BABA USMAN AHMADU PAEDIATRICIAN

IMNCI FOR THE YOUNG INFANT Young infant, defined as an infant aged up to 2 months. This includes the neonatal period, which is the first 4 weeks of life. Young infants differ from older infants and children in the way they manifest signs of infection. They frequently have only general signs such as difficulty in feeding, reduced movements, fever or low body temperature. Lower chest indrawing is another clinical sign that is different in young infants. Only severe lower chest indrawing is an important sign of severe disease. Mild chest indrawing is normal in young infants because their chest wall is soft.

NEWBORN DEATHS: presented in PANCONF 10.6 million children die every year Globally, close to 40% or 4 million babies die in the first month of life. In some countries as many as 60% of child death are newborn deaths 75% of neonatal deaths are in the first week, while 50% of neonatal deaths occur in the first 24hours of life

99% 0f newborn deaths are in developing countries Highest rates of death are in Africa  In Nigeria, U<5MR is 201/1000 live births 26 – 30% of the U<5M are neonates IMR is at 100/1000 live births, NMR 48/1000 Most newborn deaths are unrecorded

When do newborns die? Between 1 and 2 million neonatal deaths occur in the first 24 hours, 3 million die in the first week 4 million babies die in the first month of life Most babies with asphyxia die during the first day Most very small/premature babies die during the first day/week Babies dying of infection can die at any time after day 1 through day 28 especially after day 7

WHERE DO NEWBORNS DIE? Most die at home - unnamed and uncounted

What is IMNCI? It is an integrated approach to child health that focuses on the well being of the whole child. It aims to reduce death, illness and disability and to promote improved growth and development among under 5’s.It includes both preventive and curative elements that are implemented by families, communities and health facilities.

Flow Assess Ask, Look, Feel, Listen Classify Treat Counsel the mother Follow-up

LEARNING OBJECTIVES assessing and classifying a young infant for very severe disease and local bacterial infection assessing and classifying for jaundice assessing and classifying a young infant with diarrhoea Assessing for HIV checking for a feeding problem or low weight, assessing breastfeeding and classifying feeding providing pre-referral treatment to a young infant with very severe disease treating a young infant with oral or intramuscular antibiotics

teaching the mother to treat local bacterial infections and thrush at home giving fluid for treatment of diarrhoea teaching correct positioning and attachment for breastfeeding teaching the mother how to express breast milk and feed the infant by a cup teaching the mother how to feed and keep a low weight infant warm at home advising the mother how to give home care for the young infant giving follow-up care for the sick young infant

Triage The process of rapidly examining all sick children when they first arrive in a health facility in order to place them into priority groups is called triage. Those children with EMERGENCY signs who require immediate emergency Rx. They are given the first priority. They are not placed in the queue. Examples of emergency signs are convulsion, coma, severe respiratory distress, lethargy, not able to feed or breast feed. Those children with PRIORITY signs indicating that they should be given priority in the queue so that they can be assessed rapidly and treated without delay. Examples of priority signs are tiny baby (any sick child under two months of age), high fever, trauma, severe pallor, severe pain, respiratory distress, restless child, burns, severe malnutrition, and a case of referral. Those children who do not have emergency or priority signs and are therefore NON URGENT cases. They can wait for their turn in the queue.

CHECK THE YOUNG INFANT FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Picture showing difficulty in breathing & pustules

CLASSIFY ALL SICK YOUNG INFANTS FOR VERY SEVERE DISEASE AND LOCAL BACTERIAL INFECTION

Look for nasal flaring → severe disease. Look and listen for grunting → severe disease. Look and feel for bulging fontanelle → severe disease. Look for skin pustules. Are there 10 or more skin pustules or a big boil? → severe disease Look for pus draining from the ear → severe disease or local bacteria infection. IDENTIFY APPROPRIATE TREATMENT Young infants with VERY SEVERE DISEASE are often infected with a broader range of bacteria than older infants. The combination of gentamicin and ampicillin is effective against this broader range of bacteria

REFER THE YOUNG INFANT Diazepam (anticonvulsant) 1. Give diazepam per rectally. Use a plastic syringe (the smallest available) without a needle. Put the diazepam in the syringe. Gently insert the syringe into the rectum. Inject the drug and keep the buttocks squeezed tight to prevent loss of the drug. 2. Dose of diazepam – mg/kg 3. In 10 minutes, if convulsions continue, give diazepam again.

Do four steps to refer a young infant to the hospital Explain to the mother the need for referral, and get her agreement to take the young infant. In addition, explain that young infants are particularly vulnerable. When they are seriously ill, they need hospital care and need to receive it promptly. If you suspect that she does not want to take the infant, find out why. Calm the mother’s fears and help her resolve any problems. Write a referral note for the mother to take with her to the hospital. Tell her to give it to the doctor there. Give the mother any supplies and instructions needed to care for her infant on the way to the hospital

EXAMPLE OF REFERRAL NOTE :00 am Urgent referral to Safdarjung Hospital of Baby Shashi, age 4 days Referred for: VERY SEVERE DISEASE Also has a few skin pustules on her buttocks Treatment given at the PHC: First dose of amoxycillin Mother advised to breastfeed the baby and keep her warm on the way to the hospital Needs BCG and OPV 0 dose - not given Ramesh Gupta Community Health Officer Mehrauli PHC

WHERE REFERRAL IS NOT POSSIBLE Distances to a hospital might be too far; the hospital might not have adequate equipment or staff to care for the child; transportation might not be available. Sometimes parents refuse to take a child to a hospital, in spite of the health worker's effort to explain the need for it. To help reduce deaths in severely ill children who cannot be referred, you may need to arrange to have the child stay in or near the clinic where he may be seen several times a day. If not possible, arrange for visits at home.

GIVE IM AMPICILLIN AND IM GENTAMICIN If meningitis is suspected (based on convulsions or unconsciousness), treat for a total of 14 days. If meningitis is not suspected, treat for at least 5 days. Continue the treatment until the infant has been well for at least 3 days. Ampicillin and gentamicin should not be mixed in the same syringe. If it is not possible to give IM ampicillin 2-3 times a day, give oral amoxycillin if the young infant is able to accept orally. Substitute IM ampicillin with oral amoxycillin when the infant’s condition has improved substantially.

Keep the Young Infant Warm as you have already learnt in this module Manage Fluids Carefully The mother should breastfeed the infant frequently. If the infant has difficulty breathing or is too sick to suckle, help the mother express breast milk. Feed the expressed breast milk to the infant by a cup (if able to swallow) or by naso-gastric (NG) tube 8 times per day. Breast milk per kilogram of body weight at each feed is shown below. Day Day 2 10 Day Day 4 onwards 15 If the mother is not able to express breast milk, prepare a breast-milk substitute and give the same amounts as above. Treat the Child to Prevent Low Blood Sugar as you have already learnt in this module.

Dry the Ear by Wicking Dry the ear at least 3 times daily. Roll clean absorbent cloth or soft, tissue paper into a wick. Place the wick in the young infant’s ear. Remove the wick when wet. Replace the wick with a clean one and repeat these steps until the ear is dry. 2. Wash mouth with clean soft cloth wrapped around the finger and wet with salt water.

Note: Avoid giving cotrimoxazole to a young infant less than 1 month of age who is premature or jaundiced. Give this infant amoxycillin instead. 1 teaspoonful is 5mls.

FOLLOW-UP CARE FOR THE SICK YOUNG INFANT During follow-up, ask of new problems. Also, assess every young infant for signs of VERY SEVERE DISEASE. An infant who has a new problem should receive a full assessment as if it were an initial visit.

ASSESS AND CLASSIFY FOR JAUNDICE

Follow up

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ASSESS DIARRHOEA: ASK: Does the young infant have diarrhea? how long? Does it contain blood? Persistent diarrhea ≥ 14days and dysentery (blood) refer

CHECK THE CHILD FOR HIV INFECTION ASK: Has the mother or infant had a positive HIV test result? The classification of the sick young infant for HIV can only be based upon the HIV test result of the mother and /or infant. There are three possible classifications for the young infant as follows: CONFIRMED HIV INFECTION POSSIBLE HIV INFECTION / HIV EXPOSED HIV INFECTION UNLIKELY Note: Refer all possible HIV infection/HIV exposed and confirmed HIV infection to a PMTCT facility.

Pictures Exercise

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE

Assess Breastfeeding

Observe a whole breastfeed if possible, or observe for at least 4 minutes

CLASSIFY FEEDING PROBLEM OR LOW WEIGHT FOR AGE

f Follow up

Kangaroo care for Prematurity/low weight

The 10 steps of the Kangaroo Mother Program As was the case of the Baby-friendly Hospital effort, the mobilizing strategy and the 10 steps for the publicizing and dissemination of the Kangaroo Mother Program can be used, as follows: Baby-friendly Kangaroo Mother Written policy 1 Written policy Specially trained personnel2 Specially trained personnel Well-informed women 3 Well-informed women Initiate at birth 4 Initiate as quickly as possible Demonstrate5 Demonstrate Exclusive 6 Skin-to-skin breast-feeding contact Room for both mother & child 7Bed for both mother & child Freely accepted breast-feeding 8 Accompanied breast-feeding No pacifiers and bottles9 No pacifiers and bottles Assistance groups 10 Assistance groups

THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS If the mother has not received vitamin A after delivery and the infant is less than 6 weeks of age, give 200,000 I.U. of vitamin A to the mother ASSESS OTHER PROBLEMS Assess any other problems mentioned by the mother or observed by you. Refer to any guidelines on treatment of the problems. If you think the infant has a serious problem, or you do not know how to help the infant, refer the infant to a hospital.

Pitures Video Exercise