imci infant jul2013

7/27/2019 IMCI Infant Jul2013

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Management of theSick Young Infant

Age up to 2 months

Dr Nor Azmi bin Abdullah


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Introduction

Severe infection is the most commonsevere illness in the first 2 months of life

Young infants can become sick and dievery quickly from serious bacterialinfections

IMCI approach emphasizes detection of severe illness in young infants


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Identifying serious illness isdifferent in infants Young infants often sleep a lot of the time.

Is the infant sleeping or unconscious? Is the quiet young infant who is not crying

is resting or is the baby lethargic? Young infants can be difficult to assess

and may deteriorate quickly (see kisahbenar)


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Outline: Sick Young Infant up to 2 months

Ask what is the problem Check for very severe disease and local

bacterial infection

Check for jaundice Ask about diarrhoea Check for feeding problems or low weight for

age Immunization status Assess any other problems


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Check for very severe disease andlocal bacterial infection Ask: Is the infant not able to feed? Is the infant

feeding poorly? Has the infant had convulsions (fits)?

Look for rapid breathing Count the breaths in 1 minute If RR>60, count again Note: Breathing rate of young infant can be irregular.

The infant can pause for a few seconds, followed by aperiod of faster breathing. If RR > 60 during the second count, classify as

fast breathing


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Mild chest indrawingis normal in a younginfant because the

chest wall is soft Severe chest

indrawing is verydeep

Severe chestindrawing is a sign of VERY SEVERE

DISEASE

Look for severe chestindrawing


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Check for very severe disease andlocal bacterial infection Measure axillary temperature Fever: axillary temperature > 37.5C If measuring rectal temperature, fever is >

38C Fever may be the only early sign of

serious bacterial infection

Note: Young infants may also respond toinfection by lowering body temperature to< 35.5C (hypothermia)


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Local Bacterial Infection

Look at the umbilicus.Is it red or drainingpus?


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Skin pustules: staph infection


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Check for very severe disease andlocal bacterial infection Look at the young infants movements. If

infant is sleeping, ask the mother to wakehim/ her Does the infant move on his own?

If the infant is not moving, gently stimulatehim/ her

Does the infant move only when stimulatedbut then stops? Does the infant not move at all?


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Lethargy movement only whenstimulated or no movement at all


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Classify as very severe disease

Not able to feed or feeding poorlyConvulsionsFast breathing (resp rate 60 or more)Severe chest indrawingFever or low body tempMovement only when stimulated or nomovement at all


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Treatment of very severe disease

Refer urgently to hospital Advise mother how to keep infant warm on

the way to hospital Give first dose of intramuscular antibiotic Give oxygen if available

Treat to prevent low blood sugar


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Treatment of very severe disease

First dose of im antibiotics Give first dose of im ampicillin and

gentamicin If referral is not possible give ampicillin

and gentamicin for at least 5 days


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An example of a young infant

with very severe disease(kisah benar di suatu hospital)


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49 Days of life, fever

Day 49 of life term baby girl, referred byGP, complained of fever for one day prior to admission associated with vomiting. Her elder sister was also having URTI.

During admission at 12 midnight thephysical examination was unremarkable.The temperature on admission was 39.7 C

Diagnosis of viral fever was made by MO


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What is the IMCI classification

(if child was seen in clinic)


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What is the IMCI classification

(if child was seen in clinic)Very severe disease

Refer urgently to hospital


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49 Days of life, fever

Reviewed by MO and specialist 8 hoursafter admission.

Fever 38C, able to feed well, not irritable,not tachypnoeic.

Investigation FBC, urine examination

Continue paracetamol


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Convulsion 25 hours after admission

At 25 hours of admission around 1am, shedeveloped one episode of fitting in ward.The fit lasted for 5 minutes and stoppedafter IV midazolam was given.

Diagnosed as meningitis and started on IVCefotaxime and IV Penicillin. Planned for lumbar puncture in the morning.


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Shock 32 hours after admission

The next morning during ward round by medicalofficer and house officer at 8am, the child wasfound to be lethargic and irregular breathing.

She was transferred to PICU and electiveintubation was done. Subsequently shedeveloped persistent shock required boluses upto 140mls/kg and 2 inotropes.

She also had refractory seizures requiredloading phenytoin and phenobarbitone up to20mg/kg.


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Outcome

Ventilated for 16 days Survived with complications mental

retardation She presented to hospital early. Could the

infection be detected and treated earlier?


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If the child

has localbacterialinfection

Give an appropriate local antibiotic Cloxacillin 25mg/kg 4 times daily for 5 days Alternative: Erythromycin

Follow up in 2 days


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Thrush (oral candidiasis)

Home treatment Wash hands

Wash mouth with clean soft cloth wrappedaround the finger and wet with cool boiledwater

Drop 1 ml nystatin into the mouth Wash hands Do this 4 times/ day for 7 days


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bacterial infection




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Does the infant have jaundice? If yes, when did the jaundice appear (less than 24

hours of life or > 24 hrs)Look for level of jaundice Jaundice below umbilicus or above umbilicus Jaundice palms and soles


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Jaundice appearingbefore 24 hrs of age

Jaundiced palms andsoles

Classify assevere jaundice Refer urgently to

hospital Treat to prevent

low blood sugar

Jaundice appearingafter 24 hours of age

Jaundice belowumbilicus

Classify asmoderate jaundice Refer to doctor/

hospital

Advise mother tocontinue breastfeeding


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Jaundice appearing after 24 hours of age Jaundice above umbilicus

Classify as mild jaundice Advise mother to continue home care

Advise mother to return immediately if jaundiced below umbilicus Follow up in 1 day

If young infant is older than 14 days, refer to hospital /paeds clinic (prolonged

jaundice)


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Prolonged jaundice biliary atresia

Important not to miss biliary atresia

Best outcome if operated by 2 months old


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Najis normal kuning Boleh siasat di klinik

kesihatan atau rujukke Pakar Pediatrik

Najis pucat/ kelabu Rujuk segera ke

hospital (dalam 1-2hari)


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Does the young infant have diarrhoea?

Stools more frequent than usual, watery (morewater than faecal matter)1.Look at the young infants general condition Infants movement

Does the infant move on his own? Does the infant move only when stimulated but then

stops? Does the infant not move at all?

Irritable or restless?2. Look for sunken eyes3. Skin pinch


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Classify as severe dehydration

Refer urgently to hospitalIf infant has no other severe classification, give fluidfor severe dehydration plan CIf infant has another severe classification, givefrequent sips ORS and breastfeeding on the way

Classify diarrhoea for dehydration:TWO of the following signs

Movement only when stimulated or nomovement at allSunken eyes

Skin pinch goes back very slowly


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Classify as some dehydration Refer urgently to hospitalGive fluid for some dehydration- plan BIf infant has any sign of very severe disease, give

frequent sips ORS and breastfeeding on the way

Classify diarrhoea for dehydration:TWO of the following signs

Restless or irritableSunken eyes

Skin pinch goes back slowly


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Classify as no dehydration Give fluid to treat diarrhoea at home and continuebreastfeeding- plan A

Advise mother when to return immediatelyFollow up in 2 days if not improving

Classify diarrhoea for dehydration:Not enough signs to classify as someor severe dehydration


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Example

Ayu is 7 weeks old. Her weight is 3 kg. Her axillary temp is 36.4 C/O diarrhoea 3 days No convulsions. Feeding well,

Resp rate 56/min. Mild chest indrawing. Umbilicus normal. No skin pustules. No jaundice She was sleeping in her mothers arms but

woke up when examined. She began to cryand moved her arms and legs.

Assess for very severe disease and local bacterial infection


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Ayu 7 weeks old, weight 3kgdiarrhoea 3 days

Severe disease unlikely Ayu is still crying. She stopped once when

her mother put her to the breast. Shebegan crying again when she stoppedbreastfeeding. Her eyes look normal, notsunken. When the skin is pinched, it goesback slowly.

Classify diarrhoea for dehydration


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Ayu 7 weeks old, weight 3kgdiarrhoea 3 days

Som e Dehy dra t ion Since there is no sign of Very Severe

Disease, we can give fluid for somedehydration

Plan B. ORS 75ml/kg = 225 ml over 4hours

Continue breastfeeding Refer urgently to hospital


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bacterial infection




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CHECK FOR FEEDINGPROBLEM OR LOW WEIGHT

Is the infant breastfed? If yes, how manytimes in 24 hours?

Does the infant usually receive any other

foods or drinks? If yes, how often? What do you use to feed the infant? Chart the weight

ASSESS BREASTFEEDING Is the infant well attached? Is the infant suckling effectively?


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TREATMENT OFFEEDING PROBLEM OR LOW WEIGHT

Breastfeeding Teach correct positioning and attachment

Teach mother how to keep low weightinfant warm at home Follow up infant with feeding problem in 2

days Follow up low weight for age in 7 days


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Feeding problem/ Low weightImportance of follow up

If the young infant is no longer low weight for age , praise the mother for feeding the infantwell. Encourage her to continue feeding theinfant as she has been or with any additionalimprovements you have suggested.

If the young infant is still low weight for age,but is feeding well , praise the mother. Followup low weight for age in 7 days.

Lost weight or still has feeding problem: Refer tohospital


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Counsel the mother When to return (follow up)If the infant has Return for follow up in

Jaundice 1 day

Local bacterial infectionFeeding problemThrush (candidiasis)Diarrhoea

2 days

Low weight for age 7 days


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When to return immediately(come to clinic/ hospital immediately)

Feeding poorly Not able to feed Reduced activity

Becomes sicker Develops a fever Feels unusually cold Fast breathing/ Difficult breathing Jaundice below umbilicus/ reaching palms and

soles

imci infant jul2013

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