Imci Session 7 - Sick Young Infant

Session 7 :

Management Of Sick Young Infant (1 week to 2 months) 1

Learning Objectives By the end of this session, the students will be able to: (1) (2) (3) (4) (5) (6) (7) (8)

2

recognize the signs of possible bacterial infection classify the infant based on the signs found assess for diarrhea assess for feeding problems assess immunization status assess other problems identify proper treatment provide proper counseling and follow-up care

SUMMARY OF ASSESS AND CLASSIFY Ask the mother or caretaker about the young If this is an INITIAL VISIT for the problem, follow the steps below. (If this is a follow-up visit for the problem, give follow-up care according to PART VII)

Check for POSSIBLE BACTERIAL INFECTION and classify the illness.

Ask the mother or caretaker about DIARRHOEA:

If diarrhea is present: assess the infant further for signs related to diarrhea, and classify the illness according to the signs which are present or absent.

Check for FEEDING PROBLEM OR LOW WEIGHT and classify the Check the infant’s immunization status and decide if the infant needs any immunization today. Assess any other problems.

3

Then: Identify Treatment (PART IV), Treat the Infant (PART V), and Counsel the Mother (PART VI)

How to check a young infant for possible bacterial infection For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION

CHECK FOR POSSIBLE BACTERIAL INFECTION ASK: Has the infant had convulsions?

LOOK, LISTEN, FEEL: Count

the breaths in one minute. Repeat the count if elevated. YOUNG Look for severe chest indrawing. INFANT Look for nasal flaring MUST BE Look and listen for grunting. CALM Look and feel for bulging fontanelle. Look for pus draining from the ear. Look at the umbilicus. Is it red or draining pus? Does the redness extend to the skin? Measure temperature (or feel for fever or low body temperature) Look for skin pustules. Are there many or severe pustules? See if the young infant is lethargic or unconscious. 

Look at the young infants’s movements. Are they less than normal?

CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION.

Then ASK about diarrhea. CHECK for feeding problem or low weight, immunization status and for other problems.

4

Check for possible bacterial infection

 

  

5

Must be done for every sick infant Three important bacterial infections: pneumonia sepsis meningitis Assess the signs in the order Keep the young infant calm during the assessment Presence of any sign warrants referral to a hospital

Check for possible bacterial infection Signs and Symptoms of Possible Bacterial Infection in a Young Infant: convulsion RR > or = 60/min Severe chest indrawing Note: mild chest indrawing is normal in a young infant because of the soft chest wall

6

severe chest indrawing is a sign of pneumonia and is serious in a young infant.

Infant with retractions

7

Check for possible bacterial infection Signs and Symptoms of Possible Bacterial Infection in a Young Infant: nasal flaring: widening of the nostrils when the young infant breathes in grunting: short sounds a young infant makes when breathing out 8

The larynx, or voice box, is located in the neck and performs several important functions in the body. The larynx is involved in swallowing, breathing, and voice production. Sound is produced when the air which passes through the vocal cords causes them to vibrate and create sound waves in the pharynx, nose and mouth. The pitch of sound is determined by the amount of tension on the vocal folds.

9

Nasal flaring may be an indication of breathing difficulty, or even respiratory distress in infants

10

Not Nasal Flaring but Yawning

11

Grunting in an Infant

12

Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial Infection in a Young Infant: bulging fontanelle: the infant must be in an upright position and must be calm and quiet. If the fontanel is bulging rather than flat, this may mean the young infant has meningitis. 13

Bulging Fontanel

14

Check for possible bacterial infection Signs and Symptoms of Possible Bacterial Infection in a Young Infant: – –

15

pus draining from ear erythema and discharge from the umbilicus redness extending to the skin of the abdominal wall is a sign of serious bacterial infection

Umbilicus

16

Umbilicus

17

Umbilicus

18

Check for possible bacterial infection Signs and Symptoms of Possible Bacterial Infection in a Young Infant: abnormal body temperature FEVER axillary T > 37.5 C rectal T > 38.0 C HYPOTHERMIA axillary T < 35.5 C rectal T <36.0 C

19

Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial Infection in a Young Infant: severe skin pustules: these are red spots or blisters which contain pus. A severe pustule is large or has redness extending beyond the pustule; many or severe pustules indicate a serious infection 20

Skin Pustules

21

Check for possible bacterial infection Signs and Symptoms of Possible Bacterial Infection in a Young Infant: lethargy or unconsciousness: a lethargic young infant is not awake and alert when he should be. He may be drowsy and may not stay awake after a disturbance. 22

Check for possible bacterial infection Signs and Symptoms of Possible Bacterial Infection in a Young Infant:

23

lethargy or unconsciousness: If a young infant does not wake up during the assessment, ask the mother to wake him. An unconscious young infant cannot be awakened at all. He does not respond when he is touched or spoken to.

Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial Infection in a Young Infant:

24

Abnormal movements: An awake young infant will normally move his arms or legs or turn his head several times in a minute if you watch him closely. If the infant moves less than normal, this could be a sign of a possible bacterial infection.

CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION SIGNS or Fast breathing (60 breaths per minute or more) or Severe chest indrawing or Nasal flaring or Grunting or Bulging fontanelle or Pus draining from ear or Umbilical redness extending to the skin or Fever (37.5 C* or above or feels hot) or low body temperature (less than 35.5 C* or feels cold) or Many or severe skin pustules or Lethargic or unconscious or Less than normal movement.

CLASSIFY AS

Convulsions

umbilicus or draining pus or Skin pustules.

Give

first dose of intramuscular antibiotics. Treat to prevent low blood sugar. Advise mother how to keep the infant warm on the way to hospital. Refer URGENTLY to hospital POSSIBLE SERIOUS BACTERIAL INFECTION

Red

25

IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.)

Give

LOCAL BACTERIAL INFECTION

an appropriate oral antibiotic. Teach the mother to treat local infections at home. Advise mother to give home care for the young infant. Follow-up in 2 days

*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 ° C higher.

How to assess and classify a young infant for Diarrhea For ALL sick young infants check for signs of possible bacterial infection and then ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?

IF YES: ASSES AND CLASSIFY the young infant’s diarrhoea using the DIARRHOEA box in the YOUNG INFANT chart. The process is very similar to the one used for the sick child (see Chapter 8).

Then CHECK for feeding problem or low weight, immunization status and other problems.

26

Assess, Classify, and Treat a Young Infant with Diarrhea  The

normally frequent or loose stools of a breastfed baby is not diarrhea

 The

mother of a breastfed baby can recognize diarrhea because the consistency or frequency of the stools is different than normal

27

Assess, Classify, and Treat a Young Infant with Diarrhea  Assessment

is similar to the assessment of diarrhea for an older infant or young child, but fewer signs are checked.

 Thirst

is not assessed. This is because it is not possible to distinguish thirst from hunger in a young infant.

28

Assess, Classify, and Treat a Young Infant with Diarrhea  Diarrhea

in a young infant is classified in the same way as an older infant of young child.

 Classify

29

dehydration. (See Table)

Assess, Classify, and Treat a Young Infant with Diarrhea

30



Choose an additional classification if the infant has diarrhea for 14 days or more, or blood in the stool.



Note that there is only one possible classification for persistent diarrhea in a young infant. This is because any young infant who has persistent diarrhea has suffered with diarrhea in a large part of his life and should be treated.

Classification of Dehydration 

Two or more of the following signs:

-lethargic or unconscious



Classify as Severe Dehydration -give fluid for severe dehydration (Plan C)

-sunken eyes -skin pinch goes back

31

very slowly

- refer to hospital with mother giving frequent sips of ORS on the way. Continue breastfeeding.

Classification of Dehydration 

Two of the following signs: -restless, irritable -sunken eyes -skin pinch goes back slowly

32



Classify as Some Dehydration

Give fluid and food for some dehydration (Plan B) refer to hospital with mother giving frequent sips of ORS on the way. Continue breastfeeding.

Classification of Dehydration  Not

enough signs to classify as some or severe dehydration

33

 No

dehydration

give fluids to treat diarrhea at home (Plan A)

Classification of Dehydration 

Severe Persistent Diarrhea -diarrhea lasting 14 days or more -if the young infant is dehydrated, treat dehydration before referral unless the infant has also POSSIBLE SERIOUS BACTERIAL INFECTION -treat dehydration -refer to hospital



Dysentery -blood in the stool -treat for 5 days with an oral antibiotic recommended for Shigella in your area -refer urgently to hospital with the mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. Advise the mother to keep the young infant warm at all times.

-follow up in 2 days

34

For ALL sick young infants check for signs of possible bacterial infection, ask about diarrhea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT. THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT ASK: œ Is there any difficulty feeding? œ Is the infant breastfed? If yes,how many times in 24 hours? œ Does the infant usually receive any other foods or drinks? If yes, how often? œ What do you use to feed the infant? IF AN INFANT:

ASSESS BREASTFEEDING: œ Has the infant breastfed in the previous hour?

LOOK, LISTEN, FEEL: œ Determine weight for age.

Has any difficulty feeding, Is breastfeeding less than 8 times in 24 hours, Is taking any other foods or drinks, or Is low weight for age, AND Has no indications to refer urgently to hospital: If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. (If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again.) œ Is the infant able to attach? no attachment at all not well attached good attachment TO CHECK ATTACHMENT, LOOK FOR: — Chin touching breast — Mouth wide open — Lower lip turned outward — More areola visible above then below the mouth (All these signs should be present if the attachment is good.) Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? no suckling at all not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding. œ Look for ulcers or white patches in the mouth (thrush).

CLASSIFY the infant’s nutritional status using the colour-coded classification table for feeding problem or low weight.

35

Then CHECK immunization status and for other problems.

Assess and Classify a Young Infant for a Feeding Problem or Low Birth Weight How to assess breastfeeding

36

First decide whether to assess the infant’s breastfeeding: If an infant: Has any difficulty feeding, Is breastfeeding less than 8 times in 24 hours, Is taking any other foods or drinks, or Is low weight for age, AND Has no indications to refer urgently to the hospital: ASSESS BREASTFEEDING:

Assess and Classify a Young Infant for a Feeding Problem or Low Birth Weight Problems Associated with Breastfeeding  problems

with attachment

 problems

with sucking

 blocked

37

 ulcers

nose

or white patches in the mouth

CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT SIGNS Not

able to feed or  No attachment at all or Not suckling at all.

CLASSIFY AS NOT ABLE TO FEED POSSIBLE SERIOUS BACTERIAL INFECTION

IDENTIFY TREATMENT (Urgent pre-referral treatments are in bold print.) Give

first dose of intramuscular antibiotics. Treat to prevent low blood sugar. Advise the mother how to keep the young infant warm on the way to hospital. Refer

Not

well attached to breast or Not suckling effectively or Less than 8 breastfeeds in 24 hours or Receives other foods or drinks or Low weight for age or Thrush (ulcers or white patches in mouth).

low weight for age and no other signs of inadequate feeding.

Advise the mother to breastfeed as often and for as long as the infant wants, day and night. -If not well attached or not suckling effectively, teach correct positioning and attachment. -If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding.  If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or drinks, and using a cup. –If not breastfeeding at all: — Refer for breastfeeding counselling and possible relactation. — Advise about correctly prepared breastmilk substitutes and using a cup.  If thrush, teach the mother to treat thrush at home.  Advise mother to give home care for the young infant. Follow-up any feeding problem or thrush in 2 days. Follow-up low weight for age in 14 days. 

FEEDING PROBLEM OR LOW WEIGHT

Not

38

URGENTLY to hospital.

Advise

NO FEEDING PROBLEM

mother to give home care for the young infant. Praise the mother for feeding the infant well.

Identify Appropriate Treatment

Urgent referral to a hospital  

39

Young infant with possible serious bacterial infection Young infant with severe dehydration (and does not have serious bacterial infection) the infant needs rehydration with IV fluids according to plan C. - If IV therapy can be given, the infant can be treated in the clinic. - Otherwise, urgent referral is needed for IV therapy.

Identify Appropriate Treatment  Young

infant with both severe dehydration and possible severe bacterial infection (give frequent sips of ORS and continue breastfeeding while on the way to the hospital)

 Prepare

a referral note and explain to the mother the reasons to the referral

40

Treatment for a young infant who does not need urgent referral  Record  Advise

treatment

mother on what to give and when to return for a follow-up visit

41

Treatment for a young infant who does not need urgent referral  Follow-up

visits:

If infant gets worse on follow up, refer to the hospital. Advise follow up after 2 days in a young infant who:

42

(a) receives antibiotics for local bacterial infection or dysentery (b) has a feeding problem or oral thrush in 14 days in an infant with low weight for age

Treatment for a young infant who does not need urgent referral  Pre-Referral (1)

43

Treatment:

give first dose of intramuscular antibiotics (2) give an appropriate oral antibiotic, e.g. first dose of an oral antibiotic for local bacterial infection or dysentery (3) keep the infant warm on the way to the hospital ( advise the mother to wrap the infant next to her body) (4) treat to prevent low blood sugar (5) give frequent sips of ORS and continue breastfeeding

Treatment with appropriate oral or parenteral antibiotic Local Bacterial Infection Amoxicillin 40-50 mg/kg/day q8h for 5 days Co-trimoxazole 8-10 mg/kg/day of Trimethoprim q 12h for 5 days NOTE: do not give to infants < 1 month old who are premature and jaundiced

44

Treatment with appropriate oral or parenteral antibiotic  Dysentery

give antibiotic recommended for Shigella in your area for 5 days.

45

Treatment with appropriate oral or parenteral antibiotic  Possible

serious bacterial infection:

Needs coverage for gram-negative and gram-positive organisms (E. coli and Grp. B Strep): combination of gentamicin and Penicillin IM

46

Treatment with appropriate oral or parenteral antibiotic  Referral

is the best option for a young infant classified with possible serious bacterial infection. If referral is not possible, give benzylpenicillin & gentamicin for at least 5 days. Give Benzylpenicillin every 6h and gentamicin every 8h.

47

For infants in the first week of life, give gentamicin every 12h. Benzylpenicillin 50,000 units/kg/dose Gentamicin 2.5 mg/kg/dose

Treatment of Diarrhea

 Emphasize  If

to continue breastfeeding

an infant is exclusively breastfed, do not introduce any food-based fluid but may give additional ORS solution or clean water.

48

Treatment of Diarrhea

 To

treat some dehydration, during the first 4 hours of rehydration, encourage the mother to pause to breastfeed whenever the infant wants, then resume giving ORS.

 Give

a young infant who does not breastfeed an additional 100-200 ml clean water.

49

Immunization of the Sick Young Infant

 Administer

any Immunization that the young infant needs

 Tell

the mother when to bring the infant for the next immunization

50

Treatment of local infections at home Skin pustules or umbilical infections  wash

hands before and after treating the infection  gently wash off pus and crusts with soap and water  dry the area  paint with gentian violet 51

Treatment of local infections at home Oral thrush-ulcers or white patches in mouth  wash

hands before and after  wash mouth with clean, soft cloth wrapped around the finger and wet with salt water  paint the mouth with half-strength gentian violet  stop using gentian violet after 5 days 52

Oral Thrush

53

Correct positioning and attachment for breastfeeding Reasons for poor attachment and ineffective suckling: previous

non-breastfeeding especially in the first few days after delivery inexperienced

54

mother

Correct positioning and attachment for breastfeeding Good positioning is recognized by the following signs:

55

infant’s

neck is straight or bent slightly back

infant’s

body is turned towards the mother

infant’s

body is close to the mother

infant’s

whole body is supported

Correct positioning and attachment for breastfeeding Poor positioning is recognized with any of the following: infant’s

body is twisted or bent forward infant’s body is turned away from mother infant’s body is not close to mother only the infant’s head and neck are supported 56

Correct positioning and attachment for breastfeeding  Positioning

is important because poor positioning often results in poor attachment, especially in younger infants

57

Teaching correct positioning and attachment for breastfeeding Show the mother how to hold her infant:  with

the infant’s head and body straight  facing her breast, with infant’s nose opposite her nipple  with infant’s body close to her body  supporting infant’s whole body, not just neck and shoulders 58

Teaching correct positioning and attachment for breastfeeding Show her how to help the infant attach: she should: – – –

59

touch her infant’s lips with her nipple wait until her infant’s mouth is opening wide move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple

Look for signs of good attachment and effective suckling. If the attachment or suckling is not good, try again

How we can help a baby suckles Baby well attached at breast Lacteal sinuses inside mouth

60

Peristaltic wave moving along tongue and removing milk

How we can see differences in good and bad attachment: observing a mother to breastfeed

61

Good Attachment

62

Poor or Bad Attachment

63

Examples of Good and Poor Positioning

64

Counseling about other feeding problems

 Breastfeed

as often and for as long as the infant wants, day and night

 Feed

the infant any other drinks from a cup, and not from feeding bottle

 Breastfeed

65

for 8 times or more in 24h

Counseling about other feeding problems  Refer

a mother who does not breastfeed for counseling and relactation

 Advise

a mother who does not breastfeed about choosing and correctly preparing an appropriate breast milk substitute to be given with a cup and not from a feeding bottle

66

Home care for the sick young infant  Breastfeed

frequently, as often and for as long as the infant wants, to provide nourishment and help prevent dehydration

 Tell

the mother when to return for follow up visit and when to return immediately

67

Home care for the sick young infant Return immediately if the young infant has any of these signs: 

    

breastfeeding or drinking poorly becomes more sick develops fever fast breathing difficult breathing blood in stool

Keep the infant warm at all times

68

69