Management of the Sick Young Infant Age up to 2 months

Dr Nor Azmi bin Abdullah

Introduction
Severe infection is the most common severe illness in the first 2 months of life Young infants can become sick and die very quickly from serious bacterial infections IMCI approach emphasizes detection of severe illness in young infants

Identifying serious illness is different 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 kisah benar)

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

Check for very severe disease and local 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 a period of faster breathing.

If RR > 60 during the second count, classify as fast breathing

Look for severe chest indrawing

Mild chest indrawing is normal in a young infant because the chest wall is soft Severe chest indrawing is very deep Severe chest indrawing is a sign of VERY SEVERE DISEASE

Check for very severe disease and local 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 to infection by lowering body temperature to < 35.5C (hypothermia)

Local Bacterial Infection

Look at the umbilicus. Is it red or draining pus?

Skin pustules: staph infection

Check for very severe disease and local bacterial infection

Look at the young infants movements. If infant is sleeping, ask the mother to wake him/ her
Does the infant move on his own?

If the infant is not moving, gently stimulate him/ her

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

Lethargy movement only when stimulated or no movement at all

 Not able to feed or feeding poorly Convulsions Fast breathing (resp rate 60 or more) Severe chest indrawing Fever or low body temp Movement only when stimulated or no movement at all

Classify as very severe disease

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

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

Treat the young infant to prevent low blood sugar

If the young infant is able to breastfeed, ask mother to continue breastfeeding If the young infant is not able to breastfeed but able to swallow
Give 10ml/kg expressed breast milk If no EBM, give 10ml/kg dextrose 10%

If the young infant is not able to swallow

Give 10ml/kg EBM or dextrose 10% via nasogastric tube

An example of a young infant with very severe disease

(kisah benar di suatu hospital)

49 Days of life, fever

Day 49 of life term baby girl, referred by GP, complained of fever for one day prior to admission associated with vomiting. Her elder sister was also having URTI. During admission at 12 midnight the physical examination was unremarkable. The temperature on admission was 39.7 C Diagnosis of viral fever was made by MO

What is the IMCI classification (if child was seen in clinic)

What is the IMCI classification (if child was seen in clinic)

Very severe disease Refer urgently to hospital

49 Days of life, fever

Reviewed by MO and specialist 8 hours after admission. Fever 38C, able to feed well, not irritable, not tachypnoeic. Investigation FBC, urine examination Continue paracetamol

Convulsion 25 hours after admission

At 25 hours of admission around 1am, she developed one episode of fitting in ward. The fit lasted for 5 minutes and stopped after IV midazolam was given. Diagnosed as meningitis and started on IV Cefotaxime and IV Penicillin. Planned for lumbar puncture in the morning.

Shock 32 hours after admission

The next morning during ward round by medical officer and house officer at 8am, the child was found to be lethargic and irregular breathing. She was transferred to PICU and elective intubation was done. Subsequently she developed persistent shock required boluses up to 140mls/kg and 2 inotropes. She also had refractory seizures required loading phenytoin and phenobarbitone up to 20mg/kg.

Outcome
Ventilated for 16 days Survived with complications mental retardation She presented to hospital early. Could the infection be detected and treated earlier?

Menjawab surat aduan

Rawatan yang diberikan kepada pesakit pada masa tersebut adalah mengikut amalan biasa bagi merawat septicemia shock iaitu dengan memberikan bantuan pernafasan, bolus cecair (fluid bolus), ubat untuk meninggikan tekanan darah, antibiotik dan produk darah, iaitu cecair plasma. Keputusan ujian darah blood culture menunjukkan bahawa kuman yang menyerang pesakit adalah kuman jenis Group A Streptococcus. Kuman ini boleh menyebabkan renjatan yang sangat teruk dan gangren

If the child has local bacterial infection

Give an appropriate local antibiotic Cloxacillin 25mg/kg 4 times daily for 5 days Alternative: Erythromycin Follow up in 2 days

Thrush (oral candidiasis)

Home treatment Wash hands Wash mouth with clean soft cloth wrapped around the finger and wet with cool boiled water Drop 1 ml nystatin into the mouth Wash hands Do this 4 times/ day for 7 days

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

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

 Jaundice appearing before 24 hrs of age Jaundiced palms and soles

Jaundice appearing after 24 hours of age Jaundice below umbilicus

Classify as severe jaundice

Refer urgently to hospital Treat to prevent low blood sugar

Classify as moderate jaundice

Refer to doctor/ hospital Advise mother to continue breastfeeding

 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)

Prolonged jaundice biliary atresia

Important not to miss biliary atresia

Best outcome if operated by 2 months old

 Najis normal kuning Boleh siasat di klinik kesihatan atau rujuk ke Pakar Pediatrik

Najis pucat/ kelabu Rujuk segera ke hospital (dalam 1-2 hari)

Does the young infant have diarrhoea?

Stools more frequent than usual, watery (more water 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 eyes 3. Skin pinch

Classify diarrhoea for dehydration: TWO of the following signs

Movement only when stimulated or no movement at all Sunken eyes Skin pinch goes back very slowly Classify as severe dehydration Refer urgently to hospital If infant has no other severe classification, give fluid for severe dehydration plan C If infant has another severe classification, give frequent sips ORS and breastfeeding on the way

Classify diarrhoea for dehydration: TWO of the following signs

Restless or irritable Sunken eyes Skin pinch goes back slowly

Classify as some dehydration Refer urgently to hospital Give fluid for some dehydration- plan B If infant has any sign of very severe disease, give frequent sips ORS and breastfeeding on the way

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

Classify as no dehydration Give fluid to treat diarrhoea at home and continue breastfeeding- plan A Advise mother when to return immediately Follow up in 2 days if not improving

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 cry and moved her arms and legs.
Assess for very severe disease and local bacterial infection

Ayu 7 weeks old, weight 3kg diarrhoea 3 days

Severe disease unlikely Ayu is still crying. She stopped once when her mother put her to the breast. She began crying again when she stopped breastfeeding. Her eyes look normal, not sunken. When the skin is pinched, it goes back slowly. Classify diarrhoea for dehydration

Ayu 7 weeks old, weight 3kg diarrhoea 3 days

Some Dehydration Since there is no sign of Very Severe Disease, we can give fluid for some dehydration Plan B. ORS 75ml/kg = 225 ml over 4 hours Continue breastfeeding Refer urgently to hospital

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

CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

Is the infant breastfed? If yes, how many times 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?

TREATMENT OF FEEDING PROBLEM OR LOW WEIGHT

Breastfeeding Teach correct positioning and attachment Teach mother how to keep low weight infant warm at home Follow up infant with feeding problem in 2 days Follow up low weight for age in 7 days

Feeding problem/ Low weight Importance of follow up

If the young infant is no longer low weight for age, praise the mother for feeding the infant well. Encourage her to continue feeding the infant as she has been or with any additional improvements you have suggested. If the young infant is still low weight for age, but is feeding well, praise the mother. Follow up low weight for age in 7 days. Lost weight or still has feeding problem: Refer to hospital

Counsel the mother When to return (follow up)

If the infant has Jaundice Local bacterial infection Feeding problem Thrush (candidiasis) Diarrhoea Low weight for age Return for follow up in 1 day 2 days

7 days

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