Assess, classify and treat

• Ask the mother what the child’s problems are
• Check if this is an initial or follow-up visit for this problem

- if follow-up visit: see p419
- if initial visit: continue as below

1. Check for possible bacterial infection

a) Ask

• Has the infant had any convulsions?

b) Look, listen, feel

• Count the number of breaths per minute - repeat the count if this is elevated
• Look for severe chest indrawing and nasal flaring
• Look and listen for grunting
• Look and feel for a 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 the body temperature (or feel for fever or low body temperature)
• Look for skin pustules - if present, are they many or severe?
• See if the young infant is lethargic or unconscious
• Observe the young infant’s movements - are they less than normal?

c) Classify and treat possible bacterial infection as in the table over:

Notes on table

* Body temperatures are based on axillary measurement - rectal readings are approximately 0.5^oC higher

2. Check for diarrhoea/dehydration

If diarrhoea is present

a) Ask

• For how long it has been present
• If there is any blood in the stool

b) Look and feel

• Check the general appearance of the young infant Is the infant:

- lethargic or unconscious?
- restless and irritable

• Check the eyes. Are they sunken?
• Pinch the skin of the abdomen. Does it go back:

- very slowly? (takes >2 seconds)
- slowly?

c) Classify and treat the dehydration and diarrhoea as in the table over

3. Check for feeding problem or low weight

a) Ask

• Is there any difficulty feeding?
• Is the infant breastfed?

- if yes, how many times in a 24-hour period?

• Does the infant usually receive any other foods or drinks, including water?

- if yes, how often?

• What do you use to feed the infant?

b) Determine weight for age

• Weigh the child and using the chart on p423 determine if the child is low weight for its age in months

c) Classify and treat feeding problems as in the table over

Only if infant has any difficulty feeding or is breastfed <8 times/24 hours or is taking any other foods/drinks or is low WFA and has no indications for urgent hospital referral:

d) Look, listen, feel

Assess breastfeeding:

• Has the infant breastfed in the previous hour?

- if no, ask the mother to put the infant to the breast
- if yes, ask the mother if she can wait and tell you when the infant is willing to feed again

• Observe breastfeeding for a few minutes

• Is the infant able to attach properly to the breast? For good attachment, the following should be present:

- chin touching breast
- mouth wide open
- lower lip turned outwards
- more areola visible above than below the mouth

• Is the infant able to suckle effectively? This means slow, deep sucks with occasional pauses - clear a blocked nose if it interferes with breastfeeding

• Look for ulcers or white patches in the mouth (thrush)

4. Check young infant’s immunization status

See p350 for national immunization schedule

5. Assess other problems eg. presenting problems, eye problems, rashes, birth injuries, etc

6. Assess mother’s own health needs

• Check for current health problems
• Check whether family planning help is required (p425)
• Check on tetanus immunization status

7. Teach mother to treat local infections at home

• Explain how the treatment is given
• Watch her as she does the first treatment in the clinic
• Advise her to return if the infection gets worse

a) Skin pustules or umbilical infection

Wash hands before and after treatment
Gently wash off pus and crusts with soap and water
Dry the area
Apply gentian violet aqueous paint 1%
Do this twice daily

b) Thrush

Wash hands
Gently wash mouth with clean soft cloth, wetted with salt water and wrapped around the finger
Apply gentian violet aqueous paint 0.5%
Wash hands
Do this twice daily

8. Teach correct positioning and attachment for BF

• Show mother how to hold the infant:

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

• Show her how to help the infant attach, she should:

- touch her infant’s lips with her nipple
- wait until her infant’south opens 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 (p415) - if either is not good, try again

9. Advise mother on home care for the young infant

• Food & fluids: breastfeed frequently on demand (as often and for as long as the infant wants) day and night, during sickness and health

• When to return:

- for a follow-up visit:

- immediately: advise mother to return with her child immediately if any of these signs are present:

• Breastfeeding or drinking poorly
• Becomes more ill
• Develops fever
• Fast or difficult breathing
• Blood in stool

• Warmth: ensure the young infant is always warm

- in cool weather, cover the infant’s head and feet and dress the infant with extra clothing

10. Provide follow-up care for the young infant

a) Local bacterial infection

After 2 days:

• Check the umbilicus and any skin pustules

If pus discharge or redness is the same or worse:

Refer

If pus discharge or redness has improved:

Tell mother to:

- keep giving antibiotic until 5-day course is completed
- continue treating the local infection at home (p417)

b) Feeding problem

After 2 days:

• Reassess feeding (p415)
• Ask about any feeding problems found on 1^st visit
• Counsel mother about any new or continuing problems

- if this requires the mother to make major changes, ask her to return with the child again after 2 days

If the infant is low weight for age:

• Ask the mother to return 14 days after the 1^st visit to measure the child’s weight gain

Exception: if you think that feeding will not improve or if the child has lost weight: Refer

c) Low weight for age (WFA)

After 14 days:

• Weigh the young infant and using the WFA chart on p423 determine if the child is still low weight for age

• Reassess feeding (p415)

If the infant is no longer low weight for age:

• Praise the mother and encourage her to continue

If the infant is still low weight for age, but is feeding well:

• Praise the mother and encourage her to continue

• Ask her to return to have the child weighed again within 1 month or when she comes for immunization

If the infant is still low weight for age and still has a feeding problem:

• Counsel the mother about the feeding problem

• Ask her to return to have the child weighed again after 14 days or when she comes for immunization (if this is earlier)

• Continue to see the child every 2 weeks until the child is feeding well & gaining weight regularly or is no longer low WFA

d) Thrush

After 2 days:

• Check for ulcers or white patches in the mouth (thrush)
• Reassess feeding (p415)

If thrush is worse or if there are problems with attachment or suckling:

Refer

If thrush is the same or better & infant is feeding well:

Continue applying gentian violet aqueous paint 0.5% to complete a total of 5 days treatment

Summary of IMCI medicines used for young infants

Amoxicillin (every 8 hours for 5 days)

Birth-<1mth (<3kg): 31.25mg (=1.25mL syrup)
1mth-<2mths (3-<4kg): 62.5mg (=2.5mL syrup)

• Used as 2^nd line drug in local bacterial infection - if not available, use procaine penicillin injection
• amoxicillin syrup contains 125mg/5mL

Benzylpenicillin (initial single pre-referral dose)

Birth-<2mths (<4kg): 50,000 IU/kg IM

• Used together with chloramphenicol (below) as initial (pre-referral) treatment of PSBI

If referral is not possible: give every 6 hours for at least 5 days (with chloramphenicol)

Chloramphenicol (initial single pre-referral dose)

Birth-<2mths (<4kg): 40mg/kg IM

• Used together with benzylpenicillin (above) as initial (pre-referral) treatment of PSBI
• If referral is not possible: give every 6 hours for at least 5 days (with benzylpenicillin)
• If infant <1 week: reduce dose by half to 20mg/kg

Cotrimoxazole (every 12 hours for 5 days)

Birth-<1mth (<3kg): 60mg
1mth-<2mths (3-<4kg): 120mg

• Used as 1^st line drug in local bacterial infection and dysentery
• Avoid in infants <1 month who are premature or jaundiced

Nalidixic acid (every 6 hours for 5 days)

Birth-<2mths (<4kg): 62.5mg

Used as 2^nd line drug in dysentery

Procaine penicillin (once daily IM dose)

Birth-<2mths (<4kg): 50,000 IU/kg

• Used as 3^nd line drug in local bacterial infection where either:

- cotrimoxazole and amoxicillin are not available or
- cotrimoxazole is available but may not be used (see above) and amoxicillin is also not available or
- patient unable to swallow oral medication

Weight for Age Chart