bacteria ascend the urethra from the area surrounding the anus. The bacteria carried in the blood may lodge in the kidneys and then descend down the urinary tract.

Epidemiology

Urinary tract infection is common in the newborn period and early childhood..

Predisposing Conditions

• 
  Obstruction of the urethra causes incomplete or infrequent emptying of the bladder. The incomplete or infrequent emptying of the bladder allows multiplication of bacteria;
  
• 
  Vesicoureteral reflux, backflow of the urine from the bladder into the ureter, allows the bacteria to ascend the ureter and cause pyelitis and nephritis;
  
• 
  Intrarenal reflux allows infection of the kidney. Each kidney infection leads to kidney destruction and formation of a scar. Extensive scarring from repeated kidney infections leads to chronic renal failure;
  
• 
  Kidney or bladder stones facilitate the development of urinary tract infection;
  
• 
  Congenital malformations such as hydronephrosis also facilitate the establishment of urinary tract infection. (Hydronephrosis is dilatation of the ureter and the pelvis with subsequent renal damage).
  

ACTIVITY List the symptoms and signs of urinary tract infection: __________________________________________________________ ___________________________________________________________ ______________________________________________________________________________________________________________________

Check your answer as you read the following.

Clinical Manifestations

In infants, urinary tract infection may manifest with the following symptoms:

• lethargy;

• refusal to feed;

• poor colour;

• apnoea;

• jaundice;

• anaemia;

• purpura and hepatosplenomegaly.

In young children, urinary tract infection manifests with non-specific signs such as:

• 
  fever;
  
• 
  vomiting;
  
• 
  diarrhoea,
  
• 
  abdominal pain;
  
• 
  convulsions;
  
• 
  poor appetite;
  
• 
  irritability;
  
• 
  jaundice and
  
• 
  failure to thrive.
  

In older children, urinary tract infection presents with the following:

• 
  passing urine more frequently than usual;
  
• 
  pain while passing urine;
  
• 
  acute retention of urine because of very severe pain;
  
• 
  suprapubic pain or tenderness suggesting bladder infection;
  
• 
  high fever;
  
• 
  pain or tenderness in the flanks suggesting a kidney infection;
  
• 
  cloudy smelly urine;
  
• 
  haematuria, and
  
• 
  incontinence in a previously continent child.
  

Urinary tract infection may also be asymptomatic especially in infants and young children.

Investigations

Clean urine microscopy and culture where possible.

In infants and young children, the urine specimen is collected by suprapubic aspiration or catheterization In older children, the urine specimen is obtained by clean catch of mid-stream urine. Urine specimens collected by plastic bags are inadequate and may give false results.

Diagnosis:

The diagnostic urine examination findings are:

• 
  pus cells in the urine (more than 5-10 cells per high power field)
  
• 
  growth of more than 10⁵ colonies per ml of urine.
  

Complications:

The complications of urinary tract infection include septicaemia in newborns and young children and permanent renal damage.

Management:

Urinary tract infection is treated with antibiotics for 5-7 days to eradicate the infection. The recommended antibiotics are cotrimoxazole, nalidixic acid, nitrofurantoin, and ampicillin.

Urinary tract ultrasound, micturition cystourethrogram are done to detect any vesicourethral reflux and obstructive abnormalities. Any anatomic abnormalities found are treated surgically.
Vesicourethral reflux is initially managed with continuous prophylactic antibiotics while periodically assessing the upper urinary tracts with ultrasound. The prophylaxis with antibiotics is only possible if there is compliance, regular system of follow-up and possibility of doing urine culture regularly for detecting infection. Successful prophylaxis with antibiotics is indicated by the child’s remaining free of urinary tract infections, absence of new renal scars and spontaneous resolution of the vesicoureteral reflux.
Development of urinary tract infection despite the prophylaxis with antibiotics, occurrence of new renal scarring, failure of the vesicoureteral reflux to resolve, non-compliance, allergic reaction, or side effects of the antibiotics are the indications for surgical intervention to treat the vesicoureteral reflux.
Besides giving the antibiotics, you should advice the mother to increase the child’s fluid intake. The child should be asked to pass urine frequently and to ensure that she or he completely empties the bladder. When possible, a urine culture should be done 48 hours after starting the antibiotics and one week after stopping the antibiotics. Even if no abnormalities are found, several follow-up urine examinations and culture are done for one year where possible.

3: DIABETES MELLITUS
Before you read on do the following activity, it should take you 5 minutes to complete.

ACTIVITY What is diabetes? Write down your definition in the space provided below. _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Now read through the text below and see if your ideas are included.

Diabetes mellitus is a metabolic syndrome characterized by passing urine frequently, drinking frequently, eating many times, dehydration, weight loss, excessive blood sugar, and passage of sugar in the urine. An individual with diabetes is unable to use sugar normally. This explains why diabetes mellitus is also called sugar disease.
Causes

There two types of diabetes mellitus: type I and type II diabetes mellitus.

Type I diabetes mellitus

This the most common endocrine disorder of childhood and adolescence. Type I diabetes mellitus results from decreased secretion of insulin. The decreased secretion of insulin is due to progressive destruction of beta pancreatic cells by autoimmune mechanisms. Genetic factors and environmental factors also play a role in causing diabetes mellitus type I. The role of the genetic factors is supported by the occurrence of diabetes in family members. The environmental factors include viruses which may trigger the autoimmune destruction of beta pancreatic cells. There is a lifelong dependence on injected insulin to prevent complications of diabetes. Diabetes starts when about 85% of the beta pancreatic cells no longer secret insulin. The lack of insulin leads to failure of uptake of glucose into the muscle and adipose tissue. The glucose accumulates in the blood giving rise to hyperglycaemia (high blood sugar). Hyperglycaemia is worsened by utilization of proteins and formation of more new glucose. The hyperglycaemia leads to glycosuria (passage of sugar in the urine). Glycosuria is associated with excessive loss of fluids with frequent passage of urine. The loss of fluids leads to thirst. The thirst leads the child to drink a lot. Dehydration may occur if the fluid intake is inadequate.

As we have just mentioned, Type 1 diabetes is caused by decreased insulin secretion. Lack of insulin leads to increased oxidation of fat to provide energy. This in turn leads to an abnormal increase in acetyl coenzyme A, which the body uses to produce the ketone bodies (acids that build up in the blood). When the levels of ketones in the blood become very high, they upset the chemical balance of the blood and poison the body. Ketoacidosis is a life threatening conditions and should be treated without any delay.

Ketoacidosis is dangerous and can lead to coma.

(ii) Type II diabetes mellitus
This is caused by:

• 
  the resistance of the skeletal muscle, liver, and adipose tissue to insulin;
  
• 
  variable degrees of beta pancreatic cell impairment.
  

Type II diabetes mellitus is most common in the obese individuals. Ketoacidosis may also develop during severe infections or other stresses. Then the patient may need insulin to correct hyperglycaemia.

Symptoms

The symptoms of diabetes mellitus are: polyuria, polidipsia, polyphagia and weight loss. Bed wetting in a previously toilet trained child may reveal polyuria. Ketoacidosis presents with vomiting, dehydration, deep sighing respiration, anxious appearance, abdominal pains and coma.

Investigations:

• 
  Determination of blood sugar
  
• 
  Determination of urea and electrolytes
  
• 
  Determination of serum phosphate
  
• 
  Determination of acid base status
  
• 
  Testing urine for sugar and ketones.
  

Diagnosis:

The diagnosis is based on clinical features, fasting blood sugar of 10 mmol/l and glycosuria (loss of glucose in the urine).

Management:

A diabetic child without ketoacidosis.

A diabetic child who is able to feed without vomiting is managed with rapidly acting insulin (regular, insulin lispro, humalog) administered subcutaneously at a dose of 0.1 to 0.25 unit/kg every 6-8 hours before meals with simultaneous blood sugar measurement and adjustment of insulin dose. A period of 1-2 days is needed to estimate the total daily insulin requirements for guiding use of combined intermediate and short acting insulins as discussed in the following section.

Ketoacidosis with dehydration.

The treatment of ketoacidosis with dehydration involves correcting the fluid and electrolyte disorder, alkali therapy, initiation of insulin and nutrition. Let us briefly look at each in turn.

i) Fluid and electrolyte.

Giving intravenous normal saline, assuming a10% dehydration, replacing 50 to 60% of the calculated volume in the first 12 hours and the remaining 40-50% in the next 24 hours. Adding potassium supplements to the normal saline after the first 20 ml of normal saline /kg so as to give 3-5mmol of potassium /kg/24 hours.

Oral fluids (sugar free fluids and milk) are introduced as soon as the child becomes conscious and stops vomiting.
ii) Alkali therapy.

If pH is 7.2 or less, partially correct the acidosis with sodium bicarbonate 40mmol/m² at pH 7.1-7.2 and 80 mmol/m²at pH less than 7.1 over a period of 2 hours

iii) Initiation of insulin.
Insulin can be administered either as a continuous intravenous infusion (the best) or intermittently through intravenous, intramuscular or subcutaneous routes.
In continuous intravenous infusion of insulin, a priming dose of insulin is given intravenously or intramuscularly at a dose of 0.1 unit/kg followed by a constant infusion of 0.1unit/ kg hourly until ketoacidosis is corrected. If ketoacidosis is not corrected in 24 hours, you should look for sepsis and treat it and then continue the insulin infusion.

The treatment must be monitored by careful fluid balance, hourly blood sugar and two hourly electrolyte acid status measurements.

When the acidosis is corrected, insulin infusion is discontinued. Subcutaneous insulin, 0.2-0.4 units/kg is immediately given while maintaining the 5% dextrose until the child can fully tolerate food. When the child can tolerate food, insulin 0.2- 0.4 units/ kg is given before meals every 6-8 hours when the child starts eating. Measure the blood sugar before and 2 hours after the meal. Adjust the insulin dose to maintain a blood sugar of 4.4 - 10 mmol/l.

Table 1: Intermittent administration of insulin.

Blood glucose	Total Insulin dose	Intravenous	Intramuscularly	Frequency
33mmol/1	1 u/kg	0.5 / kg	0.5 u/kg	2-4 hours
17-33mmol/1	0.5u/kg	0.25u/kg	0.25/kg	2-4 hours

Intermittent doses of insulin for diabetic ketoacidosis.

Intravenous, intramuscular or subcutaneous bolus injections of insulin may also be given in the treatment of ketoacidosis. (See Table 1 on intermittent insulin doses for diabetic ketoacidosis). Hourly blood sugar and 2hourly electrolyte and acid status are measured just as in the case of intravenous insulin infusion. When the blood sugar falls to nearly 17mmo/l, insulin 0.2 -0.4 u/kg may be given subcutaneously every 6-8 hours while maintaining a 5% dextrose infusion in 0.2N saline with potassium added until the acidosis is corrected and the child can tolerate solid foods. Sips of clear fluid, broth or carbonated drinks may be given in the interval. The subcutaneous insulin dosages of 0.2-0-4 u/kg every 6-8 hours should be continued for 24 hours after the child is eating. Then you should make a switch to combined intermediate and short acting insulin.

After recovery from ketoacidosis, the daily insulin requirement should be estimated as 2/3 of the total daily dose of regular insulin administered before each meal. This dose is about 0.5 units/ kg. Both intermediate and rapid acting insulin are combined differently depending on whether the regime adopted is one daily injection or two daily injections.
With a single daily dose of the combined regimen, 2/3 of the dose is made of intermediate and the remainder is regular insulin. The injection is given ½ hour before breakfast or with breakfast if Lispro is the short acting insulin.

Step increases or decreases of 10- 15% of the daily dose are made till the desired degree of control is reached. The increases or decreases are made on the basis of the blood sugar before each meal or urine glucose or both as follows:

• 
  If hyperglycaemia is observed in the late morning, the dose of regular is increased by 10-15%.
  
• 
  If hyperglycaemia is observed late in the afternoon or in the evening, the dose of intermediate insulin is increased by 10-15 %.
  
• 
  Should hypoglycaemia occur late in the morning, the dose of regular is reduced by 10.15%.
  
• 
  If the hypoglycaemia is noted late in the afternoon or in the evening, the daily dose of intermediate insulin is reduced by 10-15 %.
  

With a two daily injections regime, intermediate and regular insulin are combined in the ratio 2:1 to 3:1. Each injection consists of intermediate and short acting insulin in proportions 2: 1 to 3:1. Two thirds of the total daily dose is given before breakfast and one third before supper. The two daily insulin injections regime is recommended for treating young children and adolescents.

• 
  The optimum regimen is one intermediate combined with regular before breakfast and then regular insulin before each meal.
  

• 
  Rapid acting insulin acts in half an hour, reaches a maximum in two hours, and has negligible effect in 6 hours.
  

• 
  Intermediate insulin has a significant effect after 6 hours, has maximum effect in 8 hours and negligible residual effect after 16 hours.
  

iv) Nutrition

The nutritional requirements of a diabetic child are the same as those of a normal child. Therefore, the diet of a diabetic child is not special but a healthy eating plan that should be followed by the whole family. Partaking of the diet by the whole family would prevent the child from feeling being different.. The diet must be balanced and adequate for normal growth, development and activities A balanced diet is that which contains the right amounts of carbohydrates, fats, proteins, vitamins and minerals. Ideally, the child should be given three main meals (breakfast, lunch and supper and three snacks (midmorning, mid-afternoon and bedtime) per day. These meals and snacks (fruit, fruit juice, or cracker) must be given at fixed times with evenly spaced intervals each day. When the carbohydrates are so evenly distributed, the movement of glucose is more or less predictable.

The caloric mixture should consist of 55% carbohydrates, 30 % fats and 15 % proteins. About 70 % of the carbohydrate content should consist of complex carbohydrates (bran, oatmeal, whole cereals, legumes, root crops boiled or baked in their skins). These foods are also rich in fibre. The fibre in these foods slows down digestion and absorption of the complex sugars. Therefore, the blood sugar rises more slowly after a meal. Foods rich in fibre are, therefore, recommended as staple components of the diet because they help in the control of blood sugar levels. High dietary fibre may also helps in the control of the blood cholesterol levels. Other foods with a high fibre content are leafy green vegetables and fruits. Excesses of carbohydrates are to be discouraged. Again, ideally, the parent should select the carbohydrates in such way that the amount carbohydrate in each meal or snack is known.

When the amount of sugar in a meal is known, it is possible to match the dose of the insulin to the food taken. A unit of insulin should be administered for every 10 to 15 grams of glucose.

Table sugar, and highly refined sugars, including those contained in sodas and sweets, are to be limited. The glucose in refined sugars is absorbed rapidly. Such a rapid absorption of glucose causes wide swings in blood sugar.
The diet must be low in animal fats which are rich in saturated fatty acids. Animal fats are avoided and replaced by vegetable oils which are rich in unsaturated fatty acids. Butter and whole milk are discouraged. Whole milk is replaced by skimmed milk.

Protein, especially animal protein, is usually limited by cost. Ideally, poultry, veal, lean meat, fish and dried beans, good sources of proteins, are recommended as substitutes for red meat for keeping saturated fat low. Visible fat is removed from the lean meat. Fatty meats such as bacon are avoided. The number of egg yolks eaten is also limited. All these measures reduce the cholesterol which predisposes to artherosclerosis in adulthood.

The total daily calories should be distributed as follows:

• 
  Breakfast 20 %
  
• 
  Lunch 20%
  
• 
  Supper 30 %
  
• 
  Three snacks 30%
  

Each snack provides 10 % of the total daily calories.

Before an unusual activity, extra carbohydrates are given. The regularity of food intake and constancy of carbohydrates intake is very important.
v) Parent education

It is important to teach the parents or caretaker on the following:

• 
  how to monitor the blood sugar and urine ketones;
  
• 
  how to prepare the injections;
  
• 
  how to inject insulin subcutaneously 30-60 minutes before breakfast and supper;
  
• 
  how to recognize and treat hypoglycaemia and maintain good hygiene.
  

Optimum control of diabetes requires combination of lente to provide background insulin and 4 daily injections of lispro or aspart insulin analogues. These analogues act rapidly at each meal. The peak of the analogues is fast and there is little overlap and short tail effect. The parents should measure blood glucose before each meal (3 times a day).

Insulin induced hypoglycaemia presents with weakness, pallor, diplopia, sweating and twitching. The hypoglycaemia is treated with 1 mg of subcutaneous glucagon. Advice the parents to treat an impending hypoglycaemia with sugar, orange juice or sweetened beverages.
The children should be encouraged to engage in normal activities and their diet adjusted with extra carbohydrates to compensate for any unusual exercise. It is not the insulin which is adjusted to compensate for the unusual exercise.

There are holiday camps for diabetic children organized by the Diabetics Association. Advice the parents to encourage the children to attend these camps.

What are the indicators of good control of diabetes?

The indicators of good control are:

• 
  Normal growth, development and activity;
  
• 
  Lack of polyuria;
  
• 
  Lack of any severe hypoglycaemic episodes.
  

Management:

Patients with type II diabetes mellitus are given oral antidiabetics.

Complications:

Diabetic coma is a common complication of diabetes. You should urgently refer the child to a hospital. If the child has a hypoglycaemic coma, give glucose and then refer the patient.

Next, let us look at another common condition, known as typhoid

4. TYPHOID

Typhoid is a bacterial disease which affects the whole body. Typhoid, therefore has a wide variety of manifestations which are at times limited to localized inflammatory lesions.

Cause

Typhoid is caused by Salmonellae. These are transmitted as follows:

• 
  most commonly by ingestion of food or drink contaminated with the faeces of carriers or patients.
  
• 
  less commonly, by direct contact with the carriers or patients.
  
• 
  transplacentally from the mother to the baby in case of congenital typhoid.
  
• 
  during birth in case of intrapartum typhoid.
  

ACTIVITY Think of circumstances that favor the spread of typhoid and write them down. _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Now compare your answers with the following information.
Typhoid is common where:

• 
  there are unsanitary conditions;
  
• 
  the personal hygiene is poor;
  
• 
  there is inadequate hygiene in food handling industries;