IMCIyoung infants aged

between 7 days and 2 months

MAJID MOHAMMADIZADEH MDASSISTANT PROFESSOR OF PEDIATRICS

ISFAHAN UNIVERSITY OF MEDICAL SCIENCESDEPARTMENT OF PEDIATRICSDIVISION OF NEONATOLOGY

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Elements of

complete IMCI case management process

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Assess a child

• Check first for danger signs (or possible bacterial infection in a young infant)

• Ask questions about common conditions

• Examine the child

• Check nutrition and immunization status

• Check the child for other health problems

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Classify a child’s illnesses using a colour-coded

triage system

urgent pre-referral treatment and referral

specific medical treatment and advice

simple advice on home management

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Because many children have more than one condition, each illness is classified according to whether it requires:

Identify specific treatments for the child

• If a child requires urgent referral, give essential treatment before the patient is transferred

• If a child needs treatment at home: – develop an integrated treatment plan for the child – give the first dose of drugs in the clinic

• If a child should be immunized, give immunizations

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Provide practical treatment instructions for caretaker

• Teach how to:• give oral drugs• feed and give fluids during illness• treat local infections at home

• Ask to return for follow-up on a specific date

• Teach how to recognize signs indicating the child should return immediately to health facility

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Assess feeding

• Assess breastfeeding practices

• Counsel to solve any feeding problems found

• Counsel the mother about her own health

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Give follow-up care

• Give it according to the problem(s) found in the first visit

• If necessary, reassess the child for new problems

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The common practice in all steps

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• The IMCI guidelines address most, but not all, of the major reasons a sick child is brought to a clinic

• A child returning with chronic problems or less common illnesses may require special care which is not described in this session

• The guidelines do not describe the management of trauma or other acute emergencies due to accidents or injuries.

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• This session is focused on young infants aged between 7 days and 2 months

• Infants in this age group are susceptible to particular infectious agents and when ill, often show less specific clinical signs

• Conditions in the first 6 days of life (mainly related to prematurity and complications in delivery) should be discussed separately

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ماه

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• As previously mentioned, young infants aged between 7 days and 2 months are susceptible to particular infectious agents and, when ill, often show less specific clinical signs, compared with children in other age groups.

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• Infections are an important cause of both morbidity and mortality in this age group

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• Infections are especially important because the deaths they cause are potentially preventable:

– either by prophylaxis (e.g. tetanus immunization during pregnancy)

– or early diagnosis and appropriate treatment (e.g. for pneumonia or sepsis)

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Burden of disease

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• According to WHO estimates in the year 2000 conditions arising in the neonatal period accounted for about 23% of all child deaths

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• Infections are estimated to cause:

• about 42% of deaths from birth up to 28 days of age in developing countries

• an even higher proportion of those in the second month of life

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• The most important, potentially lethal infections during the first 28 days of life:

– pneumonia– septicemia– meningitis – tetanus– diarrhea

• With the exception of tetanus, which occurs mostly during the first 2 weeks of life, the same infections are also the most important causes of mortality for infants aged 28 days to 2 months

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• Other important infections during the first month involve :

– umbilical stump – Skin – eyes

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• These infections are acquired :

– from a colonized maternal genital tract during labor and delivery (typically with onset during the first week of life)

– from contact after birth with organisms in the newborn’s environment (typically with onset after the first week of life)

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Serious bacterial infection

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Serious bacterial infections:

• pneumonia

• sepsis

• meningitis

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• The clinical features of young infants with septicaemia, meningitis or pneumonia are often nonspecific and overlapping

• Typically, signs and symptoms develop within a few hours or 1–2 days

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Signs & symptoms

• Temperature (axillary) >37.5 °C or <35.5 °C• Lack of spontaneous movement• Altered mental state (agitation, lethargy, or coma)• Poor feeding• Respiratory rate >60 breaths/minute• Lower chest wall indrawing• Grunting• Cyanosis• A history of convulsions• A bulging fontanel• Slow digital capillary refill

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some other signs & symptoms

• Pallor

• Jaundice

• Episodes of apnea

• Abdominal distention

• Hepatosplenomegaly

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• If there is a feeding problem:

– assess the infant’s position (attachment) and suckling during breastfeeding

– check the mouth for thrush

• In the absence of a clear cause such as thrush,

the appearance of a feeding problem can be an important sign of a serious bacterial infection

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• A newborn in the first week of life or young infant with hypoxic-ischemic encephalopathy may have some of the above signs

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• Consider neonatal tetanus in a previously well newborn who at 3–10 days after birth presents with:

– irritability

– difficulty in sucking

– trismus

– muscle spasms or convulsions

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Bulging fontanellesign of meningitis in young infants with an open

fontanel

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Bacteria isolated from blood of infants with sepsis(WHO Young Infants Study Group -multicountry1999)

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Bacteria isolated from CSF of infants with sepsis

(WHO Young Infants Study Group -multicountry1999)

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Diagnosis and management

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• There is real urgency in recognizing illness in a newborn or young infant and ensuring that the child has access to trained health care workers for assessment and most importantly, treatment with lifesaving antibiotics

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• Such care is most likely to be available at a well supplied health center or hospital

• Village health workers- especially trained in home-based neonatal care- can provide treatment and reduce deaths

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• If skin pustules are present, examine the pus after Gram staining or culture the pus

• When a bacterial infection is suspected and there are no localizing signs of infection carry out a blood culture and urine microscopy or culture

• If meningitis is suspected, carry out a lumbarpuncture and CSF examination

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Supportive care

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• proper maintenance of body temperature (to avoid hypo- or hyperthermia)

• attention to fluid status

• continued nutrition

• prevention or treatment of hypoglycemia

• attention to respiratory status (airway and oxygen, if needed and available)

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Thermal environment

• Keep the young infant dry and well wrapped.

• A bonnet or cap is helpful to reduce heat loss.

• Keep the room warm (at least 25 °C)

• As the condition of the young infant improves, keep the child close to the mother’s body

Keeping the young infant in close skin-to-skin contact with the mother (“kangaroo mother care”) for 24 hours a day is as effective as using an incubator or external heating device to avoid chilling

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Thermal environment

• Pay special attention to avoid chilling the infant during examination or investigation

• Regularly check that the infant’s temperature is

maintained in the range 36.5–37.5 °C rectal, or 36.0–37.0 °C axillary

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Kangaroo Mother Care

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Thermal environment• If there is considerable experience with the use of incubators or

indirect heating sources (such as hot water bottles or heating pads, covered with several layers of cloth or other insulation), these may be used

• However, they are no more effective than the simple measures noted above

• Prevent overheating or burns by being especially careful if you have to use a hot water bottle or heating pad

• Water bottles get cold and must be frequently replaced

• The use of heat lamps is not recommended

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High fever

• Do not use antipyretic agents such as paracetamol for controlling fever in young infants

• Control the environment • If necessary, undress the child

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Fluid and nutritional management

• Encourage the mother to breastfeed frequently, unless the child is in respiratory distress or too sick to suck from the breast

• In these cases:

• help the mother to express breast milk regularly

• give it to the infant (20 ml/kg body weight) by dropper (if able to swallow) or by nasogastric tube 6 (8) times a day (or 8–12 times in newborns aged 1–2 weeks)

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Fluid and nutritional management

• Give a total of 120 ml/kg/day

• Give 10 ml/kg expressed breast milk before departure

• If the mother is not able to express breast milk, prepare a breast milk substitute or give diluted cow's milk with added sugar

• If feeding is not possible -even by nasogastric tube- monitor the blood glucose 6 hourly and if necessary, set up an IV line to administer glucose.

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Fluid and nutritional management

• If it is essential to give IV fluids (e.g. as a vehicle for IV antibiotics), take care to avoid the risk of heart failure from fluid overload

• Do not exceed daily fluid requirements

• Monitor the IV infusion very carefully and use an infusion chamber of 100–150 ml where possible

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Hypoglycaemia

• Check for hypoglycaemia using a capillary blood dextrostix test

• If the blood glucose is <45 mg/dl treat with 10 ml/kg of 10% glucose, given by nasogastric tube, and prevent recurrences by frequent feeding

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Oxygen • central cyanosis

• grunting with every breath

• difficulty in feeding due to respiratory distress

• severe lower chest wall indrawing

• head nodding

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Oxygen

• Nasal prongs are the preferred method for delivery of oxygen to this age group, with a flow rate of 0.5 liter per minute

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Oxygen

• Thick secretions from the throat may be cleared by intermittent suction, if they are troublesome and the young infant is too weak to clear them

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Oxygen

• Oxygen should be stopped when the infant’s general condition improves and the above signs are no longer present

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Vitamin K

• Give all sick infants aged <2 weeks 1mg of vitamin K (IM)

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Treatment of convulsions

• IM phenobarbital (a loading dose of 20 (15) mg/kg)

• If they persist, continue with phenobarbital IM (10

mg/kg per dose) up to a maximum of 40 mg/kg

• If needed, continue with phenobarbital at a maintenance dose of 5 mg/kg/day

• If there is no response to this treatment, phenytoin can be given

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Parenteral antibiotics

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• for sepsis when the precise diagnosis is not established

• for meningitis when the diagnosis of meningitis has been established or is strongly suspected

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• These should be given as soon as a diagnosis of serious bacterial infection is suspected

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• IM administration of antibiotics is recommended

• However, IV administration may be preferable if there is very good monitoring to ensure that fluid overload does not occur

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WHO 2000

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Sepsis

• IM ampicillin plus IM gentamicin

• If ampicillin is not available: give IM benzylpenicillin plus IM gentamicin

• If gentamicin is not available: give instead kanamycin

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Sepsis

• Continue treatment until the infant has remained well for at least 4 days

• Once the infant’s condition has substantially improved, oral amoxicillin plus IM gentamicin can be given

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Sepsis

• Give IM cloxacillin plus IM gentamicin as the first-line treatment:

– if the infection is hospital-acquired

– if Staphylococcus aureus is known to be an important cause of neonatal sepsis locally

– if there are signs suggestive of severe staphylococcal infection such as widespread skin infection, abscesses or soft tissue infection

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Sepsis

• If there is no response to treatment in the first 48 hours or if the child’s condition deteriorates, add IM chloramphenicol

• Chloramphenicol should not be used in premature infants (born before 37 weeks of gestation) and should be avoided in infants in the first week of life

• If the response to treatment is poor and pneumococci are resistant to penicillin, change to IM or IV cefotaxime plus IM ampicillin

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Sepsis

• For neonates in the first week of life, the dosage regimens may be different to those given above for young infants

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Meningitis • IM ampicillin plus IM gentamicin

• An alternative regimen is IM ampicillin plus IM chloramphenicol

• If gentamicin is not available, kanamycin can be used instead

• If there is no response to treatment in the first 48 hours or if the child’s condition deteriorates give a third-generation cephalosporin such as ceftriaxone or cefotaxime

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Meningitis

• If accurate bacteriology reporting of CSF specimens is available and the results are known, continue treatment with the antibiotic to which the organism is sensitive

• Treatment should be continued for 14 days or until the young infant has remained well for 4 days, whichever is longer

• Treatment should be continued IM throughout the course

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WHO 2004

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Sepsis

• ampicillin (or benzyl penicillin) plus gentamicin (or kanamycin)

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Meningitis

• In infants and young children chloramphenicol plus ampicillin or chloramphenicol plus benzylpenicillin are usually effective against S. pneumoniae, H. influenzae and N. meningitidis

• Increasing resistance to these antibiotics especially among S. pneumoniae and H. influenzae may require the use of other agents

• Third-generation cephalosporins such as ceftriaxone or cefotaxime are effective alternatives

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Meningitis

• It’s important to know the local bacterial resistance patterns and to follow national guidelines as to which antibiotics to use

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Meningitis

• In neonates, the most effective antibiotic is ceftriaxone or Cefotaxime

• Alternatives are gentamicin plus ampicillin or chlopramphenicol plus ampicillin – Both combinations, however, have shortcomings:

• Gentamicin does not penetrate well into CSF

• chloramphenicol is ineffective for many E. coli and some Salmonella

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WHO 2008

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Sepsis

• IM benzylpenicillin plus IM gentamicin

• Treat with antibiotics for at least a total of 10 days (up to 3 weeks)

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Sepsis

• Continue the IM/IV treatment until the infant has been well for at least 3 days

• Then substitute the IM/IV treatment with an appropriate oral antibiotic such as amoxicillin

• Continue to give IM gentamicin until a minimum treatment of 5 days has been given

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Sepsis

• If there is no response to the treatment after 48 hours or if the infant's condition deteriorates, then give IV/IM chloramphenicol (but not in premature/low weight neonates)

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Meningitis

• IM gentamicin AND IM ampicillin if available OR with IM/IV ceftriaxone

• Treat for 21 days

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Monitoring

• The young infant should be assessed by the nurse every 6 hours (3 hourly, if very sick) and by a doctor daily

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Diarrhea

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Notice

• The normally frequent or loose stools of a breastfed baby are not diarrhea

• The mother of a breastfed baby should be able to recognize diarrhea by the fact that the consistency or frequency of the stools will be different from normal

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Assessment

• The 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

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Classification • Diarrhea in a young infant is classified in the

same way as in an older infant or young child

• 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 a large part of his life and should be referred

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Importance

• When diarrhea occurs in young infants the risk of death is high

• Dehydration is the immediate threat to a young infant with acute diarrhoea

• Exclusive breastfeeding for the first six months provides substantial protection against diarrhoea and diarrhoea-associated mortality

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special points for treatment

• Frequent breastfeeding is essential

• Encourage the mother to breastfeed more often and for longer

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special points for treatment

• If the young infant has some dehydration give 200–400 ml ORS solution by cup within the first 4 hours

• Encourage the mother to breastfeed the infant whenever the infant wants to, and then resume giving ORS solution

• Give a young infant with some dehydration, who is not breastfeeding, an additional 100–200 ml of clean water during this period

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Omphalitis

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Importance

• The necrotic umbilical stump is a particularly good medium for bacterial growth

• Although inflammation that is immediately adjacent to the umbilical stump is not lifethreatening, the close proximity to the umbilical vessels gives bacteria potential access to the bloodstream, which increases the risk of bacterial septicaemia

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Severity

• How far down the umbilicus the redness extends determines the severity of the infection

• If the redness extends to the skin of the abdominal wall, it is a serious infection

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Treatment

• Peri-umbilical skin redness that does not extend to the abdominal wall should be treated with antiseptics applied to the affected area and with an oral antimicrobial such as amoxicillin for 5 days

• The infant with local skin infection can be treated at home

• The infant should return for follow-up in 2 days to be sure the infection is improving

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Treatment

• Parenteral antibiotics and treatment in hospital are essential if:

• redness extends to the abdominal wall

• induration develops

• the umbilicus drains pus

• the infant develops signs of serious bacterial infection

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Skin infections

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Treatment

• When these are few isolated and with little or no surrounding redness, they may be treated by:

• washing carefully with soap and water

• applying a local antiseptic

• giving an oral antimicrobial such as amoxicillin

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Treatment

• If there are numerous pustules or furuncles or they coalesce to form expanding lesions:

• treatment should be given in hospital with parenteral antibiotics effective against S. aureus, Str. pyogenes and Gram-negative pathogens such as the combination of cloxacillin and gentamicin

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Ophthalmia neonatorum

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Definition

• purulent conjunctivitis in the first 28 days of life

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Etiology

• The most important causes:

– Neisseria gonorrhoeae– Chlamydia trachomatis – Staphylococcus aureus

• Infection with N. gonorrhoeae and C. trachomatis is acquired from an infected mother during passage of the infant through the birth canal

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Etiology

• In some countries, the prevalence of STDs is very low and ophthalmia neonatorum is mainly caused by staphylococcal and Gram-negative organisms

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Gonococcal ophthalmia

• often develops soon after birth, is more severe than chlamydial ophthalmia and if untreated, can lead to corneal scarring and blindness

• Because it is a preventable cause of blindness, it is critical that gonococcal ophthalmia be diagnosed and treated promptly

• The risk of neonatal infection is related directly to the prevalence of maternal infection in the area and inversely to the frequency of antimicrobial eye prophylaxis

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Chlamydial conjunctivitis

• Rarely causes permanent eye damage

• It correlates with the occurrence of nasopharyngeal colonization with this agent and with an increased risk of chlamydial pneumonia in the first few months of life

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Diagnosis

• Gram stain ofconjunctival pus may reveal Gram-negative diplococci (N.gonorrhoeae) or Gram-positive cocci (S. aureus)

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Treatment

• In areas where gonorrhoea is prevalent and where laboratory diagnosis (eye culture and/or Gram stain) is not possible, all neonates with ophthalmia should be treated for presumed gonococcal infection

• Staphylococcal ophthalmia should be treated with cloxacillin (50 mg/kg, every 6–8 hours depending on the age of the young infant)

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Local treatment

• Clean the newborn’s eyes with 0.9% saline or clean water (boiled, then cooled)

• Wipe from the inside to the outside edge, using a clean swab for each eye

• Wash the hands before and after this treatment

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Assess for possible bacterial infection

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Assess for possible bacterial infection

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• It is important to assess the signs in the order on the chart and to keep the young infant calm

• The young infant must be calm and may be asleep while you assess the first signs, that is, count breathing and look for chest indrawing, nasal flaring and grunting

Assess for possible bacterial infection

• To assess the next few signs you will pick up the infant and then undress him, look at the skin all over his body and measure his temperature

• By this time he will probably be awake and you can see if he is lethargic or unconscious as observe his movements

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Assess for possible bacterial infection

• If you find a reason that a young infant needs urgent referral, you should continue the assessment

• However, skip the breastfeeding assessment because it can take some time

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COUNT THE BREATHS IN ONE MINUTE

• If the first breath count is 60 breaths or more, repeat the count

• This is important because the breathing rate of a young infant is often irregular

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LOOK FOR SEVERE CHEST INDRAWING

• mild chest indrawing is normal in a young infant because the chest wall is soft

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MEASURE TEMPERATURE

• Fever is uncommon in the first two months of life.

• If a young infant has fever, this may mean the infant has a serious bacterial infection

• fever may be the only sign of a serious bacterial infection

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MEASURE TEMPERATURE

• If you do not have a thermometer, feel the infant’s stomach or axilla (underarm) and determine if it feels hot or unusually cool

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LOOK FOR SKIN PUSTULES

• A severe pustule is large or has redness extending beyond the pustule

• Many or severe pustules indicate a serious infection

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SEE IF THE YOUNG INFANT IS LETHARGIC OR UNCONSCIOUS

• Young infants often sleep most of the time and this is not a sign of illness

• Even when awake, a healthy young infant will usually not watch his mother and a health worker while they talk

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SEE IF THE YOUNG INFANT IS LETHARGIC OR UNCONSCIOUS

• 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

• An unconscious young infant cannot be wakened at all

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The common practice in all steps

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Urgent referral

• Possible serious bacterial infection

• Severe dehydration with possible serious bacterial infection

• Severe dehydration without possible serious bacterial infection, if the caregiver can not give IV therapy

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check a young infant for feeding problem or low weight

• The assessment has two parts:• In the first part: you determine:

– if the mother is having difficulty feeding the infant, what the young infant is fed and how often by asking her questions

– weight for age

• In the second part: if the infant has any problems with breastfeeding or is low weight for age, you assess how the infant breastfeeds

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There is no need to assess breastfeeding if the infant:

• is exclusively breastfed without difficulty and is not low weight for age

• is not breastfed at all

• has a serious problem requiring urgent referral to a hospital

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• If needed, observe:

• a whole breastfeed if possible

• for at least 4 minutes

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Assess other problems

• Assess any other problems mentioned by the mother or observed by you

• Refer to other guidelines on treatment of those problems

• Refer the infant to hospital if you:

• think the infant has a serious problem • do not know how to help the infant

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