ASSESS, CLASSIFY, AND TREAT THE SICK YOUNG INFANT AGED UP TO 2 MONTHS

Publication Details

Assess, Classify and Identify Treatment

Do a rapid apraisal of all waiting infants

Ask the mother what the young infant’s problems are

  • Determine if this is an initial or follow-up visit for this problem.
    • if follow-up visit, use the follow-up instructions
    • if initial visit, assess the young infant as follows:
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Check for very severe disease and local infection (PDF, 60K)

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Then check for jaundice (PDF, 48K)

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Then ask: Does the young infant have diarrhoea*? (PDF, 55K)

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Then check the young infant for HIV infection (PDF, 42K)

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Then check for feeding problem or low weight for age in breastfed infants* (PDF, 59K)

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Then check for feeding problem or low weight for age in infants receiving no-breast milk (PDF, 42K)

Then check the young infant’s immunization and vitamin a status

Assess other problems

Treat the young infant and counsel the mother

Give first Dose of intramuscular antibiotics

  • Give first dose of ampicillin intramuscularly and
  • Give first dose of Gentamicin intramuscularly.
  • Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, continue to give ampicillin and gentamicin for at least 5 days. Give ampicillin two times daily to infants less than one week of age and 3 times daily to infants one week or older. Give gentamicin once daily.

Treat the young infant to prevent low blood sugar

  • If the young infant is able to breastfeed:
    Ask the mother to breastfeed the young infant.
  • If the young infant is not able to breastfeed but is able to swallow:
    Give 20–50 ml (10 ml/kg) expressed breastmilk before departure. If not possible to give expressed breastmilk, give 20–50 ml (10 ml/kg) sugar water (To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water).
  • If the young infant is not able to swallow:
    Give 20–50 ml (10 ml/kg) of expressed breastmilk or sugar water by nasogastric tube.

Teach the mother how to keep the young infant warm on the way to the hospital

  • Provide skin to skin contact, OR
  • Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with a blanket.

Give an appropriate oral antibiotic for local infection

For local bacterial infection:

First-line antibiotic : _________________________________________________

Second-line antibiotic: _______________________________________________

Teach the mother how to treat local infections at home

  • Explain how the treatment is given.
  • Watch her as she does the first treatment in the clinic.
  • Tell her to return to the clinic if the infection worsens.
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The mother should do the treatment twice daily for 5 days Wash hands

  • To Treat Diarrhoea, See TREAT THE CHILD CHART.
  • Immunize Every Sick Young Infant, as needed.

Teach correct positioning and attachment for breastfeeding

  • Show the mother how to hold her infant.
    • with the infant’s head and body in line
    • with the infant approaching breast with nose opposite to the nipple
    • with the infant held close to the mother’s body
    • with the infant’s whole body supported, not just neck and shoulders.
  • Show her how to help the infant to attach. She should:
    • touch her infant’s lips with her nipple
    • wait until her infant’s mouth is opening 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. If the attachment or suckling is not good, try again.

Teach the mother how to express breast milk

Ask the mother to:

  • Wash her hands thoroughly.
  • Make herself comfortable.
  • Hold a wide necked container under her nipple and areola.
  • Place her thumb on top of the breast and the first finger on the under side of the breast so they are opposite each other (at least 4 cm from the tip of the nipple).
  • Compress and release the breast tissue between her finger and thumb a few times.
  • If the milk does not appear she should re-position her thumb and finger closer to the nipple and compress and release the breast as before.
  • Compress and release all the way around the breast, keeping her fingers the same distance from the nipple. Be careful not to squeeze the nipple or to rub the skin or move her thumb or finger on the skin.
  • Express one breast until the milk just drips, then express the other breast until the milk just drips.
  • Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
  • Stop expressing when the milk no longer flows but drips from the start.

Counsel the HIV-positive mother who has chosen not to breastfeed (or the caretaker of a child who cannot be breastfed)

The mother or caretaker should have received full counselling before making this decision

  • Ensure that the mother or caretaker has an adequate supply of appropriate breast milk substitute replacement feed.
  • Ensure that the mother or caretaker knows how to prepare milk correctly and hygienically and has the facilities and resources to do so.
  • Demonstrate how to feed with a cup and spoon rather than a bottle.
  • Make sure that the mother or caretaker understands that prepared feed must be finished within an hour after preparation.
  • Make sure that the mother or caretaker understands that mixing breastfeeding with replacement feeding may increase the risk of HIV infection and should not be done.

Teach the mother how to feed by a cup

  • Put a cloth on the infant’s front to protect his clothes as some milk can spill
  • Hold the infant semi-upright on the lap.
  • Put a measured amount of milk in the cup.
  • Hold the cup so that it rests lightly on the infant’s lower lip.
  • Tip the cup so that the milk just reaches the infant’s lips.
  • Allow the infant to take the milk himself. DO NOT pour the milk into the infant’s mouth.

How to prepare commercial formula milk

Teach the mother how to keep the low weight infant warm at home

  • Keep the young infant in the same bed with the mother.
  • Keep the room warm (at least 25°C) with home heating device and make sure that there is no draught of cold air.
  • Avoid bathing the low weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately and thoroughly after bathing and clothe the young infant immediately.
  • Change clothes (e.g. nappies) whenever they are wet.
  • Provide skin to skin contact as much as possible, day and night. For skin to skin contact:
    • Dress the infant in a warm shirt open at the front, a nappy, hat and socks.
    • Place the infant in skin to skin contact on the mother’s chest between the mother’s breasts. Keep the infant’s head turned to one side.
    • Cover the infant with mother’s clothes (and an additional warm blanket in cold weather).
  • When not in skin to skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infant with extra clothing including hat and socks, loosely wrap the young infant in a soft dry cloth and cover with a blanket.
  • Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin to skin contact.
  • Breastfeed (or give expressed breast milk by cup) the infant frequently.

Advise the Mother to Give Home Care for the Young Infant

  1. Exclusively breastfeed the young infant
    Give only breastfeeds to the young infant
    Breastfeed frequently, as often and for as long as the infant wants,
  2. Make sure that the young infant is kept warm at all times.
    In cool weather cover the infant’s head and feet and dress the infant with extra clothing.
  3. When to return:
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    JAUNDICE LOCAL BACTERIAL INFECTION

    WHEN TO RETURN IMMEDIATELY:
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    Breastfeeding poorly Reduced activity

Give follow-up care for the young infant

Assess every young infant for “very severe disease” during follow up visit.

Local bacterial infection

After 2 days:

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

Look for skin pustules.

Treatment:

  • If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.
  • If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.

Jaundice

After 1 day:

Look for jaundice. Are palms and soles yellow?

  • If palms and soles are yellow, refer to hospital.
  • If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for follow up in 1 day.
  • If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 3 weeks of age. If jaundice continues beyond three weeks of age, refer the young infant to a hospital for further assessment.

Diarrhoea

After 2 days:

Ask: Has the diarrhoea stopped ?

Treatment:

  • If the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE “Does the Young Infant Have Diarrhoea ?”
  • If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.

Possible HIV/HIV exposed

  • Follow-up after 14 days and then monthly or according to immunization programme.
  • Counsel about feeding practices. Avoid giving both breast milk and formula milk (mixed feeding).
  • Start co-trimoxazole prophylaxis at 4–6 weeks, if not started already and check compliance.
  • Test for HIV infection as early as possible, if not already done so.
  • Refer for ART if presumptive severe HIV infection as per definition above.
  • Counsel the mother about her HIV status and arrange counselling and testing for her if required.

Feeding problem

After 2 days:

Reassess feeding. > See “Then Check for Feeding Problem or Low Weight” above.

Ask about any feeding problems found on the initial visit.

  • Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant changes in feeding, ask her to bring the young infant back again.
  • If the young infant is low weight for age, ask the mother to return 14 days after the initial visit to measure the young infant’s weight gain.

Exception:

If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.

Low weight for age

After 14 days:

Weigh the young infant and determine if the infant is still low weight for age.

Reassess feeding. > See “Then Check for Feeding Problem or Low Weight” above.

  • 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. Ask her to have her infant weighed again within a month or when she returns 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 the mother to return again in 14 days (or when she returns for immunization, if this is within 14 days). Continue to see the young infant every few weeks until the infant is feeding well and gaining weight regularly or is no longer low weight for age.

Exception:

If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.

Thrush

After 2 days:

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

Reassess feeding. > See “Then Check for Feeding Problem or Low Weight” above.

  • If thrush is worse, or the infant has problems with attachment or suckling, refer to hospital.
  • If thrush is the same or better, and if the infant is feeding well, continue half-strength gentian violet for a total of 5 days.