Sylvian is an 7-month-old boy who was brought in to the hospital by his mother because he

hasn’t been eating well. He was born by normal vaginal delivery at 37 weeks, and was
diagnosed with Down Syndrome. The mother noticed that Sylvian had a runny nose with
lots of coughing, slightly milky vomits and runny stools but she couldn’t be bothered to take
him to the GP last week. She did note that he has been appearing more tired as well. He has
been eating less and more slowly even though she has been trying to feed him more than
usual. He was breast-fed and is now on formula. Sylvian’s mother has depression that is not
managed and throughout the antenatal course, she has regularly failed to attend
appointments and receive appropriate investigations. Sylvian’s mother is a part-time worker
and is taking care of Sylvian alone as the father has chosen not to be involved in the family.
Immunisation is not up to date.

According to his growth chart, Sylvian is charting consistently at 40th percentile for his height
and head circumference, but his weight has crossed over from 60 th to 34th centile over the
past few weeks.

a. What are 4 possible causes of this change in the growth chart and provide 2 features
on the history that may support it? (8 marks).

Differentials. Feature on History.

b. For 2 of the differentials listed, provide 2 examination findings that may support it (2
marks).

c. For 2 of the differentials listed, provide investigations and the findings that would
definitively confirm the diagnosis (4 marks).

One of the investigations confirmed that Sylvian a moderate-size ventricular septal defect.

d. Describe the management of this condition (4 marks).

A follow-up appointment was made with the paediatric cardiologist but Sylvian’s mother did
not attend. Sylvian’s mother explains that she finds motherhood stressful and blames her
son’s Down Syndrome as for the reason why she doesn’t have a close relationship with her
son like her friends do with their own kids. She has recently lost the motivation to go to
work, and was consequently fired from her job. She has not been eating as much and has
been more tearful than usual.

e. List 2 other possible health professionals that may be involved in managing Sylvian’s
development (2 marks).
____________
Sylvian is an 7-month-old boy who was brought in to the hospital by his mother because he
hasn’t been eating well. He was born by normal vaginal delivery at 37 weeks, and was
diagnosed with Down Syndrome. The mother noticed that Sylvian had a runny nose with
lots of coughing slightly milky vomits and runny stools but she couldn’t be bothered to take
him to the GP last week. She did note that he has been appearing more tired as well. He has
been eating less and more slowly even though she has been trying to feed him more than
usual. He was breast-fed and is now on formula. Sylvian’s mother has depression that is not
managed and throughout the antenatal course, she has regularly failed to attend
appointments and receive appropriate investigations. Sylvian’s mother is a part-time worker
and is taking care of Sylvian alone as the father has chosen not to be involved in the family.
Immunisation is not up to date.

According to his growth chart, Sylvian is charting consistently at 40th percentile for his height
and head circumference, but his weight has crossed over from 60 th to 34th centile over the
past few weeks.

a. What are 4 possible causes of this change in the growth chart and provide 2 features
on the history that may support it? (8 marks).

Differentials. Feature on History.

Gastroenteritis.
GORD.
Coeliac disease.
Ventricular septal defect.
Unintentional child neglect.
Others to consider: Hypothyroidism.
- Vomits.
- Loose stools.
- Reduced feeling.
- Vomits.
- Loose stools.
- Reduced feeding.
- Vomiting.
- Runny stools.
- Tired than usual –
secondary to iron-
deficiency anaemia.
- Tired than usual.
- Eating less.
- Coughs.
- Maternal depression.
- Stress associated with
being part-time and
taking care of him
alone.
- Poor social support.

b. For 2 of the differentials listed, provide 2 examination findings that may support it (2
marks).
Coeliac disease – dermatitis herpetiformis, enamel hypoplasia, muscle atrophy,
subcutaneous fat loss, pallor, rickets.

Ventricular septal defect- Tachypnoea, harsh systolic murmur heard at the LLSB.

Hypothyroidism- Decreased reflexes, Jaundice.

Gatroenteritis – signs of dehydration.

CMPI- excoriated bottom, eczema.

c. For 2 of the differentials listed, provide investigations and the findings that would
definitively confirm the diagnosis (4 marks).

- Duodenal biopsy – villous atrophy, crypt hyperplasia, lymphocytic infiltration

confirms coeliac disease.
- Echocardiogram – confirms diagnosis of VSD, seeing patent hole between the
ventricles. + chest x-ray.
- Cow’s milk – trial of elimination of cow’s milk.

One of the investigations confirmed that Sylvian a moderate-size ventricular septal defect.

d. Describe the management of this condition (4 marks).

- Sit Sylvian upright, provide SaO2.

- High calorie diet.
- Fluid restriction- monitor urine output, daily weight.
- Frusemide.
- ACE-I/ARBs.
- Surgical intervention e.g. pulmonary band ligation/surgical device.

A follow-up appointment was made with the paediatric cardiologist but Sylvian’s mother did
not attend. Sylvian’s mother explains that she finds motherhood stressful and blames her
son’s Down Syndrome as for the reason why she doesn’t have a close relationship with her
son like her friends do with their own kids. She has recently lost the motivation to go to
work, and was consequently fired from her job. She has not been eating as much and has
been more tearful than usual.

e. List 2 other possible health professionals that may be involved in managing Sylvian’s
development (2 marks).

- Dietician: Nutritional education.

- Audiologist: Assessing hearing problems.
- Ophthalmologist: Visual assessment.
- Social worker: Providing Sylvian’s mother support to look after her son.
- Psychologist: CBT Sylvian’s mother, managing her stress and screen for possible
depression.
Q3.
Amy is an 8 day old infant referred to the paediatric day unit by her maternal child-health nurse. • In the past 24
hours she has developed several blisters in the nappy area

What are two possible differentials? (2 marks)

- Nappy rash
- Cellulitis
- Eczema herpeticum
List 5 specific questions that would be important to ask on initial history and how they would with your
differentials? (5 marks)
- How do you change nappies?
- Ask mother about herpes?
- Hx of atopy- eczema.
- Trauma or break to skin, fever?
- Was he born preterm? GBS status? How long was membrane ruptured for? Multiple
vaginal examinations?
For two of you differentials, what are two features on examinations which would be suggestive of your
differentials? (4 marks)
- Vesicles in different stages of healing – eczema heperticulum. Excudative and
crusting.
- Eczemas- dry skin. Doesn’t present in flexures until 2 year olds. Present in other
areas.
- Impetigo- golden crust, bullous.
- Staph scalded skin- blistering, desquamation and positive nikolsky’s sign.
- Nappy rash- wet, localized to particular area/nappy distribution. No involvement of
fat folds (whereas candida does).

Subsequent investigations localised Staph Aureus from the skin. Amy looks generally well and is afebrile. She
appears well hydrated and all her observations are within normal limits. She has several flaccid, transparent,
cloudy,fluid filled bullae of varying size. Several have ruptured leaving a shallow moist eroisions. There are no
bullae on her face All other examinations are unremarkable. What is the diagnosis? (1 mark)

- Impetigo. Not SSSS because she’s not desquamating.

Outline the next steps in your management of Amy. (5 marks)
- Crusts, 1% mupirocin.
 - Isolate her.
- Treat eczema.
- If extensive or not responding, then give oral flucox or cef. If getting onto her face,
cef.
- Cover in watertight dressings.
- Give mother info sheet. Counsel when to represent. Follow up.

Explain the pathophysiology of SSSS? (2 marks)

Exotoxin A travels up.

If SSSS was to develop in this child, what is the complication which will be the most important to watch out for in
this neonate? (1 mark)
- Hypothermia as she loses her skin. Hydration becomes a problem.