Pediatrics

fractures

Fractures

Fractures

  • Fractures are complete or incomplete disruption in the continuity of the bone.
  • A fracture is a break in the continuity of a bone tissue, when subjected to excessive abnormal force or
  • A fracture is a break in the bone that occurs when more force is applied to the bone than the bone can withstand.
  • Fractures are also known as broken bones.

Common Childhood Fractures.

  • Arm bones are fractured more often than other bones.
  • Collarbone or shoulder fractures
  • Elbow fractures
  • forearm, wrist, or hand fracture
  • Leg, foot, or ankle fracture.

Causes of Fractures

  • Direct Force: in which the fracture occurs at the point of contact.
  • Torsion: in which the fracture occurs at the point opposite the location of the force, e.g. twisting of the foot may lead to break of bones of the leg.
  • Violent Contractions: e.g. forcibly throwing an object produces powerful muscle contractions which can fracture the humerus. Also in strong contractions in tetanus.
  • Disease Processes: cause weakening of the bone structure; osteoporosis, malnutrition, bone tumors

Risks for fractures

  • Sporting accidents
  • Falls from heights
  • Bike and car accidents
  • Poor nutrition; a diet low in calcium

Associated events following fractures.

When a bone is broken adjacent structures are also affected, resulting in;

  • Soft tissue edema
  • Joint dislocation
  • Ruptured tendons
  • Severed nerves
  • Damaged blood vessels
  • Hemorrhage into the muscles & joints

Classification of Fractures

Fractures can be grouped into 4 categories; i.e

  1. Communication with environment.
  2. By Anatomical Site
  3. By Pattern
  4. Miscellaneous

COMMUNICATION WITH ENVIRONMENT

  • Open/compound fracture: fractured part is exposed to the external environment. These are fractures where the bone is exposed  through the skin or mucous membrane.
  • Closed/simple fracture: fracture with the overlying skin intact. These are types of fractures that do not penetrate the skin.
  • Complete fracture/Incomplete: Foe complete, the fracture line runs entirely through the bone substance with the periosteum disrupted on both sides of the bone and 2 fragments are present on either side of the fracture line. In incomplete, the fracture doesn’t entirely destroy the continuity of the bone.
BY ANATOMICAL SITE.
  • Avulsion:  A fracture occurring from pulling effects of ligaments and tendons.
  • Potts Fracture : Type of fracture that occurs at the ankle joint.
  • Colles fracture(distal radius fracture): a fracture that occurs at the wrist joint.
BY PATTERN
  • Transverse : where the fracture in the bone is broken perpendicular to its length i.e. right angle to the bone.
  • Oblique: where the fracture extends in an oblique direction.
  • Spiral: fracture in which the born has been twisted apart.
MISCELLANEOUS
  • Green stick fracture: common in children and bone commonly bends or in severe cases, fracture line extends only half way across the bone substance. One side of the bone is broken, causing the other side to bend. A greenstick fracture resembles a broken tree branch. The branch cracks on one side but remains partially intact on the other.
  • Depressed fracture: a fracture having its edges driven below the surrounding bone surfaces, e.g. fractured skull.
  • Comminuted fracture: bone fragments are crushed or broken into small pieces. Occurs after high impact trauma eg a vehical road crash.
  • Displaced/overriding fracture: the bone fragments are separated away from the fracture line and bone ends are overlapping each other.
  • Impacted: where a bone fragment is moved into another.
  • Complicated fracture: that which is associated with many structures destroyed such as nerves, blood vessels, joints, muscles
  • Stress fracture: occurs on a normal or abnormal bone from constant exposure to stress e.g. running a long distance, jumping a rope
  • Pathological fracture: a fracture caused by a disease e.g bone cysts, paget’s disease.

Signs and symptoms of fractures

  • Pain at the site of injury : which is continuous and increases in severity until the bone fragments are immobilized.
  • Local tenderness.
  • Deformity : displacements, rotation of fragments in the fracture of the limb causes deformity(either palpable/visible). Is detectable when limb is compared with the uninjured extremity.
  • Soft tissue swelling
  • Loss of function : after the fracture, the extremity cannot function properly because normal function of muscles depends on the integrity of the bones to which they are attached.
  • Bruising
  • Involuntary muscle spasms.
  • Intense pain e.g. in the rib cage when a patient takes a deep breath or coughs.
  • Abnormal mobility
  • Involuntary muscle spasms
  • Crepitus – when the extremity is examined with the hands,  a grating sound or sensation is heard or felt when broken ends rub on each other and is called crepitus.
  • Bone may be visibly seen protruding through the skin.
  • Impaired sensation/numbness may occur if there is nervous damage
  • Shock results from blood loss
  • Swelling and discoloration: localized swelling and discoloration of the skin (Ecchymosis) occurs after a fracture, as a result of trauma and bleeding into the tissues.

Assessment and Diagnostic Findings

To determine the presence of fracture, the following diagnostic tools are used.

  • History taking.
  • Physical Examinations.
  • X-ray examinations: Determines location and extent of fracture.
  • Bone scans, computed tomography (CT)/magnetic resonance imaging (MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage.
Illustration-of-stages-in-bone-healing-after-a-fracture

Process of Fracture Healing

This process varies according to the type of bone involved type of fracture and the amount of movement at the fracture site. In the absence of rigid fixation in tubular bones, healing proceeds in five stages as follows;

1.Tissue destruction & haematoma formation:

After tissue destruction, torn blood vessels result to hematoma formation (which is a collection of clotted blood between the ends of the bones and in surrounding soft tissues. Fibrin, red blood cells, debris and inflammatory exudates come together and form a fibrin clot.

 2.Inflammation & cellular proliferation:

This follows development of acute inflammation and accumulation of inflammatory exudate containing macrophages that phagocytose the hematoma and small fragments of bone without blood supply and this takes about 5 days. Fibroblasts migrate to the site, granulation  tissue and new capillaries develop.

3. Stage of Callus formation (Soft Callus)

New bone forms as large number of osteoblasts secrete spongy bone, which unites  the broken ends, osteoclasts begin mopping up the dead bone. The new deposits of  bone and cartilage are called callus. As the immature bone (soft callus) becomes more densely mineralized, movement of the site  progressively decreases.

4.Stage of consolidation(Hard callus)

Over the next few days, callus matures and the cartilage is gradually replaced with new bone.

5.Stage of remodelling

This is the reshaping of the callus by a continuous process of resorption and laydown. Internal callus is hollowed out into marrow cavity, while external callus is slowly removed. Reshaping of the bone continues and gradually the medullary canal is reopened through the callus, and callus tissue is completely replaced with mature compact bone. Often the bone is thicker and stronger at the repair site than originally and a second fracture is more likely to occur at a different site.

Healing of Fractures

Factors necessary for bone healing

  • Haematoma formation.
  • Contact of bone end and no interposition of other tissues
  • Continued immobilization until calus is able to withstand stress.
  • Good supply of blood
  • Enough rest of the fractured site
  • Good nutrition- calcium, proteins

Factors influencing bone healing.

(a). Systemic factors

  •   -Age ( healing is almost twice as fast in   children as in adults )
  •   -Activity level.( immobilization)
  •   -Nutritional status.
  •   -Hormonal factors (GH, corticosteroids )
  •   -Diseases e.g. DM, anaemia, neuropathies
  •   -Vitamin deficiencies e.g. A C D K
  •   -Drugs e.g. anti coagulants, anti inflammatory.

(b). Local factors.

  •   -type of bone( cancellous heals faster than   cortical bone)
  •   -type of fracture. Spiral better than transverse.
  •   -blood supply ( poor circulation-poor healing.)
  •   -reduction- faster when there’s perfect   reduction.
  •   -infection
  •   -soft tissue interposition
  •   -mobilization. Early vs late mobilization.

Management

Aims of management.

  1. To regain and maintain the normal alignment of the injured part.
  2. To regain normal function of the injured part.
  3. To achieve the above objectives for the patient in the shortest time possible

Basic principles of managing fractures

The principles of fracture management are:

  • Reduction
  • Immobilization
  • Rehabilitation

(1) Reduction: Reduction is the process of restoring the bone ends (and any fractured fragments) into their normal anatomical positions. This is accomplished by open or closed manipulation of the affected area, referred to as open reduction and closed reduction. 

  •  Closed reduction is accomplished by bringing the bone ends into alignment by manipulation and manual traction. X-rays are taken to determine the position of the bones. A cast is normally applied to immobilize the extremity and maintain the reduction.
  •  In open reduction, a surgical opening is made, allowing the bones to be reduced manually under direct visualization. Frequently, internal fixation devices will be used to maintain the bone fragments in reduction.

(2) Immobilization: Immobilization is necessary to maintain fracture reduction until healing occurs. Immobilization may be accomplished by external or internal fixation.

  • Methods of external fixation include casts, splints, and continuous traction.
  •  Internal fixation devices include pins, wires, screws, rods, nails, and plates.

(3) Rehabilitation: Rehabilitation is the regaining of strength and normal function in the affected area. Specific rehabilitation for each patient will be based upon the type of fracture and the methods of reduction and immobilization used.

First aid management

This can save the client’s life so it is crucial.  A B C D of life criteria is used as follows;

Ensure that the patient is breathing then do the following:

  • Airway should be clear
  • Breathing should be maintained.
  • Check pulse and control bleeding.
  • Deformity should immobilized, Immobilize the limb to avoid more harm and pain by using splints.

Emergency Management of Fractures

  • Immediately after injury, whenever a fracture is suspected, it is important to immobilize the body part before the patient is moved.
  • If an injured patient must be removed from a vehicle before splints can be applied, the extremity is supported above and below the fracture site to prevent rotation as well as angular motion.
  • Adequate splinting, including joints adjacent to the fracture,  is essential.
  • Movement of fracture fragments causes additional pain, soft tissue damage, and bleeding.
  • Temporary, well-padded splints, firmly bandaged over clothing, serve to immobilize the fracture. 
  • Immobilization of the long bones of the lower extremities may be accomplished by bandaging the legs together, with the unaffected extremity serving as a splint for the injured one.
  • In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling.
  • The neurovascular status distal to the injury should be assessed to determine adequacy of peripheral tissue perfusion and nerve function. 
  • With an open fracture, the wound is covered with a clean (sterile) dressing to prevent contamination of deeper tissues.
  • No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound.
  • Splints are applied for immobilization. 
  • In the emergency department, the patient is evaluated completely.
  • The clothes are gently removed, first from the uninjured side of the body and then from the injured side.
  • The patient’s clothing may be cut away. The fractured extremity is moved as little as possible to avoid more damage

Management in hospital

  • Care depends on class/type of fracture
  • Immobilization/ reduction and rehabilitation is done.
  • Pain relief
  • Anti biotics
  • Supportive treatment eg feso4,FA ,multivitamin
  • Bone x- ray
  • Fluid resuscitation
  • Infection prevention
  • Nutrition – calcium
  • Exercises/ physiotherapy
  • Nursing care

Nursing Care

  • Encourage patients with closed (simple) fractures to return to their usual activities as rapidly as possible.
  • Teach patients how to control swelling and pain associated with the fracture and with soft tissue trauma and encourages them to be active within the limits of the fracture immobilization.
  • It is important to teach exercises to maintain the health of unaffected muscles and to increase the strength of muscles needed for transferring and for using assistive devices (eg, crutches, walker, special utensils).
  • Teach patients to use assistive devices safely. Plans are made to help patients modify their home environment as needed and to secure personal assistance if necessary.
  • Patient teaching include self-care, medication information, monitoring for potential complications and the need for continuing health care supervision.
  • Flracture healing and restoration of full strength and mobility may take months

Managing Fractures at Specific Sites

Maximum functional recovery is the goal of management.

Clavicle

  • Fracture of the clavicle (collar bone) is a common injury that results from a fall or a direct blow to the shoulder.
  • Monitor the circulation and nerve function of the affected arm and compare with the unaffected arm to determine variations, which may indicate disturbances in neurovascular status. 
  • Caution the patient not to elevate the arm above shoulder level until the fracture has healed (about 6 weeks).
  • Encourage the patient to exercise the elbow, wrist, and fingers as soon as possible and, when prescribed, to perform shoulder exercises.
  • Tell the patient that vigorous activity is limited for 3 months.

Humeral Neck

  • With humeral neck fractures (seen most frequently in older women after a fall on an outstretched arm), perform neurovascular assessment of the involved extremity to evaluate the extent of injury and possible involvement of the nerves and blood vessels of the arm.
  • Teach the patient to support the arm and immobilize it by a sling and swathe that secure the supported arm to the trunk.
  • Begin pendulum exercises as soon as tolerated by the patient. Instruct the patient to avoid vigorous activity for an additional 10 to 14 weeks. 
  • Inform the patient that residual stiffness, aching, and some limitation of range of motion may persist for 6 or more months.
  • When a humeral neck fracture is displaced with required fixation, exercises are started only after a prescribed period of immobilization.

Humeral shaft fractures

  • The nerves and brachial blood vessels may be injured, so neurovascular assessment is essential to monitor the status of the nerve or blood vessels.
  • Use well-padded splints to initially immobilize the upper arm and to support the arm in 90 degrees of flexion at the elbow, use a sling or collar and cuff to support the forearm, and use external fixators to treat open fractures of the humeral shaft.
  • Functional bracing may also be used for these fractures.
  • Teach patient to perform pendulum shoulder exercises and isometric exercises as prescribed.

Elbow

  • Elbow fractures (distal humerus) may result in injury to the median, radial, or ulnar nerves.
  • Evaluate the patient for paresthesia and signs of compromised circulation in the forearm and hand.
  • Monitor closely for Volkmann’s ischemic contracture (an acute compartment syndrome) as well as for hemarthrosis (blood in the joint). 
  • Reinforce information regarding reduction and fixation of the fracture and planned active motion when swelling has subsided and healing has begun.
  • Explain care if the arm is immobilized in a cast or posterior splint with a sling. Encourage active finger exercises.
  • Teach and encourage patient to do gentle range of motion exercise of the injured joint about 1 week after internal fixation. 

Radial head fractures

  • They are usually produced by a fall on the outstretched hand with the elbow extended.
  • Instruct patient in use of a splint for immobilization.
  • If the fracture is displaced, reinforce the need for postoperative immobilization of the arm in a posterior plaster splint and sling.
  • Encourage the patient to carry out a program of active motion of the elbow and forearm when prescribed

Wrist

  • Wrist fractures (distal radius [Colles’ fracture]) usually result from a fall on an open, dorsiflexed hand.
  • They are frequently seen in elderly women with osteoporotic bones and weak soft tissues that do not dissipate the energy of a fall.
  • Reinforce care of the cast, or with more severe fractures with wire insertion, teach incision care. 
  • Instruct patient to keep the wrist and forearm elevated for 48 hours after reduction.
  • Begin active motion of the fingers and shoulder promptly by teaching patient to do the following exercises to reduce swelling and prevent stiffness:
  • Hold the hand at the level of the heart. Move the fingers from full extension to flexion. Hold and release. Repeat at least 10 times every hour when awake.
  • Use the hand in functional activities. 
  • Actively exercise the shoulder and elbow, including complete range-of-motion exercises of both joints
  • Assess the sensory function of the median nerve by pricking the distal aspect of the index finger, and assess the motor function by testing patient’s ability to touch the thumb tot he little finger.
  • If diminished circulation and nerve function is noted, treat promptly. 

Hand and Fingers

  • Hand trauma often requires extensive reconstructive surgery.
  • The objective of treatment is always to regain maximum function of the hand.
  • With a non displaced fracture, the finger is splinted for 3 to 4 weeks to relieve pain and protect the fingertip from further trauma, but displaced fractures and open fractures may require open reduction with internal fixation, using wires or pins. 
  • Encourage functional use of the uninvolved portions of the hand
  • Evaluate the neurovascular status of the injured hand.
  • Teach the patient to control swelling by elevating the hand.

Pelvis

  • Pelvic fractures may be caused by falls, motor vehicle crashes, or crush injuries. At least two thirds of these patients have significant and multiple injuries.
  • Monitor for symptoms, including ecchymosis; tenderness over the symphysis pubis, anterior iliac spines, iliac crest, sacrum, or coccyx; local edema; numbness or tingling of the pubis, genitals, and proximal thighs; and inability to bear weight without discomfort. 
  • Complete a neurovascular assessment of the lower extremities to detect injury to pelvic blood vessels and nerves.
  • As pain resolves, instruct patient to resume activity gradually, using assistive mobility devices for protected weight bearing. Patients with unstable pelvic fractures may be treated with external fixation or open reduction and internal fixation (ORIF).
  • Promote hemodynamic stability and comfort, and encourage early mobilization. 
  • Examine urine for blood to assess for urinary tract injury. In male patients, do not insert a catheter until the status of the urethra is known.
  • Monitor for diffuse and intense abdominal pain, hyperactive or absent bowel sounds, and abdominal rigidity and resonance (free air) or dullness to percussion (blood), which suggest injury to the intestines or abdominal bleeding. 
  • Monitor for hemorrhage and shock, two of the most serious consequences that may occur. Palpate both lower extremities for absence of peripheral pulses, which may indicate a torn iliac artery or one of its branches.
  • Assess for injuries to the bladder, rectum, intestines, other abdominal organs, and pelvic vessels and nerves. 
  • If patient has a stable pelvic fracture, maintain patient on bed rest for a few days and provide symptom management until the pain and discomfort are controlled.
  • Provide fluids, dietary fiber, ankle and leg exercises, antiembolism stockings to aid venous return, logrolling, deep breathing, and skin care to reduce the risk for complications and to increase comfort.
  • Monitor bowel sounds. If patient has a fracture of the coccyx and experiences pain on sitting and with defecation, assist with sitz baths as prescribed to relieve pain, and administer stool softeners to prevent the need to strain on defecation.

Femur and Hip

  • Femoral shaft fractures are most often seen in young adults involved in a motor vehicle crash or a fall from a high place.
  • Frequently, these patients have associated multiple trauma and develop shock from a loss of 2 to 3 units of blood.
  • Assess neurovascular status of the extremity, especially circulatory perfusion of the lower leg and foot (popliteal, posterior tibial, and pedal pulses and toe capillary refill time as well as Doppler ultrasound monitoring). 
  • Note signs of dislocation of the hip and knee, and knee effusion, which may suggest ligament damage and possible instability of the knee joint
  • Apply and maintain skeletal traction or splint to achieve muscle relaxation and alignment of the fracture fragments before ORIF procedures, and later a cast brace. 
  • Assist patient in minimal partial weight bearing when indicated and progress to full weight bearing as tolerated.
  • Reinforce that the cast brace is worn for 12 to 14 weeks
  • Instruct in and encourage patient to perform exercises of lower leg, foot, and toes on a regular basis. 
  • Assist patient in performing active and passive knee exercises as soon as possible, depending on the management approach and the stability of the fracture and knee ligaments.

Tibia and Fibula

  • Tibia and fibula fractures (most common fractures below the knee) tend to result from a direct blow, falls with the foot in a flexed position, or a violent twisting motion.
  • Provide instruction on care of the long leg walking cast or patellar-tendon-bearing cast.
  • Instruct patient in and assist with partial weight bearing,
  • usually in 7 to 10 days.
  • Instruct patient on care of a short leg cast or brace (in 3 to 4 weeks), which allows for knee motion.
  • Instruct patient in care of skeletal traction, if applicable.
  • Encourage patient to perform hip, foot, and knee exercises  within the limits of the immobilizing device.
  • Instruct patient to begin weight bearing when prescribed (usually in about 4 to 8 weeks).
  • Instruct patient to elevate extremity to control edema.
  • Perform continuous neurovascular evaluation.

Rib

  • Rib fractures occur frequently in adults and usually result in no impairment of function but produce painful respirations.
  • Assist patient to cough and take deep breaths by splinting the chest with hands or pillow during cough.
  • Reassure patient that pain associated with rib fracture diminishes significantly in 3 or 4 days, and the fracture heals within 6 weeks.
  • Monitor for complications, which may include atelectasis, pneumonia, a flail chest, pneumothorax, and hemothorax.
COMPLICATIONS OF FRACTURES

Early complications include;

  • Shock,
  • Fat embolism,
  • Compartment syndrome, and
  • Venous thromboembolism (deep vein thrombosis [DVT],
  • Pulmonary embolism [PE]).

Delayed Complications;

  • Delayed union,
  • Malunion,
  • Nonunion,
  • Avascular necrosis (AVN) of bone, reaction to internal fixation devices
  • Complex regional pain syndrome (CRPS, formerly called reflex sympathetic dystrophy (RSD), is chronic condition of severe burning pain affecting one of the extremities
  • Heterotopic ossification- is the presence of bone in the soft tissue where bone normally does not exist

MANIFESTATION OF COMPLICATIONS

Fat embolism syndrome:

  • Occurs with blockage of the small blood vessels that supply the brain, lungs, kidneys, and other organs.
  • Sudden onset, usually occurring within 12 to 48 hour but may occur up to 10 days after injury),
  • Signs & symptoms: hypoxia, tachypnea, tachycardia, and pyrexia; dyspnea, crackles, wheezes, precordial chest pain, cough, large amounts of thick white sputum.

Compartment syndrome

  • Acute compartment syndrome may produce deep, throbbing, unrelenting pain not controlled by opioids
  • It can be due to a tight cast or constrictive dressing or an increase in muscle compartment contents because of edema or hemorrhage.
  • Signs & symptoms include; Cyanotic (blue-tinged) nail beds and pale or dusky and cold fingers or toes are present; nail bed capillary refill times are prolonged (greater than 3 seconds); pulse may be diminished or absent; and motor weakness, paralysis, and paresthesia may occur.

DIC- disseminated intravascular coagulation is evidenced by;

  • Unexpected bleeding after surgery and
  • Bleeding from the mucous membranes,
  • Venipuncture sites, and
  • Gastrointestinal and urinary tracts.

Infection. symptoms include.

  • Tenderness on examination
  • Pain (patient history)
  • Redness,
  • Swelling,
  • Local warmth,
  • Elevated temperature, and
  • Purulent drainage.

Nonunion is manifested by

  • Persistent discomfort and abnormal movement at the fracture site.

Some risk factors include;

  • Infection at the fracture site
  • Interposition of tissue between the bone ends
  • Inadequate immobilization or manipulation that disrupts callus formation,

MANAGEMENT OF COMPLICATIONS

Treatment of shock :

  • Consists of stabilizing the fracture to prevent further hemorrhage
  • Restoring blood volume and circulation
  • Relieving the patient’s pain
  • Providing proper immobilization and
  • Protecting the patient from further injury and other complications.

Prevention and management of fat embolism:

  • Include immediate immobilization of fractures
  • Adequate support for fractured bones during turning and positioning
  • Maintenance of fluid and electrolyte balance
  • Prompt initiation of respiratory support with prevention of respiratory and metabolic acidosis
  • Corticosteroids as well as vasopressor medications may be given.

Compartment syndrome:

  • Is managed by controlling swelling by elevating the extremity to heart level or by releasing restrictive devices (dressings or cast).
  • A fasciotomy (surgical decompression with excision of the fascia) may be needed to relieve the constrictive muscle fascia.
  • The wound remains open and covered with moist sterile saline dressings for 3 to 5 days.
  • The limb is splinted and elevated.
  • Prescribed passive range-of-motion exercises may be performed every 4 to 6 hours.

Nonunion (failure of the ends of a fractured bone to unite)

  • Is treated with internal fixation
  • Bone grafting
  • Electrical bone stimulation, or a combination of these.

Related Question

Josephine a thirty year old female patient has been involved in a road traffic accident and sustained a compound fracture.

  1. Outline ten signs and symptoms of fracture.
  2. Discuss the negative factors that can influence healing of a bone.
  3. Describe the healing of a bone.
  4. Mention ten complications of fractures.

SOLUTIONS

  1. a) History from the patient or the on lookers.
  • Pain aggravated by movement
  • Tenderness over the fractured limb
  • Loss of function of the affected part or the whole limb
  • Deformity
  • Shortening of the limb
  • Abnormal mobility at the affected area
  • Creepers or grating of the bone ends as they move each other
  • Swelling of the affected part
  • Shock may occur
  • The bone may be seen out if it’s a compound fracture

b)

  • Tissue fragments between bone ends; Splinters of dead bone (sequestrate) and soft tissue fragments not removed by phagocytosis delay healing.
  • Deficient blood supply; this delays growth of granulation tissue and new blood vessels. Hypoxia also reduces the number of osteoblasts and increases the number of chondrocytes that develop from there common parent cells. This may lead to cartilaginous union of fracture which results in a weaker repair.
  • Poor alignment of bone ends: This may result in the formation of a callus that heals slowly and often results in permanent disability
  • Continued mobility of bone ends; Continuous movement results in fibrosis of the granulation tissue followed fibrous union of the fracture.
  • Miscellaneous; this include
  • Infection; pathogens enter through broken skin, although they occasionally be blood borne, healing will not occur until infection resolves
  • System illness 
  • Malnutrition
  • Drugs e.g. Corticosteroids
  • Aging

 

c)

  • Following a fracture the broken ends of a bone a joined by the deposition of a new bone. This occurs in several stages
  • Hematoma forms between the ends of the bone and in the surrounding soft tissues.
  • There follows development of acute inflammation and accumulation of inflammatory exudates, continuing microphages that phagocytosis the hematoma and small fragments of a bone without blood supply(this takes place about five days). Fibroblasts migrate to the site, granulation tissue and the new capillaries develop.
  • New bone forms as large numbers of osteoblasts secretes spongy bone, which unit the broken ends, and is protected by the outer layer of the bone and cartilage, this new deposits of bone and cartilage are called callus.
  • Over the next few weeks, the callus matures and the cartilage is gradually replaced by new bone
  • Reshaping of the bone continues and gradually the medullary canal is re –opened through the callus (in weeks or month). In time the bone heals completely with callus tissue replaced with mature compact bone. Often the bone is thicker and stronger at the repair site that originally, and the second is more likely to occur at a different site.

 

  1. d)                  Complications of fractures are divided in to two.
  • General complications.
  • Local complications
  • General complications are;
  • Hemorrhage which may lead in to shock.
  • Fat embolism
  • Infections
  • Hypostatic Pneumonia
  • Damage to the nearby structures
  • Local complications
  • Keloids
  • Loss of function
  • Damage to the nerves
  • Necrosis
  • Delayed union of bones; this may be as a result of incomplete reduction, inadequate immobilization, lack of blood supply to areas, infection which disrupt formation
  • Malunion of the bones; this when there’s failure of bone fragments to unit. This as a result of a big gap between the fragment

Fractures Read More »

Prevention and Control of HIV/AIDS

Prevention and Control of HIV/AIDS

Prevention and Control of HIV/AIDS

Prevention Framework in children and infants.

 

Prevention in Pediatrics 

  1. ∙ Behavioral change and risk reduction interventions 
  2. ∙ Biomedical prevention interventions 
  3. ∙ Structural intervention 

BEHAVIORAL CHANGE AND RISK REDUCTION INTERVENTIONS 

The priority of behavioral interventions is to delay sexual debut; reduce unsafe sex and multiple, especially  concurrent sexual partnerships; and discourage cross-generational and transactional sex.

Types of behavioral change 

  • ∙ Service delivery 
  • ∙ Risk assessment for client 
  • ∙ Provide socio-behavioral change Communication (SBCC) and link to services as appropriate ∙ Condom promotion and provision 

Service delivery 

The government of Uganda ensures that  

1 . ⇒ Each health facility/program should have a focal person for HIV prevention 

2. ⇒ All staff offering prevention services need to be trained 

3. ⇒ Outreaches for key and priority populations 

Risk assessment  

4. ⇒ Offer HTS to sexually active adolescents, pregnant mothers who have not tested in the last 12  months or have had unprotected sex in last three months. 

5. ⇒ HIV testing for infants born of HIV infected mothers.

6. ⇒ Assess sexual behavior of the in pregnant mothers and adolescents (ask if condoms are used,  frequency, the number of partners, transactional sex/sex work) and if the client is involved in  transactional sex/sex work encourage correct and consistent condom use. 

Provide socio-behavioral change Communication (SBCC) and link to services as appropriate

7. ⇒ Discuss delay of onset of sexual debut in children and adolescents (abstinence) ⇒ Discuss correct and consistent condom use and offer condoms as appropriate to adolescents ⇒ Discourage multiple, concurrent sexual partnerships to promote faithfulness with a partner of  known status. 

8. ⇒ Discuss with the adolescents about sexual and reproductive health services and link to services as  appropriate. 

9. ⇒ Discourage risky cultural practices such as childhood marriages 

10. ⇒ Identify, refer and link clients to other available facility and community programs

11. ⇒ Assess for violence, (physical, emotional, or sexual); if child discloses sexual violence, assess if the  client was raped and act immediately 

Condom promotion and provision 

12. ⇒ Discuss condom use as an option for risk reduction in pregnant mothers and adolescent ∙ Discuss barriers to condom use to pregnant mothers and adolescent 

13. ⇒ Clarify any questions and dispel myths around condoms

Biomedical prevention interventions 

The key biomedical interventions include; 

  • ∙ EMTCT 
  • ∙ Safe male circumcision (SMC) 
  • ∙ ART 
  • ∙ PEP, 
  • ∙ PrEP 
  • ∙ Blood transfusion safety 
  • ∙ STI screening and treatment  

Safe male circumcision (SMC) 

  • Male circumcision is the surgical removal of the foreskin of the penis. SMC reduces the risk of HIV  acquisition among circumcised men (adolescents) by approximately 60%.  

Blood transfusion safety 

  • Ensuring the screening of blood donors for HIV and hepatitis B 
  • Ensuring proper storage and administration 

STI screening and treatment 

  • Integration of STI services in all health programs e.g. YCC, MCH. 

EMTCT (Elimination of Mother-to-Child Transmission of HIV)

  • Measures of reducing the risk of HIV transmission to the child during pregnancy, labor, puerperium and  breastfeeding. 
Post-exposure prophylaxis (PEP)
  • Post-exposure prophylaxis (PEP) is the short-term use of ARVs to reduce the likelihood of acquiring HIV  infection after potential occupational or non-occupational exposure. 

Types of exposure: 

  1. ∙ Occupational exposures occur in the health care or laboratory setting and include sharps and  needlestick injuries or splashes of body fluids to the skin and mucous membranes. 
  2. Non-occupational exposures include unprotected sex, exposure following assault like in rape and  defilement, and road traffic accidents. 

Steps for providing Post Exposure Prophylaxis 

Step 1: Clinical assessment and providing first aid 

  • Conduct a rapid assessment of the client to assess exposure and risk and provide immediate care. Occupational exposure: 

After a needlestick or sharp injury 

  • ∙ Do not squeeze or rub the injury site 
  • ∙ Wash the site immediately with soap or mild disinfectant (chlorhexidine gluconate solution) ∙ Use antiseptic hand rub/gel if no running water 
  • ∙ Don’t use strong, irritating antiseptics (like bleach or iodine) 

After a splash of blood or body fluids in contact with intact skin 

  • ∙ Wash the area immediately 
  • ∙ Use antiseptic hand rub/gel if no running water 
  • ∙ Don’t use strong, irritating antiseptics (like bleach or iodine) 

Step 2: Eligibility assessment 

Provide PEP when: 

  • ∙ Exposure occurred within the past 72 hours; and 
  • ∙ The exposed individual is not infected with HIV; and 
  • ∙ The ‘source’ is HIV-infected, has unknown HIV status or is high risk 

Do not provide PEP when: 

  • ∙ The exposed individual is already HIV-positive 
  • ∙ The source is established to be HIV-negative 
  • ∙ Individual was exposed to bodily fluids that do not pose a significant risk (e.g. tears, non-blood stained saliva, urine, sweat) 
  • ∙ Exposed individual declines an HIV test 

Step 3: Counseling and support  

Counsel on: 

  • ∙ The risk of HIV from the exposure 
  • ∙ Risks and benefits of PEP 
  • ∙ Side effects of ARVs  
  • ∙ Enhanced adherence if PEP is prescribed 
  • ∙ Importance of linkage for further support for sexual assault cases 

Step 4: Prescription 

∙ PEP should be started as early as possible, not beyond 72 hours of exposure ∙ Recommended regimens include: 

  • ⇒ Pregnant mothers/adults: TDF+3TC+ATV/r
  • ⇒ Children: ABC+3TC+LPV/r 

∙ A complete course of PEP should run for 28 days 

∙ Do not delay the first doses because of lack of baseline HIV test 

∙ Document the event and patient management in the PEP register (ensure confidentiality of patient  data) 

Step 5: Provide follow-up 

  • ∙ Discontinue PEP after 28 days 
  • ∙ Perform follow-up HIV testing three months after exposure 
  • ∙ Counsel and link to HIV clinic for care and treatment if HIV-positive 
  • ∙ Provide prevention and education/risk reduction counseling if HIV-negative
ORAL PRE-EXPOSURE PROPHYLAXIS (PrEP) 

PrEP is the use of ARV drugs by people who are not infected with HIV to block the acquisition of HIV.  

The process of providing pre-exposure prophylaxis (PrEP) 

  1. ∙ Eligibility for PrEP 
  2. ∙ Screening for PrEP eligibility 
  3. ∙ Steps to initiation of PrEP 
  4. ∙ Follow-up/ monitoring clients on PrEP 
  5. ∙ Guidance on discontinuing PrEP 

Step 1: Eligibility for PrEP 

PrEP provides an effective additional biomedical prevention option for HIV-negative people at substantial  risk of acquiring HIV infection. These include people who: 

  • ∙ Have multiple sexual partners 
  • ∙ Engage in transactional sex including sex workers 
  • ∙ Use or abuse injectable drugs and alcohol 
  • ∙ Have had more than one episode of an STI within the last twelve months 
  • ∙ Are part of a discordant couple, especially if the HIV-positive partner is not on ART or has been on  ART for less than six months 
  • ∙ Are recurrent users of PEP (3 consecutive cycles of PEP) 
  • ∙ Engage in anal sex 

These risk factors are likely to be more prevalent in populations such as sex workers, fisher folk, long distance truck drivers, men who have sex with men (MSM), uniformed forces, and adolescents and young  women engaged in transactional sex. 

Step 2; Screening for PrEP eligibility 

After meeting the eligibility criteria: 

  • ∙ Confirm HIV-negative status 
  • ∙ Rule out acute HIV infection 
  • ∙ Assess for hepatitis B infection: if negative, patient is eligible for PrEP; if positive, refer patient for  management
  • ∙ Assess for contraindications to TDF/FTC 

Step 3: Steps to initiation of PrEP 

  • Provide risk-reduction and PrEP medication adherence counseling: 
  • ∙ Provide condoms and education on their use 
  • ∙ Initiate a medication adherence plan 
  • ∙ Prescribe a once-daily pill of TDF (300mg) and FTC (200mg) 
  • ∙ Initially, provide a 1-month TDF/FTC prescription (1 tablet orally, daily) together with a 1-month  follow-up date 
  • ∙ Counsel client on side effects of TDF/FTC 

Step 4: Follow-up/ monitoring clients on PrEP 

  • ∙ After the initial visit, the patient should be given a two-month follow-up appointment and  thereafter quarterly appointments 
  • ∙ Perform an HIV antibody test every three months 
  • ∙ For women, perform a pregnancy test based on clinical history 
  • ∙ Review the patient’s understanding of PrEP, any barriers to adherence, tolerance to the medication  as well as any side effects 
  • ∙ Review the patient’s risk exposure profile and perform risk-reduction counseling ∙ Evaluate and support PrEP adherence at each clinic visit 
  • ∙ Evaluate the patient for any symptoms of STIs at every visit and treat as needed 

Step 5: Guidance on discontinuing PrEP 

  • ∙ Acquisition of HIV infection 
  • ∙ Changed life situations resulting in lowered risk of HIV acquisition 
  • ∙ Intolerable toxicities and side effects 
  • ∙ Chronic non-adherence to the prescribed dosing regimen despite efforts to improve daily pill-taking ∙ Personal choice 
  • ∙ HIV-negative in a sero-discordant relationship when the positive partner has achieved sustained viral  load suppression (condoms should still be used consistently.

MOTHER-TO-CHILD TRANSMISSION OF HIV 

Approximately one-third of the women who are infected with HIV can pass it to their babies. 

Elements of elimination of mother to child transmission 

  1. ∙ : Primary prevention of HIV infection Women and men of reproductive age including  adolescents 
  2. ∙ : Prevention of unintended pregnancies among women living with HIV Women including  adolescents living with HIV and their partners. 
  3. ∙ : Prevention of HIV transmission from women living with HIV to their infants Pregnant and  breastfeeding women including adolescents living with HIV 
  4. ∙: Provision of treatment, care, and support to women infected with HIV, their children and  their families Women living with HIV and their families 

Cause 

Time of transmission; 

  • ∙ During pregnancy (15-20%) 
  • ∙ During time of labour and delivery (60%-70%) 
  • ∙ After delivery through breast feeding (15%-20%) 

Pre-disposing factors 

  • ∙ High maternal viral load 
  • ∙ Depleted maternal immunity (e.g. very low CD4 count) 
  • ∙ Prolonged rupture of membranes 
  • ∙ Intra-partum haemorrhage and invasive obstetrical procedures 
  • ∙ If delivering twins, first twin is at higher risk of infection than second twin 
  • ∙ Premature baby is at higher risk than term baby 
  • ∙ Mixed feeding carries a higher risk than exclusive breastfeeding or use of replacement feeding

Investigations 

 

  1. ∙ Blood: HIV serological test 
  2. ∙ HIV -DNA/ PCR testing of babies.

Management 

All HIV services for pregnant mothers are offered in the MCH clinic. After delivery, mother and baby will  remain in the MCH postnatal clinic till HIV status of the child is confirmed, then they will be transferred to  the general ART clinic. 

The current policy aims at elimination of Mother-to-Child Transmission (eMTCT) through provision of a continuum of care with the following elements: 

  • ∙ Primary HIV prevention for men, women and adolescents 
  • ∙ Prevention of unintended pregnancies among women living with HIV 
  • ∙ Prevention of HIV transmission from women living with HIV to their infants 
  • ∙ Provision of treatment, care and support to ALL women infected with HIV, their children and their families 

Management of HIV Positive Pregnant Mother 

Key Interventions for eMTCT ;

  • ∙ Routine HIV Counseling and Testing during ANC (at 1st contact. If negative, repeat HIV test in the  third trimester/ labour. 
  • ∙ Enrolment in HIV care if mother is positive and not yet on treatment
  • ∙ If mother already on ART, perform viral load and continue current regimen 
  • ∙ ART in pregnancy, labour and post-partum, and for life – Option B+ 

Treatment  

Recommended ARV for option B+ 

  • One daily Fixed Dose Combination (FDC) pill containing TDF + 3TC + EFV started early in pregnancy  irrespective of the CD4 cell count and continue during labour and delivery, and for life, Alternative regimen for women who may not tolerate the recommended option are: ∙ 
  • If TDF contraindicated: ABC+3TC+EFV 
  • If EFV contraindicated: TDF + 3TC + ATV/r 

Prophylaxis for opportunistic infections 

  • Cotrimoxazole 960 mg 1 tab daily during pregnancy and postpartum 

   NB.  Mothers on cotrimoxazole DO NOT NEED IPTp with SP for malaria 

Notes 

  • ∙ TDF and EFV are safe to use in pregnancy 
  • ∙ Those newly diagnosed during labour will begin HAART for life after delivery 

Caution 

∙ In case of low body weight, high creatinine, diabetes, hypertension, chronic renal disease, and  concomitant nephrotoxic medications: perform renal function investigations before starting TDF ∙ TDF is contraindicated in advanced chronic renal disease.

Prevention and Control of HIV/AIDS Read More »

Treatment of HIV/AIDS in Children (ARV therapy)

hiv / aids Treatment in Children

Treatment Modalities of HIV/AIDS

Treatment Modality

Description

Antiretroviral Therapy (ART)

Suppresses viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.

Treatment of Acute Bacterial Infections

Addresses immediate bacterial infections.

Prophylaxis and Treatment of Opportunistic Infections

Prevents and manages opportunistic infections.

Maintenance of Good Nutrition

Ensures adequate nutrition to support overall health.

Immunization

Administers vaccines to prevent opportunistic infections.

Management of AIDS-Defining Illnesses

Addresses specific illnesses associated with advanced HIV infection.

Psychological Support for the Family

Provides emotional support and guidance for affected families.

Palliative Care for the Terminally Ill

Offers comfort and support for patients nearing the end of life.

ANTIRETROVIRAL DRUG TREATMENT 

The goal of ART 

Goal of ART: Suppress viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.

When to Initiate ARV:

  • All HIV-infected children below 12 months.
  • Clinical AIDS
  • Mild to moderate symptoms and immunosuppression.

Process of Starting ART:

  •  Assess all clients for opportunistic infections especially TB and cryptococcal meningitis. If the patient has TB or cryptococcal meningitis, ART should be deferred and initiated after starting treatment for these OIs. Treatment for other OIs and ART can be initiated concurrently.
  •  For patients without TB or cryptococcal meningitis, offer ART on the same day through an opt-out approach. In this approach, the patients should be prepared for ART on the same day and assessed for readiness to start ART using the readiness checklist 
  • If a client is ready, ART should be initiated on the same day. If a client is not ready or opts out of same-day initiation, a timely ART preparation plan should be agreed upon with the aim of initiating ART within seven days for children and pregnant women, and within one month for adults. 

Principles for selecting the ARV regimens 

The first-line ART regimens for treating HIV infection in Uganda were selected based on the following  principles: 

  • ∙ Regimen with lower toxicity 
  • ∙ Better palatability and lower pill burden 
  • ∙ Increased durability and efficacy 
  • ∙ Sequencing: spares other available formulations for use in the 2nd line regimen ∙ Harmonization of regimen across age and population 
  • ∙ Lower cost 
  • ∙ Help the country to achieve a recommended regimen for the vast majority of PLHIV(People Living With HIV)

Available ARVs in Uganda

Drug Class

Examples

Nucleoside Reverse Transcriptase Inhibitors (NRTIs): Incorporate into the DNA of the  virus, thereby stopping the building process. 

 

Tenofovir (TDF), Zidovudine (AZT), Lamivudine (3TC), Abacavir (ABC)

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): stop HIV production by binding directly onto the reverse transcriptase enzyme, and prevent the conversion of RNA to DNA.

Efavirenz (EFV), Nevirapine (NVP), Etravirine (ETV)

Integrase Inhibitors: interfere with the HIV DNA’s ability to insert itself into the host DNA and copy  itself.

Dolutegravir (DTG), Raltegravir (RAL)

Protease Inhibitors (PIs): prevent HIV from being successfully assembled and released from the infected CD4 cell.

Atazanavir (ATV), Lopinavir (LPV), Darunavir (DRV)

Entry Inhibitors:  prevent the HIV virus particle from infecting the CD4 cell.

Enfuvirtide (T-20), Maraviroc

 

Uses of ART (Antiretroviral Therapy)

  1. Treatment of HIV/AIDS: ART is the primary treatment for managing HIV/AIDS, helping to control the viral load and maintain the health of the immune system.
  2. Prevention of Mother-to-Child Transmission (PMTCT): ART is crucial in preventing the transmission of HIV from an infected mother to her baby during pregnancy, childbirth, and breastfeeding.
  3. Post-Exposure Prophylaxis (PEP): ART is used as an emergency intervention for individuals who have been potentially exposed to HIV. It must be started within 72 hours of exposure to be effective.
  4. Pre-Exposure Prophylaxis (PrEP): ART can be taken by HIV-negative individuals at high risk of infection to prevent acquiring HIV. This is particularly useful for people with HIV-positive partners, among others.
  5. Treatment and Support for Children: Ensuring children with HIV receive ART is essential for their growth, development, and long-term health. Adherence to the treatment regimen is crucial for its effectiveness.
  6. Reducing Viral Load to Undetectable Levels: ART helps reduce the viral load in the body to undetectable levels, significantly lowering the risk of HIV transmission and improving overall health.
  7. Improving Quality of Life: Effective ART can improve the quality of life for people living with HIV by reducing the incidence of opportunistic infections and other HIV-related complications.
  8. Increasing Life Expectancy: ART has been shown to increase the life expectancy of people living with HIV, allowing them to live longer, healthier lives.
  9. Preventing Sexual Transmission of HIV: By reducing the viral load to undetectable levels, ART can prevent the sexual transmission of HIV, a strategy known as “treatment as prevention” (TasP).
  10. Reducing HIV-Related Stigma and Discrimination: Successful ART can help reduce stigma and discrimination associated with HIV by enabling individuals to lead healthy, productive lives, thereby changing perceptions about the disease.
  11. Managing Co-Infections: ART can help in managing co-infections such as hepatitis B and C, tuberculosis, and other conditions that are common in people living with HIV.

Recommended First Line Regimens in Adults, Adolescents, Pregnant Women and Children

HIV management guidelines are constantly being updated according to evidence and public policy decisions. Always refer to the latest official guidelines.

The 2022 guidelines recommend DOLUTEGRAVIR (DTG) an integrase inhibitor as the anchor ARV in the preferred first and second-line treatment regimens for all HIV infected clients; children, adolescents, men, women (including pregnant women, breastfeeding women, adolescent girls and women of child bearing potential).

Patient Category

Preferred Regimens

Alternative Regimens

Adults and Adolescents

  

Adults (including pregnant women, breastfeeding mothers, and adolescents ≥30Kg)

TDF + 3TC + DTG

– If DTG is contraindicated: TDF + 3TC + EFV400

– If TDF is contraindicated: TAF + FTC + DTG 

– If TDF or TAF is contraindicated: ABC + 3TC + DTG 

– If TDF or TAF and DTG are contraindicated: ABC + 3TC + EFV400 

 – If EFV and DTG are contraindicated: TDF + 3TC + ATV/r or ABC + 3TC + ATV/r

Children

  

Children ≥20Kg – <30Kg

ABC + 3TC + DTG

– If DTG is contraindicated: ABC + 3TC + LPV/r (tablets) 

 – If ABC is contraindicated: TAF + FTC + DTG (for children >6 years and >25Kg) 

 – If ABC and TAF are contraindicated: AZT + 3TC + DTG

Children <20Kg

ABC + 3TC + DTG

– If intolerant or appropriate DTG formulations are not available: ABC + 3TC + LPV/r granules 

– If intolerant to LPV/r: ABC + 3TC + EFV (in children >3 years and >10Kg) 

 – If ABC is contraindicated: AZT + 3TC + DTG or LPV/r

Notes:

  • Contraindications for DTG include known diabetics, patients on anticonvulsants (carbamazepine, phenytoin, phenobarbital) – use the DTG screening tool prior to DTG initiation.
  • Contraindications for TDF and TAF include renal disease and/or GFR <60ml/min, weight <30Kg.
  • TAF can be used in subpopulations with bone density anomalies.
  • Children will be assessed individually for their ability to correctly take the different formulations of LPV.

Notes from Ministry of Health

  1. For clients on an ABC-3TC-DTG based regimen weighing >25 kg, use the fixed-dose combination of Abacavir/Lamivudine/Dolutegravir 600/300/50 mg instead of the separate pills of Abacavir/Lamivudine 600/300 mg plus Dolutegravir 50 mg.
  2. Use Abacavir/Lamivudine 600/300 mg for patients on the following regimens: ABC-3TC-ATV/r, ABC-3TC-LPV/r, and ABC-3TC-DRV/r.
  3. Use the single pill of Dolutegravir 50 mg for patients on AZT-3TC-DTG based regimens.
  4. For eligible patients on ATV/r and LPV/r, optimize to Dolutegravir.
  5. For PrEP, while the guidelines provide options for the use of either TDF/3TC 300/300 mg or TDF/FTC 300/200 mg, use TDF/FTC 300/200 mg for PrEP in terms of programmatic implementation.

RECOMMENDED FIRST-LINE REGIMEN FOR INITIATION OF ART IN CHILDREN UNDER 3 YEARS OF AGE

Recommended first-line regimen: ABC+3TC+LPV/r 

All HIV-infected children under 3 years should be initiated on abacavir + lamivudine + ritonavir-boosted  lopinavir (ABC+3TC+LPV/r). 

NB: Children younger than 36 months have a reduced risk of discontinuing treatment, viral failure or death  if they start on an LPV/r based regimen instead of the NVP-based regimen. Also, surveillance of drug  resistance among vertically infected children younger than 18 months in 

Uganda has revealed high levels of resistance to NNRTIs and LPV/r is known to have a high barrier to  resistance. 

When to use alternative first-line regimens AZT+3TC+LPV/r 

AZT+3TC+ LPV/r should only be used in children who experience a hypersensitivity reaction to abacavir  (ABC), however, this is rare in African populations. 

WHAT REGIMEN TO SWITCH TO (SECOND-LINE AND THIRD-LINE ART) 

Second-line ARVS in adolescents/children above 10 years 

Recommended 2nd line regimen: 2 NRTIs +ATV/r 

HIV-infected adolescents/children above 10 years, initiating 2nd line ART should be initiated on 2 NRTIs and  ritonavir-boosted atazanavir (ATV/r). The choice of NRTI should be determined based on the regimen the  patient was on. 

The recommended sequence is: 

  1. After failing on TDF + 3TC or ABC+3TC based regimen, use AZT+3TC 
  2. After failing on AZT+3TC based regimen, use TDF + 3TC 

When to use alternative 2nd line regimen: 2 NRTIs +LPV/r 

LPV/r is should only be used to initiate adolescents/children who weigh less than 40kg. 

Second-line ARVS in children aged 3 years to less than 10 years 

RECOMMENDED 2nd line REGIMEN: 2 NRTIs +LPV/r 

HIV-infected children aged 3 to less than 10 years initiating 2nd line ART should be initiated on 2 NRTIs and  ritonavir-boosted lopinavir (LPV/r). The recommended formulation is the LPV/r 100/25mg tablet. The choice of NRTI should be determined based on the regimen the patient was on The recommended sequence of the NRTIs is below: 

∙ After failing on ABC+3TC based regimen, use AZT+3TC. 

∙ After failing on AZT+3TC based regimen, used ABC+3TC. 

Second-line ARVS in children under 3 years 

Recommended 2nd line regimen: 2 NRTIs +RAL 

HIV-infected children less than 3 years of age initiating 2nd line ART should be initiated on 2 NRTIs and RAL. The choice of NRTI should be determined based on the regimen the patient was on (Table 55). The recommended sequence of the NRTIs is: 

∙ After failing on ABC+3TC based regimen, use AZT+3TC. 

∙ After failing on AZT+3TC based regimen, used ABC+3TC. 

The rationale for using raltegravir

Raltegravir is the recommended drug of choice for the second line ARVs in children with prior exposure to  protease inhibitors because there is no data on safety and efficacy of dolutegravir in children under six  years, while darunavir is contraindicated in this age group. 

When to use alternative 2nd line regimen: 2 NRTIs + LPV/r 

LPV/r is recommended in children who have used NNRTI (NVP) in their first line regimen.

Monitoring of ARV Treatment

The monitoring of patients on antiretroviral therapy (ART) serves several purposes:

  1. Assess Response to ART and Diagnose Treatment Failure
  2. Ensure Safety of Medicines: Identify Side Effects and Toxicity
  3. Evaluate Adherence to ART

Methods of Monitoring ARV Treatment

1. Clinical Monitoring: Involves medical history and physical examination.

2. Laboratory Monitoring: Includes various laboratory tests.

  • Viral Load Monitoring: Preferred for assessing response to ART and diagnosing treatment failure.
  • CD4 Monitoring: Recommended in specific scenarios.
  • Other Minor Laboratory Tests: Includes tests for specific indications.

Viral Load Monitoring

  • Preferred method for monitoring ART response. A patient who has been on ART for more than 6 months and is responding to ART should have viral suppression (VL <1000 copies/ml) irrespective of the sample type (either DBS or plasma). 
  • Provides an early and more accurate indication of treatment failure and the need to switch from first line to second-line drugs, hence reducing the accumulation of drug resistance mutations and improving  clinical outcomes. 
  • Early and accurate indication of treatment failure.
  • Differentiates between treatment failure and non-adherence.
  • Recommended frequency: Every six months for children and adolescents under 19 years.

CD4 Monitoring

  • Baseline CD4 count is essential for assessing opportunistic infection risk.
  • Recommended for patients with high viral load or advanced clinical disease.

Other Laboratory Tests

Tests

Indication

CrAg

Screen for cryptococcal infection

Complete Blood Count (CBC)

Assess anaemia risk

TB Tests

Suspected tuberculosis

Serum Creatinine

Assess kidney function

ALT, AST

Evaluate liver function

Lipid Profile, Blood Glucose

Assess metabolic health

 

Problems Associated with ARV Treatment

Immune Reconstitution Inflammatory Syndrome (IRIS)

IRIS is a spectrum of clinical signs and symptoms linked to immune recovery triggered by ART. It occurs in 10–30% of individuals starting ART, usually within the first 4–8 weeks.

  • Serious Forms: Most severe cases happen in patients co-infected with TB, Cryptococcus, Kaposi’s sarcoma, and herpes zoster.
  • Risk Factors: Include low CD4+ cell count (<50 cells/mm3) at ART initiation and disseminated opportunistic infections.
  • Management: Usually self-limiting; treat co-infections to reduce symptoms and reassure patients to maintain ART adherence.

Steps to Reduce IRIS Development

  1. Early HIV Diagnosis: Initiate ART before CD4 declines to below 200 cells/mm3.
  2. Optimal Management of Opportunistic Infections: Screen and treat infections before starting ART, especially TB and cryptococcus.

ARV Drug Toxicity

  • Range of Toxicities: ARVs can cause mild to life-threatening side effects.
  • Challenges: Differentiating between ARV toxicity and HIV complications can be complex.
  • Management: Assess patients for side effects at every clinic visit and take appropriate actions based on severity.

Management of ARV Side Effects/Toxicities

Category

Action

Severe, Life-threatening Reactions (e.g., SJS/TEN, severe hepatitis)

– Discontinue all ARVs immediately. 

– Manage the medical event and substitute offending drug when stable.

Severe Reactions (e.g., Hepatitis and Anemia)

– Substitute offending drug without stopping ART.

Moderate Reactions (e.g., Gynaecomastia, Lipodystrophy)

– Substitute with a drug in the same class or different class with a different toxicity profile. 

– Do not discontinue ART; continue if feasible.

Mild Reactions (e.g., Headache, Minor Rash, Nausea)

– Do not discontinue or substitute ART. 

– Provide reassurance and support to mitigate adverse reactions. 

– Counseling about the events.

Management of HIV Positive Pregnant Mother

Key Interventions for eMTCT:

  • Routine HIV Counseling and Testing during ANC (at 1st contact. If negative, repeat HIV test in the third trimester/ labour).
  • Enrolment in HIV care if the mother is positive and not yet on treatment.
  • If the mother is already on ART, perform viral load and continue the current regimen.
  • ART in pregnancy, labour, post-partum, and for life – Option B+.

Recommended ARV for option B+:

One daily Fixed Dose Combination (FDC) pill containing TDF + 3TC + EFV started early in pregnancy irrespective of the CD4 cell count and continued during labor and delivery, and for life.

Alternative regimens for women who may not tolerate the recommended option are:

  • If TDF contraindicated: ABC+3TC+EFV
  • If EFV contraindicated: TDF + 3TC + ATV/r
  • TDF and EFV are safe to use in pregnancy.
  • Those newly diagnosed during labor will begin HAART for life after delivery.

Prophylaxis for Opportunistic Infections

Cotrimoxazole 960 mg 1 tab daily during pregnancy and postpartum –– Mothers on cotrimoxazole DO NOT NEED IPTp with SP for malaria.

Care of HIV Exposed Infant

HIV-exposed infants should receive care at the mother-baby care point together with their mothers until they are 18 months old. A mother-baby care point is a healthcare facility that provides comprehensive services to both HIV-exposed infants and their parents.

 The goals of HIV-exposed infant care services are:

  • To prevent the infant from being HIV infected.
  • Among those who get infected: to diagnose HIV infection early and treat it.
  • Offer child survival interventions to prevent early death from preventable childhood illnesses.

The HIV Exposed Infant and the mother should consistently visit the health facility at least nine times during that period i.e  (i.e., at 6, 10 and 14 weeks, then at 5, 6, 9,  12, 15 and 18 months). 

Nevirapine Prophylaxis

Provide NVP syrup from birth for 6 weeks: Give NVP for 12 weeks for babies at high risk, that is breastfeeding infants who mothers: 

  • Have received ART for 4 weeks or less before delivery; or 
  • Have VL >1000 copies in 4 weeks before delivery; or 
  • Diagnosed with HIV during 3rd trimester or breastfeeding period (Postnatal) 

Do PCR at 6 weeks (or at first encounter after this age) and start cotrimoxazole prophylaxis 

  • If PCR positive, start treatment with ARVs and cotrimoxazole and repeat PCR (for confirmation) 
  • If PCR negative and the baby never breastfed, the child is confirmed HIV negative. Stop cotrimoxazole, continue clinical monitoring and do HIV serology test at 18 months. 
  • If PCR is negative but the baby has breastfed/is breast feeding, start/continue cotrimoxazole prophylaxis and repeat PCR 6 weeks after stopping breastfeeding.
  • Follow up any exposed child and do PCR if they develop any clinical symptom suggestive of HIV at any  time and independently of previously negative results.
  • For negative infants, do serology at 18 months before final discharge.

Dosages of Nevirapine

Age Group

Weight Range

Dosage

Syrup Volume (10 mg/ml)

Child 0-6 weeks

2-2.5 Kg

10 mg once daily

1 ml

Child 0-6 weeks

>2.5 Kg

15 mg once daily

1.5 ml

Child 6 weeks – 12 weeks

Any weight

20 mg once daily

2 ml

Cotrimoxazole Prophylaxis: Provide cotrimoxazole prophylaxis to all HIV exposed infants from 6 weeks of age until they are proven to be uninfected.

  • Child <5 kg: 120 mg once daily  
  • Child 5-14.9 kg: 240 mg once daily 

Isoniazid (INH) Preventive Therapy (IPT): 

  • Give INH for six months to HIV-exposed infants who are exposed to TB.
  • Isoniazid 10 mg/kg + pyridoxine 25 mg daily 
  • For newborn infants, if the mother has TB disease and has been on anti-TB drugs for at least two weeks before delivery, INH prophylaxis is not required. 

Immunization

Immunise HIV exposed children as per national immunisation schedule.

In case of missed BCG at birth, do not give if the child has symptomatic HIV.

Avoid yellow fever vaccine in symptomatic HIV.  

Measles vaccine can be given even in symptomatic HIV.

Counselling on Infant Feeding Choice

  • Explain the risks of HIV transmission by breastfeeding (15%) and other risks of not breastfeeding (malnutrition, diarrhoea).
  • Mixed feeding may also increase the risk of HIV transmission and diarrhoea.
  • Tell her about options for feeding, advantages, and risks.
  • Help her to assess choices, decide on the best option, and then support her choice.

Feeding Options

  • Recommended option: Exclusive breastfeeding, then complementary feeding after the child is 6 months old.
  • Exclusive breastfeeding stopping at 3-6 months old if replacement feeding is possible after this.
  • If replacement feeding is introduced early, the mother must stop breastfeeding.
  • Replacement feeding with home-prepared formula or commercial formula and then family foods (provided this is acceptable, feasible, safe, and sustainable/affordable).

If Mother Chooses Breastfeeding

  • The risk may be reduced by keeping the breasts healthy (mastitis and cracked nipples raise HIV infection risk).
  • Advise exclusive breastfeeding for 3-6 months.

If Mother Chooses Replacement Feeding

  • Counsel and teach her on safe preparation, hygiene, amounts, times to feed the baby, etc.
  • Follow up within a week from birth and at any visit to the health facility.

hiv / aids Treatment in Children Read More »

Treatment of HIV/AIDS in Children (ARV therapy)

Treatment of HIV/AIDS in Children (ARV therapy)

Treatment of HIV/AIDS in Children (ARV therapy)

Treatment of HIV/AIDS begins after confirmation through the following diagnostic procedures.

Diagnostic Measures / Investigations.

Criteria for diagnosis of HIV/AIDS: 

  • ∙ Clinical Stage criteria 
  • ∙ HIV blood test must be positive  

A reactive rapid test result must be confirmed before a diagnosis of infection can be given. Most commonly used to screen blood for donation in order to exclude those in the window period is ELISA  AglAb tests 

The test that Detects the genetic material of HIV itself (rather than antibodies or antigens) are known as  PCR tests PCR (polymerase chain reaction) test is a type of test under Nucleic-acid Amplification testing (NAT). 

NB: These tests should be used in conjunction with the clinical status, history, and risks factors of the  person being tested.  

HIV testing provision steps/protocol 

  • ∙ Pre-test information and counseling 
  • ∙ HIV testing 
  • ∙ Post-test counseling (individual/couple) 
  • ∙ Linkage to other services 

Step 1: Pre-test information and counseling 

Help the client/patient to know the ways HIV is transmitted and basic HIV preventive measures, benefits of  HIV testing, possible test results and services available, consent and confidentiality, individual risk  assessment, and fill the HTS card. Allow clients/patients to ask questions. 

Step 2: HIV testing 

Will be done using blood. For those below 18 months, a DNA PCR test will be done and those above 18 months an antibody test will be done. Refer to the HIV testing  algorithms for the different age groups. 

Step 3: Post-test counseling (individual/couple) 

Assess readiness to receive results. Give results simply. Address concerns, disclosure, partner testing and  risk reduction. Provide information about basic HIV care and ART care; complete the HTS card and HTS register. 

Step 4: Linkage to other services 

Provide information about services; fill the triplicate referral form. When the patient is enrolled, enter the  pre-ART enrolment number into the HTS register and subsequently into the ART register when the patient  is initiated on ART. 

Principles of HIV testing services (HTS) 

HTS delivery shall be non-discriminatory and offered using a human rights approach that observes the 5Cs  (Confidentiality, Consent, Counseling, Correct test result and Connection to appropriate services). These  principles are described below. 

∙ Confidentiality: All providers should ensure privacy during HTS provision. All information discussed  with clients should not be disclosed to another person without the client’s consent. 

∙ Consent: All persons 12 years and above should consent to HTS on their own. In situations where  consent cannot be obtained, the parent or guardian (of a child), next of kin, or legally authorized person should consent. 

∙ Counseling: All persons accessing HTS should be provided with quality counseling before and after  testing as per the approved HTS protocol. 

∙ Correct test result: HTS providers should adhere to the national testing algorithm and must follow  the Standard Operating Procedure for HIV testing to ensure that clients receive correct HIV test results. 

∙ Connect to other services: Providers should link HTS clients to appropriate HIV prevention,  treatment, care and support services.

Places to prick a child 
  • ∙ Infants age 1-4 months, less than 6kg heels work best 
  • ∙ Infants age 5-10 months, less than 10kg toes work best 
  • ∙ Larger infants and older children use the ring or middle finger

HIV testing algorithm for infants and children below 18 months of age 

A virological test (DNA/PCR) is recommended for determining HIV status in infants and children below 18  months of age. The sample for testing should be collected using dried blood spot (DBS) specimens. The 1st DNA/PCR test should be done at six weeks of age or the earliest opportunity thereafter. Interpretation of the results and further testing are guided by the testing algorithm. 

∙ A POSITIVE DNA/PCR test result indicates that the child is HIV-infected. All infants with a positive  DNA/PCR test result should be initiated on ART and another blood sample should be collected on  the day of ART initiation to confirm the positive DNA/PCR HIV test result. 

∙ A NEGATIVE 1st DNA/PCR test result means that child is not infected, but could become infected if  they are still breastfeeding. Infants testing HIV negative on DNA/PCR should be retested using  DNA/PCR six weeks upon cessation of breastfeeding. Infants with  2nd negative DNA/PCR test should have a final rapid antibody test performed at 18 months.

Antibody tests can be used: 

In children <18months of age to:  

  • ∙ Determine HIV- exposure in infants born to mothers of unknown HIV status  
  • ∙ Exclude infection in an infant at 18 months of age if the child has ceased breastfeeding for at least 6  weeks 

∙ In Children > 18 months of age to confirm HIV infection 

  • ∙ HIV DNA PCR testing should be carried out on: 
  • ∙ Every HIV-exposed baby at 6 weeks of life or at first clinic visit if > 6weeks of age
Figure showing HIV testing algorithm for children <18 months of age
Procedure for DBS collection
  1. Warm the area
  2. Position baby with foot down
  3. Sterilize area with alcohol
  4. Allow to air dry
  5. Press lancet into foot, prick skin
  6. Wipe away first drop
  7. Allow large drop to collect
  8. Add 50ul (approx 2 drops) into one circle and fill it
  9. Fill at least 3 circles
  10. Clean foot, do not bandage
  11. Dispose of all contaminated material appropriately

treatment choice to pick dbs

Figure showing serial HIV testing algorithm for persons above 18 months of age

Cautions during HIV testing 

  • ∙ Never use expired HIV test kits. 
  • ∙ Avoid modification of procedures 
  • ∙ Avoid use of clotted blood. 
  • ∙ Avoid use of ‘dirty’ blood (skin flakes, powder, sweat etc.) 
  • ∙ Avoid introducing air bubbles into the devices when adding the sample. 

∙ Do not 

  • ⇒ Add more or less blood 
  • ⇒ Add more or less buffer 
  • ⇒ Exchange buffers 
  • ⇒ Contaminate the buffer 
  • ⇒ Modify the incubation time  

LINKAGE FROM HIV TESTING TO HIV PREVENTION, CARE AND TREATMENT 

Linkage refers to the process of connecting individuals who have tested positive for HIV from one service  point to another.

Linkage to care is successful if the patient/client receives the services they have been  referred to receive. For all clients who test HIV-positive, linkage should occur within seven days (within the  same facility) and 30 days for inter-facility or community-to- facility referrals. It is recommended to use lay  providers (community- and facility-based) as linkage facilitators. The process of linkage within the same  health facility is described below 

Types of linkages 

  • ∙ Internal facility linkage 
  • ∙ Inter facility linkage 
  • ∙ Community facility linkage 
Internal facility linkage  

Inter-facility linkage refers to connecting a newly diagnosed patient at one department to another  department in the same facility for HIV treatment, care, and support services. 

Steps of internal linkage facilitation 

Post-test counseling 

  • ∙ Provide results accurately 
  • ∙ Provide information about care available at facility and elsewhere in catchment area ∙ Describe the next care and treatment steps 
  • ∙ Discuss the benefits of early treatment initiation and cons of delayed treatment ∙ Identify and address any barriers to linkage 
  • ∙ Involve the parent and child in the decision-making process regarding care and treatment ∙ Fill in client card and include referral notes 
  • ∙ Fill in the triplicate referral form 
  • ∙ Introduce and hand the patient to a linkage facilitator 
  • ∙ If same day linkage is not possible, book an appointment for the client at the clinic and follow-up to  ensure the patient attends 

Patient is escorted to the HIV clinic 

  • ∙ Linkage Facilitator escorts client to ART clinic with the linkage forms 
  • ∙ Hand over client to responsible staff at that clinic 

Enrolling at HIV clinic 

  • ∙ Register the patient in the pre-ART register 
  • ∙ Open an HIV/ART card/ file for the patient 
  • ∙ Offer ART preparatory counseling 
  • ∙ Conduct baseline investigations 
  • ∙ If the patient is ready to start ART, initiate ART and continue with counseling support (disclosure,  psychosocial) 
  • ∙ Coordinate integrated care if require (e.g. TB/HIV treatment, 
  • ∙ PMTCT) 
  • ∙ Discuss and make an appropriate appointment with the patient 
Inter facility linkage 

Inter-facility linkage refers to connecting a newly diagnosed patient at one facility to another facility for HIV  treatment, care, and support services.

The referring facility should track (follow up) all HIV-positive patients  referred to other facilities and ensure they are enrolled in care and on ART within 30 days, using the follow up/tracking schedule. 

Community-facility-community linkages 

Community-facility linkage refers to connecting a client who tests HIV-positive in the community to a health  facility for HIV treatment, care, and support services. 

HTS programs should establish functional community  health systems with linkage systems including Peer Leaders, Expert Clients, VHTs and CHEWs. These should  be involved in the mobilization for the targeted outreaches and follow up to link all who testing positive.  Linkage from community to facility should be done within 30 days after diagnosis.  

10 point care package for comprehensive Pediatrics AIDS care 

1∙ Confirm HIV status as early as possible 

2∙ Monitor the child’s growth and development 

3∙ Ensure Immunizations are started & completed as per schedule 

4∙ Provide prophylaxis for OI 

5∙ Actively look for and treat infections early 

6∙ Counsel mother & family on: 

  • ∙ Optimal infant feeding 
  • ∙ Good personal & food hygiene 
  • ∙ Follow up recommendations for the child 

7∙ Conduct disease staging for the infected child 

8∙ Offer ARV treatment for the infected child, if needed 

9∙ Provide psychosocial support for the infected child and mother 

10∙ Refer the infected child to higher levels of specialized care if necessary  

Treatment of HIV/AIDS in Children (ARV therapy)

click here to continue

Treatment of HIV/AIDS in Children (ARV therapy) Read More »

Clinical HIV & AIDS in Children

Clinical Manifestation of HIV / AIDS in Children

Clinical Manifestation of HIV / AIDS in Children

On history taking 

 

  •  Unusually frequent and severe occurrences of common childhood bacterial infections, such as otitis  media, sinusitis, and pneumonia 
  •  Recurrent fungal infections, such as candidiasis (thrush), that do not respond to standard antifungal  agents: Suggests lymphocytic dysfunction 
  •  Recurrent or unusually severe viral infections, such as recurrent or disseminated herpes simplex or  zoster infection or cytomegalovirus (CMV) retinitis; seen with moderate to severe cellular immune  deficiency 
  •  Growth failure 
  •  Failure to thrive 
  •  Wasting 
  •  Failure to attain typical milestones: Suggests a developmental delay; such delays, particularly  impairment in the development of expressive language, may indicate HIV encephalopathy ∙ Behavioral abnormalities (in older children), such as loss of concentration and memory, may also  indicate HIV encephalopathy 

During Physical examination inclusive of investigations 

 

  • Candidiasis: Most common oral and mucocutaneous presentation of HIV infection ∙ Thrush in the oral cavity and posterior pharynx: Observed in approximately 30% of HIV-infected  children
  •  Linear gingival erythema and median rhomboid glossitis
  •   Parotid enlargement and recurrent aphthous ulcers
  •  Hepatic infection with herpes simplex virus (HSV): May manifest as herpes labialis,  gingivostomatitis, esophagitis, or chronic erosive, vesicular, and vegetating skin lesions; the involved  areas of the lips, mouth, tongue, and esophagus are ulcerated
  •  HIV dermatitis: An erythematous, papular rash; observed in about 25% of children with HIV  infection
  •  Dermatophytosis: Manifesting as an aggressive tinea capitis, corporis, versicolor, or onychomycosis ∙ Pneumocystis jiroveci (formerly P carinii) pneumonia (PCP): Most commonly manifests as cough,  dyspnea, tachypnea, and fever
  •  Lipodystrophy: Presentations include peripheral lipoatrophy, truncal lip hypertrophy, and  combined versions of these presentations; a more severe presentation occurs at puberty ∙ Digital clubbing: As a result of chronic lung disease
  •  Pitting or non-pitting edema in the extremities
  •  Generalized cervical, axillary, or inguinal lymphadenopathy

Signs/conditions very specific to HIV infection

  • Pneumocystis pneumonia
  • Esophageal candidiasis
  • Extrapulmonary cryptococcosis
  • Invasive salmonella infection
  • Lymphoid interstitial pneumonitis
  • Herpes zoster (shingles) with multi-dermatomal involvement
  • Kaposi’s sarcoma
  • Lymphoma
  • Progressive multifocal encephalopathy

 Signs/conditions common in HIV-infected children and uncommon in uninfected children

 

  • Severe bacterial infections, particularly if recurrent
  • Persistent or recurrent oral thrush
  • Bilateral painless parotoid enlargement
  • Generalized persistent non-inguinal Lymphadenopathy
  • Hepatosplenomegally (in non-malaria endemic areas)
  • Persistent and recurrent fever
  • Neurologic dysfunction
  • Herpes zoster, single dermatome
  • Persistent generalized dermatitis (unresponsive to treatment)

 Conditions common in HIV-infected children but also common in ill uninfected children

  • Chronic recurrent otitis with ear discharge
  • Persistent or recurrent diarrhoea
  • Severe pneumonia
  • Tuberculosis
  • Bronchiectasis
  • Failure to thrive

Opportunistic Infections in Children

Common clinical conditions associated with HIV

  • Babies are born with an immature and immunologically naïve immune system, predisposing them to an increased frequency of bacterial infections. The immunosuppressive effect of HIV are additive to those of immature immune system and place HIV-infected infants at high risk of invasive bacterial infections. Common childhood infections and conditions are more frequent in HIV-infected children and have a higher case fatality compared to uninfected children. These infections include:
  • Diarrhea
  • Acute suppurative otitis media
  • Sinusitis
  • Failure to thrive
  • Immunization and cotrimoxazole prophylaxis significantly decreases the frequency of invasive bacterial infections in HIV-infected children.

 Common Opportunistic Infections

  • Cytomegalovirus: presents with encephalitis with retinitis or neuritis
  • Cryptococcus: presents with fever, headache, seizures, change in mental status; focal neurological signs are uncommon
  • Toxoplasmosis: most common manifestations are encephalitis, mental changes, fever, headache, and mental confusion
  • Herpes simplex virus: is associated with fever, altered state of consciousness, personality changes, convulsions
  • Kaposi’s sarcoma: this presents as early as the first month of life. It is associated with human herpes virus and usually presents as generalized Lymphadenopathy, black/purple mucocutaneous lesions (skin, eye, mouth)
  • Bacterial pneumonia: It is the leading cause of hospital admissions and death in HIV infected children. Streptococcus pneumoniae is the most common pathogen isolated. Other organisms include: H. influenzae, staphylococcus aureus, Klebsiella.
  • Pneumocystis pneumonia (PCP): PCV is caused by a fungus called Pneumocystis jiroveci(formally known as pneumocystis carnii). It is a major cause of severe pneumonia and death in HIV-infected infants.
  • Tuberculosis: Tuberculosis and HIV-co-infection; The HIV pandemic has led to the resurgence of tuberculosis in both adults and children. Children are at increased risk of developing primary progressive tuberculosis because of the associated severe immune suppression resulting from their young age and HIV. There is a high fatality rate for children who are co-infected with tuberculosis and HIV.
  • Lymphoid interstitial pneumonia (LIP): LIP is common in children (occurs in about 40% of children with perinatal HIV) and usually occurs in children more than 2 years of age.
  • Viral pneumonitis: It develops due to a number of viruses, including respiratory syncytial virus, para-influenza virus, influenza virus, adenovirus, varicella, measles and Cytomegalovirus (CMV).

Examples of Opportunistic infections 

Bacterial OIs 

  • ∙ Pneumococcal pneumonia 
  • ∙ Pulmonary tuberculosis 
  • ∙ Salmonellosis 
  • ∙ Extra-pulmonary tuberculosis 

Viral OIs 

  • ∙ Herpes zoster 
  • ∙ Recurrent/disseminated viral herpes simplex 

Parasitic OIs 

  • ∙ Pneumocystis cariini pneumonia 
  • ∙ Toxoplasmosis 

Fungal OIs 

  • ∙ Cryptosporidium 
  • ∙ Oro-pharyngeal candida 
  • ∙ Candida Esophagitis 
  • ∙ Histoplasmosis 
  • ∙ Coccidioidomycosis,  
  • ∙ Cryptococcal meningitis  

Opportunistic cancers 

  • ∙ Invasive cervical cancer (caused by human papilloma virus) 
  • ∙ Kaposi sarcoma (caused by human herpes virus 8 HHV-8)
  • ∙ Non Hodgkin lymphoma  

Causes of opportunistic infections in HIV/AIDS children 

  • ∙ Poor adherence to treatment 
  • ∙ Presence of other diseases e.g. juvenile diabetes mellitus 
  • ∙ Delay in identification of the Infection 
  • ∙ High viral load 
  • ∙ Poor nutrition 
  • ∙ Exposure to opportunistic infectious agents 
  • ∙ Ingestion of substances contaminated with opportunistic infectious agents ∙ Missing out immunization programs  
  • ∙ Poor hygiene of the child 
  • ∙ Poor sanitation 
  • ∙ Poor ventilation 

Prevention of opportunistic infections 

  • ∙ Avoidance of contact with the disease agents 
  • ∙ Proper treatment of other underlying diseases 
  • ∙ Adherence on HIV drug treatment 
  • ∙ Immunization of children against killer diseases 
  • ∙ Ensuring that children eat well cooked food and boiled water 
  • ∙ Early identification and treatment of the opportunistic diseases ∙
  • ∙ Health education of the family and infected child about opportunistic infection 

General management of opportunistic infections 

  • Assessment of the child 

⇒ History taking from the mother/caregiver and the child if he/she is verbal ∙ Physical examination 

⇒ Vital observations 

⇒ Head to toe examinations 

⇒ Investigations e.g. blood microscopy e.t.c 

  •  Provision of treatment

No. 

Type of infections 

Drugs of choice

1. 

Fungal infections 

Anti – fungals

2. 

Bacterial infections 

Anti – bacterials

3. 

Viral infections 

Anti – virals

4. 

Parasitic 

Anti – protozoa

5. 

Cancers 

Cytotoxic drugs

 

  

WHO CLINICAL STAGING OF HIV

Staging HIV infection and disease in children

Staging is a standardized method for assessing disease stage/progression and for making treatment decision. Clinical and laboratory parameters are used to stage HIV disease.

WHO staging for HIV infection and disease in children above 10 years 
Clinical Stage I: 
  1. Asymptomatic 
  2. Persistent generalized lymphadenopathy 
Clinical Stage II: 
  1. Moderate weight loss (less than 10% of presumed or measured body weight) 
  2. Minor muco-cutaneous manifestations (seborrhoeic dermatitis, prurigo, fungal nail infections,  recurrent oral ulcerations, angular stomatitis) 
  3. Herpes zoster within the last five years 
  4. Recurrent upper respiratory tract infections, e.g., bacterial sinusitis, tonsillitis, otitis media and  pharyngitis  
Clinical Stage III: 
  1. Severe weight loss (more than 10% of presumed or measured body weight) 
  2. Unexplained chronic diarrhea for more than one month 
  3. Unexplained prolonged fever, intermittent or constant, for more than one month 4. Oral candidiasis 
  4. Oral hairy leukoplakia 
  5. Pulmonary tuberculosis (current) 
  6. Severe bacterial infections such as pneumonia, pyomyositis, empyema, bacteremia or meningitis 8. Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis.
  7. Unexplained anemia (<8gm/dl), neutropenia (<0.5× 109 per liter), or chronic thrombocytopenia  (<50× 109 per liter) 

And/or Performance Scale 3: Bed-ridden for less than 50% of the day during the last month 

Clinical Stage IV: 
  1. HIV wasting syndrome – weight loss of more than 10%, and either unexplained chronic diarrhea for  more than one month or chronic weakness or unexplained prolonged fever for more than one  month 
  2. Pneumocystis pneumonia (PCP) 
  3. Recurrent severe bacterial pneumonia 
  4. Toxoplasmosis of the brain 
  5. Cryptosporidiosis with diarrhea for more than one month 
  6. Chronic isosporiasis 
  7. Extra-pulmonary cryptococcosis including meningitis 
  8. Cytomegalovirus infection (retinitis or infection of other organs) 
  9. Herpes simplex virus (HSV) infection, mucocutaneous for more than one month, or visceral at any  site 
  10. Progressive multifocal leukoencephalopathy (PML) 
  11. Any disseminated endemic mycosis such as histoplasmosis, coccidioidomycosis 
  12.  Candidiasis of the oesophagus, trachea, bronchi or lungs 
  13. Atypical mycobacteriosis, disseminated 
  14. Recurrent non-typhoid salmonella septicemia 
  15. Extra-pulmonary tuberculosis 
  16. Lymphoma 
  17. Invasive cancer of the cervix 
  18. Kaposi’s sarcoma 
  19. HIV encephalopathy – disabling cognitive and/or motor dysfunction interfering with activities of  daily living, progressing slowly over weeks or months, in the absence of concurrent illness or  condition other than HIV infection that could account for the findings. 
  20. Atypical disseminated leishmaniasis 
  21. Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy And/or Performance Scale 4: Bed-ridden for more than 50% of the day during the last month 
WHO staging for HIV infection and disease in infants and children 
Clinical Stage I: 
  1. Asymptomatic 
  2. Persistent generalized lymphadenopathy 
Clinical Stage II: 
  1. Unexplained persistent hepatosplenomegaly 
  2. Papular pruritic eruptions 
  3. Extensive wart virus infection 
  4. Extensive molluscum contagiosum 
  5. Recurrent oral ulcerations 
  6. Unexplained persistent parotid enlargement 
  7. Linear gingival erythema 
  8. Herpes zoster 
  9. Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis)
  10. Fungal nail infections 
Clinical Stage III: 
  1. Unexplained moderate malnutrition not adequately responding to standard therapy 
  2.  Unexplained persistent diarrhea (14 days or more) 
  3. Unexplained persistent fever (above 37.5 ºC, intermittent or constant, for longer than one month) 
  4.  Persistent oral candidiasis (after first six weeks of life) 
  5. Oral hairy leukoplakia 
  6. Acute necrotizing ulcerative gingivitis/periodontitis 
  7. Lymph node Tuberculosis
  8. Pulmonary Tuberculosis
  9. Severe recurrent bacterial pneumonia 
  10. Symptomatic lymphoid interstitial pneumonitis 
  11. Chronic HIV-associated lung disease including bronchiectasis 
  12. Unexplained anaemia (<8.0 g/dl), neutropenia (<0.5 x 109/L3) or chronic thrombocytopenia (<50 x  109/ L3) 
Clinical Stage IV: 
  1. Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
  2.  Pneumocystis pneumonia (PCP) 
  3. Severe recurrent bacterial infections (e.g. empyema, pyomyositis, bone or joint infection,  meningitis, but excluding pneumonia) 
  4. Chronic herpes simplex infection; (oro labial or cutaneous of more than one month’s duration, or  visceral at any 
  5. site) 
  6. Extra-pulmonary Tuberculosis 
  7. Kaposi’s sarcoma 
  8. Oesophageal candidiasis (or Candida of trachea, bronchi or lungs) 
  9. Toxoplasmosis of the brain (after the neonatal period) 
  10. HIV encephalopathy 
  11. Cytomegalovirus (CMV) infection (retinitis or infection of other organs) with onset at age over one  month 
  12. Extra-pulmonary cryptococcosis (including meningitis) 
  13. Disseminated endemic mycosis (extra-pulmonary histoplasmosis, coccidiomycosis)
  14.  Chronic cryptosporidiosis (with diarrhea ) 
  15. Chronic isosporiasis 
  16. Disseminated non-tuberculous mycobacteria infection 
  17. Cerebral or B-cell non-Hodgkin lymphoma 
  18. Progressive multifocal leukoencephalopathy 
  19. HIV-associated cardiomyopathy or nephropathy
Diagnostic Measures

click here

Clinical Manifestation of HIV / AIDS in Children Read More »

Clinical HIV & AIDS in Children

HIV & AIDS in Children

HIV & AIDS in Children

 HIV (Human Immunodeficiency Virus) is a unique type of virus (i.e. a retrovirus) that invades the T- helper cells (CD4 cells) in the body of the host (defense mechanism of a person).

AIDS (Acquired Immunodeficiency Syndrome) is a disease of the human immune system caused by infection with human immunodeficiency virus. In children it is acquired perinatally or by vertical -maternal-infant transmission.

HIV is the virus that causes AIDS

Introduction to HIV & AIDS in Children.

Considerable progress has been made towards eliminating human immunodeficiency virus (HIV) among children; however, the global burden of pediatric HIV and acquired immune deficiency syndrome (AIDS) remains a challenge for health care workers around the world, particularly in developing countries.

Epidemiology

Each day, some 1500 children under 15 years of age become infected with HIV, an estimated 90% of whom live in sub-Sahara-Africa. In 2005, there were 2.3 million (1.7–3.5 million) children living with HIV worldwide, most of whom acquired the virus in utero, during birth or while being breastfed, ways of contracting HIV that can be prevented.

For many children infected with HIV, the chances of survival are slim. Worldwide, AIDS now accounts for 3% of deaths in children under five years of age—and 6% of those in sub-Saharan Africa, where AIDS has become one of the major killers of young children.

One in seven people dying of HIV-related illness worldwide is a child under 15 years old. This is due largely to the failure to introduce programs for preventing mother-to-child transmission of HIV on the scale needed. Without HIV care, including antiretroviral therapy, the progression of HIV infection in children is particularly aggressive. In 2005, an estimated 380 000 (290 000–500 000) children died of HIV-related causes. It is likely that one half of them did not live past their second birthday.

Mode of Transmission

There are several potential modes of transmission of HIV to children:

  • Mother to child transmission: more than 95% of HIV-infected infants in Africa acquire HIV from their mothers during pregnancy, at the time of delivery, or potentially through breast feeding. Without any intervention, between 30 to 40% of breast-feeding HIV positive women transmit HIV to their newborns.
  • Sexual transmission among adolescents
  • Sexual abuse of children
  • Transfusion of infected blood or blood products
  • Unsterile injection procedures, and scarification

Risk factors for mother to child HIV-transmission

The risk factors associated with maternal to child transmission include the following:

 Maternal factors

  • Women with high viral load are more likely to transmit HIV to their newborns
  • Women with severe immunosuppression (CD4 count below 200) and those with advanced disease.
  • Maternal micronutrient deficiencies increase the risk of MTCT of HIV significantly
  • Prolonged rupture of membranes, chorioamnionitis, and STIs
  • During breastfeeding, cracked nipples and breast abscesses
  • HIV-1 is more readily transmitted from an HIV-infected woman to her infant than is HIV-2.

Infant factors

  • Prematurity
  • Breastfeeding
  • Oral thrush and oral ulcers
  • Invasive fetal monitoring
  • Birth order (first twin) in twin pregnancy

Pathogenesis

  • The human body is made out of millions of different cells. Each body cell often makes new cell parts in order to stay alive and to reproduce.
  • Viruses hide their own material inside the cells of the body, and then, when the body cells try to make new parts, they accidentally make new viruses as well. 
  • HIV mostly enters cells of the immune system.
  • Although HIV infects a variety of cells, its main target is the T4-lymphocyte (CD4): a kind of white blood cell that is responsible for warning the immune system that there are invaders (diseases) in the body.
  • Once HIV binds to a cell structure, it hides its material inside the cell. This turns the cell into a sort of HIV factory.
  • HIV enters the CD4 cell VIRAL GP120- (fusion and entry)
  • Now, HIV enters the centre of the cell. To do this, it needs to make some important changes in the way it looks so that it will not be ‘recognized’ by the cell. HIV has a special substance to make these changes in its structure.- (reverse transcription)
  • HIV is present in the centre of the cell, but in a different shape- (integration to genome).
  • The centre of the cell starts to make new parts of HIV instead of making new parts for the body’s defence. (transcription and translation).
  • Before leaving the cell, the new parts of HIV need to be put together, just like parts of a car need to be put together in the factory before they can leave the factory to be sold. HIV has a special substance that helps to put the different parts together to form a new HIV before it leaves the cell- budding
  • HIV attacks many CD4 cells. The infected CD4 cells will first produce many new copies of the virus, and then die. The new copies of HIV will then attack other CD4 cells, which will also produce new copies of HIV and then die. This goes on and on: more and more CD4 cells are destroyed, more and more new copies of HIV are made, and new CD4 cells get infected.

Steps / Phases in HIV entry

CD4 & chemokine receptors are needed for HIV entry therefore the following are the phases

  1.  Viral Entry: Binding of gp 120, CD4 and chemokine receptors results in changes in gp41 and fusion of the virion and cell surface membrane. Strands of viral RNA are released into the cell cytoplasm
  2.  Reverse Transcription: In nature DNA produces RNA, but retroviruses can convert single stranded RNA into double stranded DNA using an enzyme called reverse transcriptase
  3.  Integration: Viral DNA integrates into the host chromosome DNA to form a provirus
  4.  Transcription: back to RNA. In activated lymphocytes, transcription of viral DNA results in production of multiple copies of viral RNA. HIV RNA has 9 genes which code for the production of structural proteins like the viral envelope and core, in addition to reverse transcriptase, integrase,
    and protease
  5. Translation: RNA to protein
  6.  Viral protease; Viral protease cleaves [cuts] the polypeptide chain into enzyme components like integrase and reverse transcriptase which help produce new virions
  7.  Assembly and budding: Viral RNA and proteins are packaged and released from lymphocyte surface

How HIV attacks the body.

  • The CD4 (white blood cell), is a friend of the body. Problems like cough, diarrhoea try to attack the body, but the CD4 fights them to defend the body, its friend.
  • Now, HIV enters and starts to attack the CD4. The CD4 notices it cannot defend itself against HIV. Soon, CD4 loses its fight against HIV. The body remains without defence.

The body is all alone, without defence, so all kinds of problems, like cough and diarrhoea take advantage and start to attack the body. In the end, the body is so weak that all diseases can attack without difficulty.

Clinical Manifestation of HIV / AIDS in Children

HIV & AIDS in Children Read More »

Resuscitation of a newborn

Resuscitation

Resuscitation of a Newborn

Resuscitation is a mean of restoring life to a baby from the state of asphyxia.

It is a single intervention of birth asphyxia (Devi, Upendra, and Bard, 2017). Resuscitation is helping a baby to breath.

The first 28 days of life is called neonatal period and incontrovertibly, it is the most vulnerable and high risk time in life because of the highest mortality and morbidity that occur in this period. The day of birth is the riskiest time to a baby (Sajjad, 2012; and WHO, 2015).

APAGAR SCORE

APGAR-score-resuscitation

Aims of Management.

  • To initiate and/or restore respiration /breathing
  • To prevent infection
  • To prevent other complications
  • To Prevent hypothermia

Requirements 

  • A pair of surgical gloves 
  • Warm baby’s clothes. 
  • Suction device e.g bulb syringe
  • Ventilation bag and mask (ambu bag)
  • Endotracheal tube to give oxygen direct to the lungs (size 1mm for full term or 0.5mm preterm babies)
  • laryngoscope 
  • Nasal gastric tube
  • 3 Gallipots 
  • 3 Receivers   
  • Mothers chart
  • Tray containing a gallipot of wet swab, syringes. 
  • Pediatric stethoscope
  • Strapping 
  • Naso prongs (oxygen catheters)

Drugs

  • Naloxone hydrochloride 1mg ampoule 400mg/1ml
  • Adrenaline (Epinephrine) 1:1000
  • Normal saline 0.9%
  • Ringers lactate
  • Sodium bicarbonate 4.2%
  • Dextrose 10%
  • Vitamin K
  • Sterile water

Bed side 

  • Resuscitation table
  • Timer (clock watch)
  • Light source
  • Oxygen source 
  • Displayed chats for steps 

Principles of Management.

  • Temperature regulation. Ensure adequate warmth for the baby to prevent hypothermia which leads to decreased metabolic which cause additional stress to the baby.
  • Ensure adequate oxygenation to the baby to prevent hypoxia by administration of oxygen and monitoring oxygen perfusion. An endotracheal tube should be inserted  and oxygen administered
  • Prevention of hypoglycemia by regular monitoring blood glucose and if risk for hypoglycemia is identified administer dextrose as per prescription.

Steps for Resuscitation

TABCs of resuscitation

STEP 1

  • Dry the baby, wipe the baby’s mouth with gauze and remove any wet cloth.

STEP 2

Clear the air way by;

  • Suck blood or mucus from mouth using a bulb syringe or mucus extractor.
  • Position baby’s head in a neutral position with head extended.
  • Place a small towel under the shoulders to maintain the position.

infant resuscitation

STEP 3

Support breathing by;

  • Stand at the baby`s head, apply ambu-bag and a small mask to the baby’s face ensuring that the mask covers the face and mouth to form a seal.
  • Give five inflation breaths (each 2-3seconds duration).
  • Observe response by looking at the chest movements (chest rising) or increase in the heart rate. (if chest does not rise then reapply mask, reposition baby’s head, and suction.)
  • Continue ventilating at a rate of 30-40 breathes for a minute.
  • Circulation/External Cardiac Massage
  • Chest compression should be performed when the heart rate is less than 100b/m and falling inspite adequate ventilation
  • If no heart beats are recorded after one minute, do external compressions.
  • Wrap your palms around the baby`s chest, placing the thumbs / first finger over the lower part of the sternum.
  • Chest is compressed at rate of 100–120 times 1 minute at a ratio of 3 compressions to one ventilation
  • Use the thumb to gently compress the chest, depressing it ½ to ¾ inch each time.
  • If in 20 minutes the breathing is not established. Consider intubation.  
  • When the infant has no spontaneous breathing then continuous positive pressure ventilation (CPPV)  should be started with bag and mask.
  • The rate of chest compressions in one minute should be 90 along with 30 PPVs, (3:1), a total of 120 events.
  • If the heart rate is <60, despite of effective ventilation, chest compression and two intravenous doses of adrenaline (Epinephrine), the sodium bicarbonate 4.2% solution (0.5mmol/ml) can be administered using 2–4ml / kg (1-2mmol/ml) by slow intravenous.
Intubation
Intubation

Adrenaline (Epinephrine)

  • This is indicated if the heart rate is <60, despite 1 min of effective ventilation and chest compression. An initial dose of 0.1-0.3 ml/kg of 1:10,000 solution give i.v. repeated after 3 minutes for a further two doses. 

10% dextrose

  • (Hypoglycemia is not usually a problem) 3mls/kg i.v via the umbilical vein to correct low blood sugar of <2.5mmol/L
  • Volume replacement
  • On rare occasions, bradycardia will not respond to volume expansion and bradycardia that does not respond to chest compressions or drugs is suggestive of hypovolemia–0.9% normal saline 10 ml /kg initially via the umbilical vein. 

Naloxone hydrochloride

  • This is not an emergency drug parse it is a powerful anti-opioid drug used to reverse the effects of maternal narcotic drugs given towards the end of first stage of labour (Preceding 3hours.) 
  • Dose 0.1–0.2 mg per kilogram body weight intramuscular. 

Calcium gluconate

  • A dose of 100mg kg body weight and 150 adrenaline 0.1-0.5mg/kg 1 min given for severe bradycardia or cardiopulmonary arrest
  • Vitamin K–given prophylaxis against bleeding disorder.

Drugs 

  • If there is no heart beat after 1 minute of breathing for the baby:
  • Inject 0.5 mls of 1;10,000 adrenaline solution intravenously or through the umbilical vein. Give 1 to 2 mls per kilogram body weight of 25% dextrose solution intravenously.
  • Continue to monitor response to resuscitation by using APGAR score.
    • If the baby responds to resuscitation  keep the baby warm and transfer to the special unit (NICU).
    • If baby is breathing well, keep reassuring the mother
    • If baby is breathing well, breast feeding should be encouraged. If no response discontinue resuscitation.

Resuscitation Read More »

Hydrocele

Hydrocele

HYDROCELE

A hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord.

A hydrocele is accumulation of serous fluid within the tunica vaginalis that produces swelling in the inguinal region or scrotum.

It often presents as painless swelling in the scrotum. Provided there is no hernia present, hydrocoeles below the age of 1 year usually resolve spontaneously.

 

In infants it is usually as a  result of incomplete closure of the processus vaginalis. It may or may not be associated with inguinal hernia. In older boys and men it may be idiopathic.

 

Anatomy of the Scrotum.

Anatomy of the Scrotum.

Scrotum, is a thin external sac of skin that is divided into two compartments; each compartment contains one of the two testes, the glands that produce sperm, and one of the epididymis, where the sperm is stored.

  • The function of the scrotum is to protect the testes and to keep them at a temperature below the normal body temperature. The scrotum thus protrudes from the body wall. When contracted, it conserves heat; while relaxed it is smooth and elongated, permitting the circulation of air that effects cooling. The relatively cool temperature of the scrotum is thought to be important for the production of viable sperm.
  • A vertical septum of subcutaneous tissue in the center divides it into two parts, each containing one testis.
  • Smooth muscle fibers, called the dartos muscle, in the subcutaneous tissue contract to give the scrotum its wrinkled appearance. When these fibers are relaxed, the scrotum is smooth.
  • The cremaster muscle consists of skeletal muscle fibers and controls the position of the scrotum and testes. When it is cold or a man is sexually aroused, this muscle contracts to pull the testes closer to the body for warmth.
Etiology/Causes of a Hydrocele

Etiology/Causes of a Hydrocele

The causes of hydrocele can be categorized into four main factors:

  • Excessive production of fluid within the sac: This occurs when there is an overproduction of fluid within the sac surrounding the testicle e.g. in acute/chronic epididymo-orchitis.
  • Defective absorption of fluid: This refers to a situation where the normal absorption of fluid within the sac is impaired, leading to the accumulation of fluid e.g. in testicular tumors, Hematocele.
  • Interference with lymphatic drainage of scrotal structures: Certain conditions, such in case of elephantiasis, torsion of testis, can disrupt the normal drainage of lymphatic fluid from the scrotal area, resulting in the development of a hydrocele.
  • Connection with a hernia of the peritoneal cavity: In the congenital variety, a hydrocele may be associated with a hernia of the peritoneal cavity, leading to the presentation of a hydrocele of the cord e.g. in patent tunica vaginalis.
Risk Factors
  • Direct Injury or inflammation of the testes
  • Prematurity
  • Testicular tumors
  • Infections in the testicle or the epididymitis

Pathophysiology

  • During the seventh month of fetal development, the testicles move from the abdomen into the scrotum.
  • When the testicle travels downward, a remnant piece of peritoneum wrapped around the testicle, called the  tunica vaginalis and this allows fluid present in the abdominal cavity to surround the testicle.
  • This sac usually closes before birth, preventing additional fluid from going from the abdomen into the scrotum, and the fluid is gradually absorbed within the first year of life.
  • When the sac remains open tunica vaginalis is patent and connects with the general peritoneal cavity leading to development of a communicating Hydrocele.
  • The communication is usually too small to allow herniation of intra-abdominal contents. Digital pressure on the Hydrocele does not usually empty it, but the Hydrocele fluid may drain into the peritoneal cavity when the child is lying down.
types of hydrocele

Types of hydrocele

Non-communicating Hydrocele

  • Here there is no connection between the abdominal cavity and the sac around the testicle in the scrotum.
  • This type of Hydrocele is often found in newborns and these often resolve or go away over time.
  • It may take up to one year for this to happen, but as long as the swelling is decreasing, it can be safely observed.

Communicating Hydrocele

  • Here the sac does not close and this means that the fluid around the testicle can flow back up into the abdomen.
  • It is noticeable that the Hydrocele looks smaller early in the day and larger in the evening; the pressure changes cause the fluid to flow back into the abdomen.
CLASSIFICATIONS OF HYDROCELES

CLASSIFICATIONS OF HYDROCELES

 Primary hydrocele: A primary hydrocele is characterized by a soft, painless swelling that is usually large in size and makes it difficult to feel the testis. Transillumination can demonstrate the presence of fluid. Although these hydroceles are often asymptomatic, their large size can cause inconvenience and, if left untreated, may lead to atrophy of the testis due to compression or obstruction of blood supply. Early diagnosis during a complete physical examination may reveal small hydroceles in which the testis can be easily palpated within a lax hydrocele. However, in cases where the hydrocele sac is dense, ultrasound imaging is necessary to visualize the testis and reveal any underlying abnormalities. Primary hydroceles are usually painless, similar to testicular tumors.

A common method of diagnosing a primary  hydrocele is through transillumination, where shining a strong light through the enlarged scrotum will pass light in the case of a primary hydrocele, while a tumor will not, except in the case of a malignancy with reactive hydrocele.

Congenital Hydrocele:

Its subdivided into four types.

Congenital Hydrocele:

  • Occurs when the processus vaginalis, a tube-like structure connecting the abdomen to the scrotum, remains open and communicates with the peritoneal cavity.
  • This allows peritoneal fluid to move, but the opening is usually too small to allow intra-abdominal contents to herniate through.
  • When pressure is applied to the hydrocele, it usually does not empty, but the fluid may drain into the peritoneal cavity when the individual is lying down.
  • The swelling cannot be felt above the inguinal ring, resembling a hernia.

Infantile Hydrocele:

  • Occurs when the processus vaginalis becomes closed at the level of the deep inguinal ring, but the portion beyond it remains open, allowing fluid to accumulate.
  • This condition is not exclusive to infants and can also occur in adults.
  • The swelling cannot be felt above the inguinal ring.

Encysted Hydrocele of the Cord:

  • In this type, both the proximal and distal portions of the processus vaginalis become closed off, while the central portion remains open, leading to the accumulation of fluid within it.
  • This results in a smooth oval swelling near the spermatic cord, which can be mistaken for an inguinal hernia.
  • When the testis is gently pulled downwards, the swelling moves downwards and becomes less mobile.

Vaginal Hydrocele (in females):

  • In females, a related condition known as a “hydrocele of the canal of Nuck” can occur.
  • This occurs when the canal of Nuck, the equivalent structure to the processus vaginalis in males, fails to close properly, leading to the development of a hydrocele.
  • This condition may present as a swelling in the groin or labia majora.

Secondary hydrocele: A secondary hydrocele arises from an underlying condition, such as infections (e.g., filariasis, tuberculosis of the epididymis, syphilis), trauma or injury (e.g., post herniorrhaphy hydrocele or malignancy).

  •  Secondary hydroceles are generally smaller, with the exception of those caused by filariasis, which can lead to very large hydroceles. 
  • Testicular infarction, microlithiasis of the testicle, and lithiasis of tunica vaginalis can also contribute to the development of secondary hydroceles.
  • Testicular diseases, including cancer, trauma (e.g., hernia), and orchitis (inflammation of the testis), can result in secondary hydroceles. They may also occur in infants undergoing peritoneal dialysis. It is important to note that a hydrocele is not a cancerous condition, but clinical evaluation is needed if a testicular tumor is suspected, as there are no documented cases associating hydroceles with testicular cancer in the world literature.

Secondary hydroceles are most commonly linked with acute or chronic epididymo-orchitis and are also observed with testicular torsion and certain testicular tumors. Commonly, a secondary hydrocele is soft and moderately sized, and the underlying testis can be felt. The secondary hydrocele usually resolves when the primary condition is treated.

Other predisposing factors for secondary hydroceles include acute/chronic epididymo-orchitis, testicular torsion, testicular tumors, hematocele, filarial hydrocele, post herniorrhaphy, and hydrocele of a herniated sac.

Diagnosis and Investigations

Through Clinical Presentation: A primary hydrocele is described as having the following characteristics/presentations.

Clinical Presentation.
  1. Fluctuating Size: The swollen area may vary in size, being smaller in the morning and larger later in the day. This fluctuation is known as a positive fluctuation test.
  2. Discomfort: Patients may experience discomfort due to the heaviness of the swollen scrotum.
  3. Scrotal Swelling: Hydroceles can present as painless unilateral or bilateral scrotal swelling.
  4. Transillumination: When examined with a focused beam of light, the scrotum transilluminates, displaying a uniform glow without any internal shadows. Transillumination positive.
  5. Impulse on Coughing: In most cases, the impulse on coughing is negative, although it may be positive in congenital hydroceles.
  6. Reducibility: Hydroceles are usually non-reducible, meaning they cannot be easily pushed back into the abdomen. Reducibility absent.
  7. Palpable Fullness: Upon examination, hydroceles present as a soft, non-tender fullness within the scrotum, which can be felt. Testis cannot be palpated separately. (exception – funicular hydrocele, encysted hydrocele)
Investigations and Diagnostic Findings
  • Laboratory studies. laboratory studies may be indicated to exclude other surgical or medical conditions that may be in the differential diagnosis.
  • Ultrasonography. Ultrasonography provides excellent detail of the testicular parenchyma; spermatoceles can be clearly distinguished from hydroceles on sonograms, a testicular tumor can also be identified.
  • Duplex ultrasonography. Duplex studies  provide  information regarding testicular blood flow when a hydrocele may be associated with chronic torsion.
  • Plain abdominal radiography. Plain radiography may be useful for distinguishing an acute hydrocele from a hernia.

Management and Treatment of Hydroceles

  1. Observation for Infants: Most hydroceles appearing in the first year of life often resolve without treatment and therefore require only observation.
  2. Surgical Removal: Hydroceles that persist after the first year or occur later in life may require surgical removal through a procedure known as hydrocelectomy, as they have little tendency towards regression. The method of choice for surgical removal is an open operation under general or spinal anesthesia for adults, and general anesthesia for children. Local infiltration anesthesia is not recommended due to its inability to relieve abdominal pain caused by traction on the spermatic cord.
  3. Aspiration Precautions: If a testicular tumor is suspected, a hydrocele should not be aspirated, as this can lead to the dissemination of malignant cells. Ultrasonography should be used to clinically exclude the presence of a tumor. If no tumor is present, the hydrocele fluid can be aspirated with a needle and syringe.
  4. Post-operative Care: After surgery, the scrotum should be supported, and ice bags can be used to alleviate pain. Regular changes of surgical dressings, observation of drainage, and monitoring for complications are necessary to prevent re-operation.
  5. Complications Management: In cases with the presence of complications, open operation with or without orchiectomy may be preferred, depending on the severity of the complications.
  6. Jaboulay’s Procedure: After aspiration of a primary hydrocele, fluid reaccumulates over the following months, necessitating periodic aspiration or operation. For younger patients, operation is usually preferred, while the elderly or unfit can have aspirations repeated whenever the hydrocele becomes uncomfortably large. Sclerotherapy is an alternative method, involving the injection of 6% aqueous phenol with 1% lidocaine for analgesia, which can inhibit reaccumulation. Multiple treatments may be necessary.
  7. Aspiration and Sclerosing Agents: Aspiration of the hydrocele contents and injection with sclerosing agents, sometimes with tetracyclines, can be effective but is often very painful. However, these alternative treatments are generally regarded as unsatisfactory due to the high incidence of recurrences and the frequent necessity for repetition of the procedure.

Surgical Management.

The surgical management of hydroceles can be approached in several ways, including inguinal, scrotal, and sclerotherapy methods.

  • Inguinal Approach: This method involves ligation of the processus vaginalis high within the internal inguinal ring and is mostly the preferred procedure for pediatric hydroceles. In cases where a testicular tumor is detected on testicular ultrasonography, an inguinal approach with high control/ligation of the cord structures is necessary.
  • Scrotal Approach: The scrotal approach includes excision or eversion and suturing of the tunica vaginalis and is recommended for chronic noncommunicating hydroceles. However, this approach should be avoided if there is any suspicion of underlying malignancy.
  • Sclerotherapy: An additional adjunctive, if not definitive procedure is scrotal aspiration and sclerotherapy of the scrotum using tetracycline or doxycycline solutions. It’s important to note that recurrence after sclerotherapy is common, as is significant pain and epididymal obstruction, making this treatment a last resort in poor surgical candidates with symptomatic hydroceles and in men in whom fertility is no longer an issue.
  • Hydrocelectomy: This surgical procedure aims to excise the hydrocele sac or reconfigure the remnant of the tunica vaginalis to allow lymphatic drainage via scrotal lymphatics. This method may be considered in cases where other surgical approaches have not been successful.
Nursing Interventions

The nursing interventions appropriate for the child are:

  1. Health education. Provide preoperative education, including a visit with OR personnel before surgery when possible. Discuss anticipated things that may concern the patient, such as masks, lights, IVs, BP cuff, electrodes, the feel of oxygen cannula or mask on nose or face, autoclave and suction noises, and the possibility of the child crying. Additionally, involve the child in age-appropriate discussions about the surgical procedure and encourage the expression of feelings and concerns.
  2. Pre, Intra and Post operative care:

Pre-Operative Care:

  • Patient Assessment: Conduct a thorough assessment of the patient’s medical history, current health status, and any allergies. This includes obtaining baseline vital signs, laboratory tests, and diagnostic imaging as required.
  • Education: Provide the patient with information about the upcoming surgery, including preoperative instructions, potential risks, and what to expect during the recovery period.
  • Medication Management: Review the patient’s current medications and ensure appropriate management, including any required adjustments or discontinuations prior to surgery.
  • Psychological Support: Offer emotional support and address any anxiety or concerns the patient may have about the surgery.
  • Preparing the Surgical Site: Ensure the surgical site is properly prepared and sterile, including hair removal if necessary.

Intra-Operative Care:

  • Patient Positioning: Assist with positioning the patient on the operating table to ensure optimal access for the surgical team.
  • Monitoring: Continuously monitor the patient’s vital signs, including heart rate, blood pressure, oxygen saturation, and ECG, and respond to any changes promptly.
  • Sterile Technique: Assist the surgical team in maintaining a sterile environment and provide the necessary equipment and supplies as required.
  • Anesthesia Management: Collaborate with the anesthesiologist to ensure the patient’s comfort and safety during the administration of anesthesia.
  • Communication: Facilitate effective communication between the surgical team and other healthcare professionals, and provide support and reassurance to the patient throughout the procedure.

Post-Operative Care:

  • Recovery Monitoring: Monitor the patient’s vital signs, pain levels, and consciousness as they recover from anesthesia.
  • Pain Management: Administer prescribed pain medications and assess the patient’s pain levels regularly, providing comfort measures as needed.
  • Wound Care: Monitor the surgical site for any signs of infection or complications, and provide appropriate wound care as directed by the surgical team.
  • Mobilization: Encourage early mobilization and assist the patient with repositioning to prevent complications such as deep vein thrombosis and pressure ulcers.
  • Patient Education: Provide the patient and their family with postoperative instructions, including information on medication management, activity restrictions, and signs of potential complications.
  • Emotional Support: Offer emotional support to the patient and their family, addressing any concerns and providing reassurance during the recovery process.

3. Reduce risk for infection. Verify that preoperative skin, scrotal, and bowel cleansing procedures have been completed as needed depending on the specific surgical procedure. Apply a sterile dressing to prevent environmental contamination of the fresh wound. Administer antibiotics as indicated and ensure proper hand hygiene and aseptic techniques during care.

4. Monitor fluid volume. Measure and record intake and output, including tubes and drains. Monitor vital signs, noting changes in blood pressure, heart rate and rhythm, and respirations. Gradually resume oral intake as indicated, ensuring the child remains well-hydrated.

5. Relief from pain. Regularly evaluate the child’s pain, noting its characteristics, location, and intensity on a 0–10 scale. Assess and address any anxiety or fear related to the procedure. Identify and address any causes of discomfort other than the operative procedure. Provide additional comfort measures, such as backrubs, heat or cold applications, and age-appropriate distraction techniques. Administer pain medication as prescribed and assess the effectiveness of pain relief measures. Encourage the child to communicate their pain and comfort needs.

6. Promote mobility. Encourage early mobilization and ambulation as tolerated postoperatively to prevent complications such as deep vein thrombosis and promote circulation and respiratory function.

7. Monitor for complications. Assess for signs of postoperative complications such as infection, bleeding, or adverse reactions to anesthesia or medications. Monitor surgical incision sites for signs of inflammation, drainage, or other abnormalities.

8. Encourage adequate nutrition. Provide the child with a balanced and nutritious diet to support the healing process. Offer small, frequent meals if the child’s appetite is reduced and encourage fluid intake to prevent dehydration.

9. Collaborate with the interdisciplinary team. Work closely with the surgical team, child life specialists, and other healthcare professionals to ensure comprehensive care for the child. Communicate any concerns or changes in the child’s condition promptly.

10. Provide age-appropriate activities. Offer age-appropriate activities and play opportunities to promote the child’s emotional well-being and assist with their recovery. Arrange for appropriate entertainment and distraction to alleviate anxiety and boredom during hospitalization.

Complications of Hydroceles

Complications of Hydroceles

  1. Hematocele Formation: Hematocele, a collection of blood within the sac, can occur due to spontaneous bleeding into the sac or as a result of trauma. If not drained, it may lead to the formation of a clotted hematocele.
  2. Calcification of the Sac: The sac may calcify, leading to the formation of a clotted hydrocele, often resulting from a slow, painless ooze of blood into the tunica vaginalis. This can make it difficult to differentiate from a testicular tumor.
  3. Postherniorrhaphy Hydrocele: A relatively rare complication of inguinal hernia repair, possibly due to disruption of the lymphatics draining the scrotal contents.
  4. Infection and Pyocele: Infection may lead to the formation of pyocele, a collection of pus within the sac.
  5. Testicular Atrophy: Long-standing cases of hydrocele may lead to atrophy of the testis.
  6. Rupture: Rupture of the sac may occur due to trauma or spontaneously. In some cases, absorption of the fluid may lead to a cure.
  7. Herniation: In long-standing cases, the hydrocele sac may herniate through the dartos muscle.

Test Questions

1. Which of the following applies to the defect emerging from residual peritoneal fluid confined within the lower segment of the processus vaginalis?

A. Inguinal hernia
B. Incarcerated hernia
C. Communicating hydrocele
D. Noncommunicating hydrocele

1. Answer: D. Noncommunicating hydrocele

  • Option D: With a noncommunicating hydrocele, most commonly seen at birth, residual peritoneal fluid is trapped within lower segment of the processus vaginalis (the tunica vaginalis). There is no communication with the peritoneal cavity and the fluid usually is absorbed during the first months after birth.
  • Option A: An inguinal hernia arises from the incomplete closure of the processus vaginalis leading to the descent of an intestinal portion.
  • Option B: Incarceration occurs when the hernia becomes tightly caught in the hernia sac.
  • Option C: A communicating hydrocele usually is associated with an inguinal hernia because the processus vaginalis remains open from the scrotum to the abdominal cavity.

2. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?

A. Massaging the groin area twice a day until the fluid is gone.
B. Referral to a surgeon for repair.
C. No treatment is necessary; the fluid is reabsorbing normally.
D. Keeping the infant in a flat, supine position until the fluid is gone.

 

2. Answer: C. No treatment is necessary; the fluid is reabsorbing normally.

  • Option C: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis; illumination of the scrotum with a pocket light demonstrates the clear fluid; in most cases, the fluid reabsorbs within the first few months of life and no treatment is necessary.
  • Options A and D: Massaging the area or placing the infant in a supine position would have no effect.
  • Option B: Surgery is not indicated.

3. Nurse Jeremy is evaluating a client’s fluid intake and output record. Fluid intake and urine output should relate in which way?

A. Fluid intake should be double the urine output.
B. Fluid intake should be approximately equal to the urine output.
C. Fluid intake should be half the urine output.
D. Fluid intake should be inversely proportional to the urine output.

 

3. Answer: B. Fluid intake should be approximately equal to the urine output.

  • Option B: Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality.
  • Option A: Fluid intake that is double the urine output indicates fluid retention
  • Option C: Fluid intake that is half the urine output indicates dehydration.
  • Option D: Normally, fluid intake isn’t inversely proportional to the urine output.

4. When explaining to the parents of a child with hydrocele about the possible cause of the condition, the nurse bases this explanation on the interpretation that hydrocele is most likely the result of which of the following:

A. Blockage in the inguinal canal.
B. Failure of the upper part of the processus vaginalis to atrophy.
C. A patent processus vaginalis that results in the collection of fluid along the spermatic cord.
D. An obliterated processus vaginalis that allows fluid to accumulate in the scrotal sac.

 

4. Answer:  C. A patent processus vaginalis that results in the collection of fluid along the spermatic cord.

  • Option C: A hydrocele is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord.
  • Options A, B, C: These processes does not occur in hydrocele.

5. Shortly after an infant is returned to his room following hydrocele repair, the infant’s mother tells the nurse that the child’s scrotum looks swollen and bruised. Which of the following responses by type nurse is the most appropriate?

A. “Let me see if the doctor has ordered aspirin for him. If he did, I’ll get it right away.”
B. “Why don’t you wait in his room? Then you can ask me any questions when I get there.”
C. “What you are describing is unusual after this type of surgery. I’ll let the doctor know.”
D. “This is normal after this type of surgery. Let’s look at it together just to be sure.”

 

5. Answer: D. “This is normal after this type of surgery. Let’s look at it together just to be sure.”

  • Option D: Swelling and bruising of the surgical site is a usual occurrence right after the surgery. Elevation of the scrotal area and anti-inflammatory agents can be administered as ordered by the physician.
  • Option A: Aspirin is not the drug of choice given for pediatric patients.
  • Option B: Answering questions could relieve the anxiety felt by the family and the patient.
  • Option C: Swelling and bruising are normal occurrences for the patient after the surgery.

Hydrocele Read More »

Acute Glomerulonephritis

Acute Glomerulonephritis

Acute Glomerulonephritis

Acute glomerulonephritis refers to a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of glomerular tissue that can result in damage to the basement membrane, mesangium, or capillary endothelium.

OR

Acute glomerulonephritis (GN) is an inflammatory process involving the glomerulus of the kidney.

It is inflammation of the glomerulus.

Acute glomerulonephritis is the most serious and potentially devastating form of the various renal syndromes. Acute glomerulonephritis progresses to chronic glomerulonephritis in about 30% of adults. 

This condition usually results in a clinical syndrome consisting of:

  •  Hematuria
  •  Proteinuria
  •  Hypertension
  • Renal insufficiency
  • Azotemia. (elevated urea and creatinine compounds)

Incidence

Glomerulonephritis can occur at any age; it has a higher incidence in males than in females.

 It is common in the young ones and the peak age is 7-10 years. Adolescents and young adults are also commonly affected by the acute glomerulonephritis.

CLICK HERE for the Anatomy of the Urinary System

Risk Factors

  • Throat infection: Winter or early spring
  • Pyoderma : Risk of infection after pyoderma: 25%
  • Peak incidence in pre‐school children.
  • Clinically apparent GN
    occurs in < 2% of children infected with strep infection

Etiology

Acute GN can be due to a primary renal disease or to a systemic disease:

  • Its onset is usually secondary to  infection of the upper respiratory tract, most commonly caused by group A beta – hemolytic streptococci (post streptococcal infection)
  • Malaria parasites (falciparum malariae)

It may be a result of the primary infection elsewhere in the body and be caused by primary staphylococcus, pneumococcus or a virus

 It is thought to be due to an abnormal immune reaction to infection

Non streptococcal postinfectious GN may also result from infection by other bacteria, viruses, parasites, or fungi. Bacteria besides group A streptococci that can cause acute GN include the following:

  • Staphylococci, Diplococci, Other streptococci, Mycobacteria, Salmonella Tryphosa, Brucella sues, Treponema pallidum, Corynebacterium bovis Actinobacilli e.t.c.
  • Viruses e.g. Cytomegalovirus (CMV), coxsackievirus, Epstein-Barr virus (EBV), hepatitis B virus (HBV)

 Goodpasture syndrome, a group of diseases affecting the lungs and kidneys.

Rare diseases that inflame blood vessels like granulomatosis with polyangiitis (formerly Wegener’s disease) Granulomatosis with polyangiitis is an uncommon disorder that causes inflammation of the blood vessels in your nose, sinuses, throat, lungs and kidneys. Formerly called Wegener’s granulomatosis, this condition is one of a group of blood vessel disorders called vasculitis. It slows blood flow to some of your organs

Pathophysiology

  • Following an occurrence of a streptococcal infection which can either be sore throat or a skin infection, there follows an immune response which is mounted against the streptococcal infection (a specific antibody is produced against streptococci)
  • These antibodies destroy the glomerulus because it resembles the antigens of the streptococci.
  • This usually occurs 2-3 weeks after the streptococcal infection has taken place. This is characterized by diffused inflammation of the renal cortex (glomeruli) of both kidneys.
  • The destruction of the glomerulus permits the red blood cells which is passed in urine as haematuria and pus-cells, RBC casts.
  • The destruction further causes reduction in the filtration process
  • Reduced ultra filtration stimulates angiotensin I release which in turn is changed to angiotensin II which causes constriction of arterioles, hence increasing total arteriolar resistance, leading to elevation of blood pressure.
  • Angiotensin ii release further causes production of aldosterone which causes reabsorption of sodium and water, leading to increase in cardiac output and elevation of blood pressure.
acute glomerulonephritis

Clinical Features of Acute Glomerulonephritis.

Most often, the patient is a boy, aged 2-14 years, who suddenly develops puffiness of the eyelids and facial edema in the setting of a poststreptococcal infection. The urine is dark and scanty, and the blood pressure may be elevated.

  1. Onset of symptoms is usually abrupt.
  2. Nonspecific symptoms include weakness, fever, abdominal pain, and malaise.
  3. Usually sudden onset with history of sore throat or skin infection, elevated temperature, headache and vomiting.
  4. Body swellings of the face and lower extremities which tends to become worse in the mornings on waking up with elevation of hypostatic pressure.
  5. Costovertebral angle tenderness and flank pain likened to renal colic.
  6. Hematuria is a universal finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients.
  7. Oliguria
  8. Edema (peripheral or periorbital) is reported in approximately 85% of pediatric patients; edema may be mild (involving only the face)
  9. Hypertension often develops. In severe cases, it may be extremely high with severe headache, palpitations, easy fatigability, visual disturbances, vomiting and convulsions (hypertensive encephalopathy).
  10. Features of cardiac failure
  11. As the disease progresses, the patient experiences shortness of breath, lethargy and anorexia.
  12. Headache may occur secondary to hypertension; confusion secondary to malignant hypertension may be seen in as many as 5% of patients.
  13. Shortness of breath or dyspnea on exertion secondary to heart failure or pulmonary edema; usually uncommon, particularly in children.
  14. Possible flank pain secondary to stretching of the renal capsule.
  15. Urinary changes:
  • Decreased urinary output-oliguria
  • Microscopic haematuria making the urine to appear dark, concentrated and smoky
  • Albumin is always present in large amounts
  • Casts may be present and can be seen

Clinical Features Summary

Abrupt onset
• Age 4‐ 12 years, M>F
• Latent period : Throat infection : 1‐2 weeks
• Skin infection : 3‐6 weeks
HEMATURIA
• Smoky brown or Cola colored
• Glomerular: dysmorphic RBC, casts in freshly spun urine
PROTEINURIA
• Mild to moderate but nephrotic range is rare
OLIGURIA
• Transient – 50%, Anuria rare
EDEMA : 85%
– Mild : periorbital or pedal
– Severe : hypertension, pleural effusion or ascites
– Adolescents : more likely face and legs
HYPERTENSION: in 80%
– Headache, Somnolence
– Changes in mental status
– Anorexia, Nausea , Convulsions
• HYPERTENSIVE EMERGENCY: 10%
‐ BP > 30% increased for age and sex
‐ Evidence of encephalopathy
‐ Heart failure or pulmonary edema
• AZOTEMIA : varying degrees
• CIRCULATORY CONGESTION : 20%
‐ Dyspnea, Orthopnea
‐ Cough, Tachycardia, Gallop rhythm
‐  CCF, Pulmonary edema

Diagnosis

In the setting of a postinfectious acute nephritis, a latent period of up to 3 weeks occurs before onset of symptoms. However, the latent period may vary; typically 1-2 weeks for post pharyngitis cases and 2-4 weeks for cases of post dermal infection (i.e, pyoderma).

  • Onset of nephritis within 1-4 days of streptococcal infection suggests preexisting renal disease.
  • Urine: protein, microscopy for pus cells, red blood cells, red blood cell casts, proteins positive, glucose positive.
  • Blood: urea and Creatinine levels, and electrolytes
  • Ultrasound scan of the kidneys
  • Blood pressure
  • Throat and skin swab where indicated for C&S
  • Blood cultures: Indicated in patients with fever, immunosuppression, intravenous drug use history, indwelling shunts, or catheters.
  • Antinuclear antibody (systemic lupus erythematosus)
  • Renal biopsy is required for definitive diagnosis, particularly in primary renal diseases. Renal Biopsy is indicated only in;
    • Hepatitis B infection
    • Nephritis
    • Infective endocarditis
    • Associated with HSP(Henoch-Schonlein purpura (also known as IgA vasculitis) is a disorder that causes the small blood vessels in your skin, joints, intestines and kidneys to become inflamed and bleed)

Management

  1. Admission is recommended for patients with anuria, nephrotic syndrome, massive proteinuria, significant hypertension, or pulmonary symptoms.
  2. Salts (sodium restriction)
  • Should not be used in cooking or added to food (salt free diet). 
  • If oedema is severe, no salt diet should be given.
  • Avoid or use with caution any drugs excreted in by the kidney
  • The disease is usually self-limiting and the majority of patients may recover spontaneously.

       3. Rest:

  •      The patient should be nursed in a bed rest in a warm well-ventilated room.  Ambulation is encouraged in an attempt to reduce oedema and DVT.

          4. Dietary regulations (Diet regimen)

  • Proteins in the diet, about 20 – 40g of protein daily will be adequate.
  • Adequate calorie from carbohydrates and fats ensures minimum protein breakdown.

        5. Fluids and electrolytes

  • Assess the patient frequently for signs and symptoms of fluid overload.
  • Daily weighing of the patient.
  • Fluids must be encouraged2-3lires in24hours to increase urinary output.
  • An intake and output chart must be kept and the urine examined daily for albumin, RBCs and casts.
  • Correction of electrolyte abnormalities (ie, hypocalcemia, hyperkalemia) and acidosis, if present
  • Restrict fluids in patients with significant edema.
  • Loop diuretics are indicated for patients with nephrotic syndrome (4% of patients) or massive proteinuria.
  • Eradicate streptococcal causes by oral antibiotic therapy; Penicillin is indicated in nonallergic patients e.g. Phenoxy methyl penicillin 500mg qid. Child: 10 – 20mg per dose Or Amoxicillin 500mg tds. Child: 15mg/kg per dose. If allergic to penicillin give erythromycin every 6hours. Child: 15mg/kg per dose

        6.  Prophylactic treatment: penicillin every month or erythromycin  to minimize reoccurrence.

     7. Agents useful in treating hypertension include calcium channel blockers e.g. nifedipine, amlodipine and nitroprusside sodium.

    8. Dialysis incase of;
– Fluid overload
– Severe azotemia
– Electrolyte abnormalities 

   9. Pulmonary edema
– Aggressive diuresis , Oxygen, Morphine, Ventilation

    10. Hyperkalemia
– Oral/iv Restriction, Potassium binding resins
– Nebulized Salbutamol, Glucose insulin
– Calcium infusion

Prognosis

Is always poor with acute glomerulonephritis than with nephritic syndrome

Nursing Diagnosis

  1. Ineffective breathing pattern related to the pulmonary edema or cardia failure as evidenced by shortness of breath.
  2. Altered urinary elimination related to decreased bladder capacity or irritation secondary to infection as evidenced by oliguria.
  3. Excess fluid volume related to a decrease in regulatory mechanisms (renal failure) as evidenced by edema.
  4. Risk for infection related to a decrease in the immunological defense.
  5. Imbalanced nutrition less than body requirements related to anorexia, nausea, vomiting.
  6. Risk for impaired skin integrity related to edema and pruritus.
  7. Hyperthermia related to the ineffectiveness of thermoregulation secondary to infection as evidenced by a thermometer reading above normal ranges.
  8. Dialysis in case of;
    – Fluid overload
    – Severe azotemia
    – Electrolyte abnormalities
  9. Pulmonary edema
    – Aggressive diuresis , Oxygen, Morphine, Ventilation
  10. Hyperkalemia
    – Oral/iv Restriction, Potassium binding resins
    – Nebulized Salbutamol, Glucose insulin
    – Calcium infusion

Nursing Care Planning and Goals

Nursing care planning goals for a child with acute glomerulonephritis are:

  • Excretion of excessive fluid through urination.
  • Demonstration of behaviors that would help in excreting excessive fluids in the body.
  • Improvement of distended abdominal girth.
  • Improvement of respiratory rate.
  • Participation and demonstration of various ways to achieve effective tissue perfusion.

Nursing Interventions

  • Activity. Bed rest should be maintained until acute symptoms and gross hematuria disappear.
  • Prevent infection. The child must be protected from chilling and contact with people with infections.
  • Monitor intake and output. Fluid intake and urinary output should be carefully monitored and recorded; special attention is needed to keep the intake within prescribed limits.
  • Monitor Blood Pressure. Blood pressure should be monitored regularly using the same arm and a properly fitting cuff.
  • Monitor urine characteristics. The urine must be tested regularly for protein and hematuria using dipstick tests.

Evaluation

Goals are met as evidenced by:

  • Excretion of excessive fluid through urination.
  • Demonstration of behaviors that would help in excreting excessive fluids in the body.
  • Improvement of distended abdominal girth.
  • Improvement of respiratory rate.
  • Participation and demonstration of various ways to achieve effective tissue perfusion.

Prevention

  • Early treatment of throat and skin infections
  • Avoid overcrowding
  • Adequate ventilation in dwellings.

Complications

  • Renal failure
  • Nephritic syndrome 
  • Hypertensive encephalopathy
  • Heart failure
  • Pulmonary edema.
  • The patient may have both nephritic syndrome and acute glomerulonephritis and they are called to have nephritic nephritis and the prognosis is poor.

Acute Glomerulonephritis Read More »

Hypoxic Ischemic Encephalopathy

Hypoxic Ischemic Encephalopathy

Hypoxic Ischemic Encephalopathy

Hypoxic Ischemic Encephalopathy (HIE) is a type of newborn brain damage caused by oxygen deprivation and limited blood flow.

Hypoxic Ischemic Encephalopathy is when the brain does not get enough oxygen, permanent brain damage can result. Hypoxic Ischemic Encephalopathy is a type of birth injury; this is a broad term used to refer to any harm that a baby experiences at or near the time of birth. Other terms used for HIE include birth asphyxia, perinatal asphyxia, and neonatal encephalopathy.

Hypoxic Ischemic Encephalopathy falls under the Broad term “Encephalopathy“

Encephalopathy

Encephalopathy is a general term used to describe damage or disease affecting brain function. The causes are varied and can be related to infection, liver conditions, drug toxins, and more.

Some of the major types include the following:

  • Chronic Traumatic Encephalopathy: This condition occurs due to direct injury to the brain, leading to nerve damage. This type is commonly found in athletes.
  • Hepatic Encephalopathy: Often caused by liver cirrhosis, when the liver is not able to filter and function properly, toxins accumulate in the blood and brain.
  • Glycine Encephalopathy: This type of encephalopathy is genetic with symptoms appearing after birth.
  • Toxic Metabolic Encephalopathy: This type of encephalopathy results from toxins, infections, or organ failure. When chemical composition in the body becomes imbalanced, it can impact the brain’s normal function. 
  • Hypoxic-Ischemic Encephalopathy: When the brain does not get enough oxygen, permanent brain damage can result.
  • Hypertensive Encephalopathy: Prolonged hypertension that is not treated can cause the brain to swell resulting in neurological damage.
  • Uremic Encephalopathy: If the kidneys are not functioning properly, they cannot filter harmful substances. The buildup of uremic toxins can cause confusion and other symptoms.

Etiology of Hypoxic Ischemic Encephalopathy

Pathologically, any factors which interfere with the circulation between maternal and fetal blood exchange in form of  maternal factors, delivery factors and fetal factors.

Maternal factor: 
  • hypoxia,
  • anemia,
  • diabetes,
  • hypertension,
  • smoking,
  • nephritis,
  • heart disease,
  • too old or too young,etc 
Delivery condition: 
  • Abruption of placenta,
  • placenta previa,
  • prolapsed cord,
  • premature rupture of membranes,etc 
Fetal factor: 
  • Multiple birth,
  • congenital or malformed fetus,etc 

High Risk Factors

  • Mismanagement of a high-risk pregnancy: Women with conditions such as preeclampsia and gestational diabetes require more extensive monitoring and treatment.
  • Umbilical cord complications: The umbilical cord is like a lifeline between mother and baby, supplying oxygen and nutrients and removing fetal waste. Anything that compresses the cord or reduces its function puts the baby at risk of HIE.
  • Placental or uterine complications: The placenta and uterus also play very important roles in providing oxygenated blood to the baby. Examples of placental and uterine issues that may cause HIE include:
    • Placental abruption: when the placenta separates from the uterus before the baby is born
    • Placenta previa: when the placenta attaches too close to the cervix; this can cause dangerous bleeding and oxygen deprivation during delivery
    • Placental insufficiency: when the placenta is unable to deliver enough blood to the baby
    • Uterine rupture: when the uterus tears, partially or completely
  • Infections: Infections in the mother can spread to the baby during labor and delivery, especially if the medical team do not take adequate precautions (such as doing indicated infection screening and prescribing antibiotics when needed).
  • Improper fetal heart monitoring: If a baby shows signs of fetal distress on the fetal heart monitor, doctors and nurses can often intervene so that their oxygen supply is restored. If necessary, this may involve an emergency C-section. However, if monitoring is sporadic or does not occur, important signs of danger may be missed.
  • Failure to prevent a premature birth: Premature babies are at higher risk for HIE and other birth injuries because their lungs are so underdeveloped. Therefore, it is very important that doctors do what they can to prevent premature birth, such as performing a cervical cerclage (a stitch placed in the cervix to stop it from opening too early) or providing progesterone treatment.
  • Allowing prolonged labor to continue: Labor is stressful for babies because uterine contractions compress the placenta and umbilical cord that supply their oxygen. If something is preventing labor from progressing, and physicians do not offer intervention (such as an emergency C-section), this is negligence. Prolonged labor is more likely to occur when a baby is larger than normal, or the mother’s pelvis is smaller than normal.
  • Medication problems: Sometimes physicians prescribe medications such as Pitocin and Cytotec in order to induce or enhance labor. Unfortunately, these medications can also cause uterine contractions to become so strong and frequent that the baby is dangerously deprived of oxygen.
  • Mismanagement of a neonatal condition: Hypoxic-ischemic injury can be caused by complications during the neonatal period, i.e. a baby’s first month of life. Problems such as respiratory distress, jaundice, and neonatal hypoglycemia can all contribute to an HIE diagnosis, especially if mismanaged.

Clinical Features of Hypoxic Ischemic Encephalopathy

  • Breathing problems
  • Feeding problems
  • Missing reflexes (for example, the baby does not respond to loud noises)
  • Seizures
  • Low Apgar scores
  • Low or high muscle tone
  • Altered level of consciousness (e.g. not alert)

Classification of Hypoxic Ischemic Encephalopathy 

Clinical Classification

  • Mild(stage I): hyperalert, irritable, normal muscular tone & reflex, no seizure, normal EEG 
  • Moderate(stage II): lethargy, hypotonia, weak sucking & Moro response, often seizure, EEG+
  • Severe(stage III): coma, absent muscular tone & reflex, persistent seizure, EEG++

Levene Classification

FeatureMildModerateSevere
CONSCIOUSNESSIrritableLethargyComatose
TONEHypotoniaMarkedSevere
SEIZURENoYesProlonged
SUCKING/ RESPIRATIONPoor SuckUnable to SuckUnable to maintain Spontaneous respiration

Sarnat Staging Classification 

(Commonly used)

Sarnat staging is used alongside electroencephalogram findings to provide information about the prognosis for the infant.

 Grade I MildGrade II ModerateGrade III Severe
AlertnessHyperalertLethargyComa
Muscle toneNormal or increasedHypotonicFlaccid
SeizuresNoneFrequentUncommon
PupilsDilated, reactiveSmall, reactiveVariable, fixed
RespirationRegularPeriodicApnoea
Duration< 24 Hours2 – 14 DaysWeeks

EEG brain scans may detect signs of autism in 2-year-olds - CBS Newselectroencephalogram

 

Management of Hypoxic Ischemic Encephalopathy

This is a pediatrics emergency.

  • HIE is managed using a treatment called therapeutic hypothermia, where the baby’s brain or body is cooled down below normal temperatures to slow damage.
  • This allows the baby’s brain to recover and reduces the level of disability they may have as they grow. According to current guidelines, the treatment must be given within six hours of birth, not exceeding  24 hours.
  • The treatment of encephalopathy varies, depending on the underlying cause of the condition.

Generalized treatment: 

  • Ventilation: CPAP(continuous positive airway pressure) , CMV(continuous mandatory ventilation), HFOV (High-frequency oscillatory ventilation )
  • Perfusion/Circulation: Dopamine/Dobutamine
  •  Energy: normal glucose level maintained (50-110mg/dl): Hypo and hyperglycemia avoided
  • Fluid: 60-80ml/kg/d – restriction if SIADH(Syndrome of inappropriate antidiuretic hormone secretion)
  • Electrolytes- Sodium and Calcium should be monitored.
  • Avoid Polycythemia: If Hct>65-70, partial exchange transfusion is done to bring Het level to 55.
  • Control of seizures: HIE seizures are difficult to control ;
  • Phenobarbital loading dose 15-20mg/kg, iv maintenance dose 3-5mg/kg, iv
  •  Phenytoin  loading dose 15-20mg/kg, iv maintenance dose 5mg/kg, iv Midazolam: 0.1-0.3mg/kg, iv Leveracetam, Topiramate
  • EEG 
Special Investigations 
  • Continous AEEG- Amplified EEG used for cerebral function monitoring. Detects voltage pattern- burst, low voltage, isoelectric Detects electrical seizure activity
  •  CT scan: only indicated in emergency 
Prognosis 

Depend on the severity of brain damage & medical treatment, usually: 

  • Mild or moderate cases could be cured completely, but severe cases represent poor prognosis with high mortality or cerebral complications such as mental retardation & cerebral palsy.
  • Overall mortality – 20%
  • Overall incidence of sequele – 30%
  • Mild: 100% good prognosis
  • Moderate: 80% normal
  • Severe : 50% death, 50% sequele 

Presence of seizure increases chance of Cerebral palsy by 50-70 times. 

Prevention 
  • Better Obstetric care
  • Skilled resuscitation teams and neonatal facilities.

Nursing Diagnosis

  1. Acute Confusion related to Hypoxia ,Disturbance in cerebral metabolism ,Accumulation of toxins in the brain, Structural changes in the brain as evidenced by Cognitive dysfunction , Altered psychomotor performance , Tremors, Fluctuation in the level of consciousness, Agitation, Misperception, Neurobehavioral manifestations, Difficulty initiating purposeful behavior.
  2.  Impaired Memory related to Neurological disturbances related to encephalopathy, Inadequate intellectual stimulation, Changes in brain structure and processes, Irreversible brain damage, Depressive symptoms as evidenced by Reports experiences of forgetfulness, Consistently forgets to schedule or keep appointments , Difficulty recalling events, Difficulty recalling familiar names, objects, and words, Inability to learn or retain new skills or information, Inability to perform a previously learned skill.
  3. Disturbed Thought Processes related to Insufficient oxygen supply to the brain secondary to encephalopathy, Head trauma related to encephalopathy, Infections as evidenced by Incorrect perception of stimuli, Difficulty performing activities of daily living , Difficulty communicating verbally, Impaired interpretation of events, Impaired judgment, Impaired decision making, Inadequate emotional responses, Disorientation

Hypoxic Ischemic Encephalopathy Read More »

Want this in PDF?

Copy the link

Send it to 0726113908 on WhatsApp

Prepare Shs. 5000 (1.3$)

And you will get the full PDF sent to you on WhatsApp.

Scroll to Top

Terms and Conditions - Privacy Policy