Pediatric Ward

Today we did rounds in the pediatric ward with Dr. Pawelos Seyoum, a doctor originally from Ethiopia. Many children here are born to HIV+ mothers and have a 30% chance of acquiring HIV if their mothers are not on antiretroviral therapy.  This is why ARTs are so important for the mothers to adhere to as it reduces the child's chance of acquiring HIV perinatally to less than 2%.  A child born to an HIV+ mother cannot be tested for HIV for at least 6 months because they still have the mother's antibodies.  This is noted on the child's chart as being "exposed" but it can not be determined definitively until later in the child's life involving testing at 6, 12, and 18 months.  If the child is negative at 18 months, it can be diagnosed as definitively HIV negative.  All exposed babies are put on Bactrim after 6 weeks of age to reduce the chances of developing opportunistic infections such as PCP, despite their HIV status. 

A common theme we saw in the infants today was gastroenteritis and pneumonia.  The gastroenteritis can be due to the HIV virus, but can also be bacterial.  With the infants that are marked as exposed, it is hard to tell what the source of the gastroenteritis is, thus prophylactic antibiotics are given.  In the case of an HIV+ baby, the protocol is to do symptomatic treatment and rehydration therapy.  In patients with pneumonia, ceftriaxone is the standard of therapy.

 

 

 

One interesting case in particular we saw was a 6 year old girl who had accidentally ingested paraffin, similar to kerosene or gasoline.  She came in with difficulty breathing and cough and her chest x-ray showed infiltrates.  The paraffin had caused a chemical pneumonitis similar to aspiration pneumonia.  The patient could not be treated with activated charcoal as this was not a solid mass, but rather a liquid.  She was given oxygen therapy and IV fluids coupled with antibiotics.  She is doing much better and will probably be discharged tomorrow. 

 

Another case of interest and much confusion was a 12 year old boy with hypertensive encephalopathy.  He was admitted to the ICU in a coma  with active seizures on May 26th with a blood pressure of >160/120 mmHg putting him in a hypertensive emergency.  He was discharged to the pediatric ward after he had come out of his coma.  This was very interesting to us because we usually see primary hypertension in the US and this was a case of secondary hypertension to which the etiology is still unknown.  We did a differential diagnosis ruling out obesity, diabetes, family history, etc.  The patient's joints were also very stiff in his legs and could not be extended without causing him extreme pain.  We believe this could be a (+) Kernig's sign indicative of meningitis which needs to be followed up on.  The patient was also continuously rocking back and forth which could not be explained further.  We believe this may be some type of neurological disturbance or seizure disorder.  The patient was given Captopril and Lasix for his hypertension which has brought the blood pressure down to 148/108 mmHg, which is still uncontrolled.  He was given phenobarbitol and phenytoin in the ICU for his seizures and has not had another charted seizure since his discharge from the ICU.  His HR is 144 bpm and WBC count at 20.4 K which are both elevated above normal.  This is a patient we are interested in investigating further and following up on to see his progress. 

 

The pediatric ward is also home to its own separate malnutrition ward which was started by Dr. Pawelos.  Unlike America where we mostly see malnourishment as obesity, malnourishment in Swaziland usually involves undernutrition defined as weight being <85% of ideal body weight.  There are usually two types of malnutrition seen.  Kwashiorkor involves protein malnutrition usually characterized by swelling in the limbs or abdomen.  Marasmus involves calorie deficiency and is usually characterized by an emaciated-looking child.  Children are usually started on F-75, which is a formula high in carbohydrates which helps with hypoglycemia and poor absorption due to long-standing poor diets.  The patients are then switched to F-100 which is high in protein. 

 

 

We found it somewhat difficult to adjust to the charting system at RFM.  Everything is done by hand and is sometimes hard to read or locate information.  Also, information may be incomplete at times, which makes it a challenge to fully assess a patient’s status.  For example, in the patient with hypertensive encephalopathy, we were informed that a brain CT and lumbar puncture was done, yet we could not find the results of this in the patient’s chart.  Also, the pain in his lower extremities and uncontrolled rocking movement was not noted anywhere in the chart.  Although the charting system may not be up to the standards we are used to, the RFM health care staff does the best they can with limited funding, staff, and resources.