Session 7

Management
Of Sick Young Infant

(1 week to 2 months)
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 Learning Objectives
By the end of this session, the students will be able to:

(1) recognize the signs of possible bacterial infection

(2) classify the infant based on the signs found
(3) assess for diarrhea
(4) assess for feeding problems
(5) assess immunization status
(6) assess other problems
(7) identify proper treatment
(8) provide proper counseling and follow-up care
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 SUMMARY OF ASSESS AND CLASSIFY
Ask the mother or caretaker about the young

If this is an INITIAL VISIT for the problem, follow the steps below.
(If this is a follow-up visit for the problem, give follow-up care according to PART VII)

Check for POSSIBLE BACTERIAL INFECTION and classify the illness.

Ask the mother or caretaker about If diarrhea is present:

DIARRHOEA: assess the infant further for signs related to
diarrhea, and
classify the illness according to the signs which
are present or absent.

Check for FEEDING PROBLEM OR LOW WEIGHT and classify the

Check the infant’s immunization status and decide if the infant needs any immunization today.

Assess any other problems.

Then: Identify Treatment (PART IV), Treat the Infant (PART V), and
Counsel the Mother (PART VI)
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How to check a young infant for possible bacterial infection
For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION

CHECK FOR POSSIBLE BACTERIAL INFECTION

ASK: LOOK, LISTEN, FEEL:
Count the breaths in one minute.
Has the infant had
Repeat the count if elevated. YOUNG
convulsions? Look for severe chest indrawing.
INFANT
Look for nasal flaring
MUST BE
Look and listen for grunting.
CALM
Look and feel for 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 temperature (or feel for fever or low body temperature)
Look for skin pustules. Are there many or severe pustules?
See if the young infant is lethargic or unconscious.


Look at the young infants’s movements. Are they less than normal?

CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION.

Then ASK about diarrhea. CHECK for feeding problem or low weight, immunization status and for other problems.

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 Check for possible bacterial infection

 Must be done for every sick infant

 Three important bacterial infections:
pneumonia
sepsis
meningitis
 Assess the signs in the order
 Keep the young infant calm during the assessment
 Presence of any sign warrants referral to a hospital

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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial Infection in

a Young Infant:

convulsion
RR > or = 60/min
Severe chest indrawing

Note:
mild chest indrawing is normal in a young infant
because of the soft chest wall

severe chest indrawing is a sign of pneumonia and is

6 serious in a young infant.
 Infant with retractions

7
 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial

Infection in a Young Infant:

nasal flaring: widening of the nostrils when the

young infant breathes in

grunting: short sounds a young infant makes

when breathing out
8
 The larynx, or voice box, is
located in the neck and performs
several important functions in the
body. The larynx is involved in
swallowing, breathing, and voice
production. Sound is produced
when the air which passes
through the vocal cords causes
them to vibrate and create sound
waves in the pharynx, nose and
mouth. The pitch of sound is
determined by the amount of
tension on the vocal folds.

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 Nasal flaring may be an indication of breathing
difficulty, or even respiratory distress in infants

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 Not Nasal Flaring but Yawning

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 Grunting in an Infant

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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial

Infection in a Young Infant:

bulging fontanelle: the infant must be in an

upright position and must be calm and quiet. If the
fontanel is bulging rather than flat, this may mean
the young infant has meningitis.

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 Bulging Fontanel

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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial

Infection in a Young Infant:

– pus draining from ear

– erythema and discharge from the
umbilicus
redness extending to the skin of the
abdominal wall is a sign of serious bacterial
infection

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 Umbilicus

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 Umbilicus

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 Umbilicus

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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial Infection in

a Young Infant:

abnormal body temperature

FEVER
axillary T > 37.5 C
rectal T > 38.0 C

HYPOTHERMIA
axillary T < 35.5 C
rectal T <36.0 C
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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial

Infection in a Young Infant:
severe skin pustules: these are red
spots or blisters which contain pus.

A severe pustule is large or has redness

extending beyond the pustule; many or severe
pustules indicate a serious infection
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 Skin Pustules

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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial

Infection in a Young Infant:

lethargy or unconsciousness: 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.

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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial

Infection in a Young Infant:

lethargy or unconsciousness: If a young

infant does not wake up during the
assessment, ask the mother to wake
him. An unconscious young infant
cannot be awakened at all. He does
not respond when he is touched or spoken to.
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 Check for possible bacterial infection

Signs and Symptoms of Possible Bacterial

Infection in a Young Infant:

Abnormal movements: An awake young

infant will normally move his arms or legs or
turn his head several times in a minute if you
watch him closely. If the infant moves less than
normal, this could be a sign of a possible
bacterial infection.
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 CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION
IDENTIFY TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
Convulsions or Give first dose of intramuscular antibiotics.
Fast breathing (60 breaths per
minute or more) or Treat to prevent low blood sugar.
Severe chest indrawing or Advise mother how to keep the infant warm
Nasal flaring or
Grunting or
on the way to hospital.
Bulging fontanelle or Refer URGENTLY to hospital
Pus draining from ear or
Umbilical redness extending to
POSSIBLE
the skin or SERIOUS
Fever (37.5 C* or above or feels BACTERIAL
hot) or low body temperature (less INFECTION
than 35.5 C* or feels cold) or
Many or severe skin pustules or
Lethargic or unconscious or
Less than normal movement.

Red umbilicus or Give an appropriate oral antibiotic.

draining pus or LOCAL Teach the mother to treat local infections at
Skin pustules. BACTERIAL home.
INFECTION Advise mother to give home care for the young
infant.
Follow-up in 2 days

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*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 ° C higher.
 How to assess and classify a young infant
for Diarrhea
For ALL sick young infants check for signs of possible bacterial infection and
then
ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?

IF YES: ASSES AND CLASSIFY the young infant’s diarrhoea using the
DIARRHOEA box in the YOUNG INFANT chart. The
process is very similar to the one used for the sick child (see Chapter 8).

Then CHECK for feeding problem or low weight, immunization status and other
problems.

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 Assess, Classify, and Treat a
Young Infant with Diarrhea

 Thenormally frequent or loose stools of a

breastfed baby is not diarrhea

 The mother of a breastfed baby can

recognize diarrhea because the consistency
or frequency of the stools is different than
normal
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 Assess, Classify, and Treat a
Young Infant with Diarrhea

 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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 Assess, Classify, and Treat a
Young Infant with Diarrhea

 Diarrhea
in a young infant is classified in the
same way as an older infant of young child.

 Classify dehydration. (See Table)

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 Assess, Classify, and Treat a
Young Infant with Diarrhea

 Choose an additional classification if the infant has

diarrhea for 14 days or more, or blood in the stool.

 Note that 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 in a large part of his life and
should be treated.

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 Classification of Dehydration

 Two or more of the  Classify as Severe

following signs: Dehydration

-lethargic or -give fluid for severe

unconscious dehydration (Plan C)

-sunken eyes
- refer to hospital with
-skin pinch goes back mother giving frequent
sips of ORS on the way.
Continue breastfeeding.
31 very slowly
 Classification of Dehydration

 Two of the following  Classify as Some

signs: Dehydration

-restless, irritable Give fluid and food for

some dehydration (Plan B)
-sunken eyes
refer to hospital with
mother giving frequent sips
-skin pinch goes of ORS on the way.
Continue breastfeeding.
back slowly
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 Classification of Dehydration

 Not enough signs  No dehydration

to classify as
some or severe give fluids to treat
dehydration diarrhea at home (Plan
A)

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 Classification of Dehydration
 Severe Persistent Diarrhea
-diarrhea lasting 14 days or
more
-if the young infant is
dehydrated, treat dehydration
before referral unless the infant
has also POSSIBLE SERIOUS
BACTERIAL INFECTION
-treat dehydration
-refer to hospital
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 Dysentery
-blood in the stool
-treat for 5 days with an oral
antibiotic recommended for
Shigella in your area
-refer urgently to hospital with
the mother giving frequent sips
of ORS on the way. Advise the
mother to continue breastfeeding.
Advise the mother to keep the
young infant warm at all times.
-follow up in 2 days
 For ALL sick young infants check for signs of possible bacterial infection, ask about
diarrhea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT.

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT

ASK: LOOK, LISTEN, FEEL:
œ Is there any difficulty feeding? œ Determine weight for age.
œ Is the infant breastfed? If yes,how many times in 24 hours?
œ Does the infant usually receive any other foods or drinks?
If yes, how often?
œ What do you use to feed the infant?

IF AN INFANT: Has any difficulty feeding,

Is breastfeeding less than 8 times in 24 hours,
Is taking any other foods or drinks, or
Is low weight for age,
AND
Has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING:
œ Has the infant If the infant has not fed in the previous hour, ask the mother to put her
breastfed in the infant to the breast. Observe the breastfeed for 4 minutes.
previous hour?
(If the infant was fed during the last hour, ask the mother if she can wait
and tell you when the infant is willing to feed again.)

œ Is the infant able to attach?

no attachment at all not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:
— Chin touching breast
— Mouth wide open
— Lower lip turned outward
— More areola visible above then below the mouth
(All these signs should be present if the attachment is good.)
Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
no suckling at all not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
œ Look for ulcers or white patches in the mouth (thrush).

CLASSIFY the infant’s nutritional status using the colour-coded classification table for feeding problem or low weight.

35 Then CHECK immunization status and for other problems.

 Assess and Classify a Young Infant for a
Feeding Problem or Low Birth Weight

How to assess breastfeeding

First decide whether to assess the infant’s breastfeeding:
If an infant:
Has any difficulty feeding,
Is breastfeeding less than 8 times in 24 hours,
Is taking any other foods or drinks, or
Is low weight for age, AND
Has no indications to refer urgently to the hospital:
ASSESS BREASTFEEDING:
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 Assess and Classify a Young Infant for
a Feeding Problem or Low Birth Weight

Problems Associated with Breastfeeding

 problems with attachment

 problems with sucking

 blocked nose

 ulcers or white patches in the mouth

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 CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT
SIGNS
Not able to feed or
 No attachment at all or
Not suckling at all.
Not well attached to breast or
Not suckling effectively or
Less than 8 breastfeeds in
24 hours or
Receives other foods or
drinks or
Low weight for age or
Thrush (ulcers or white
patches in mouth).
Not low weight for age and
no other signs of inadequate
feeding.
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IDENTIFY TREATMENT
CLASSIFY AS (Urgent pre-referral treatments are in bold print.)
NOT ABLE TO FEED Give first dose of intramuscular antibiotics.
POSSIBLE Treat to prevent low blood sugar.
SERIOUS BACTERIAL Advise the mother how to keep the young infant
INFECTION warm on the way to hospital.
Refer URGENTLY to hospital.
 Advise the mother to breastfeed as often and for as long as the infant
wants, day and night.
-If not well attached or not suckling effectively, teach correct
positioning and attachment.
-If breastfeeding less than 8 times in 24 hours, advise to
increase frequency of feeding.
 If receiving other foods or drinks, counsel mother about
FEEDING PROBLEM OR breastfeeding more, reducing other foods or drinks, and using a cup.
LOW WEIGHT –If not breastfeeding at all:
— Refer for breastfeeding counselling and possible
relactation.
— Advise about correctly prepared breastmilk
substitutes and using a cup.
 If thrush, teach the mother to treat thrush at home.
 Advise mother to give home care for the young infant.
Follow-up any feeding problem or thrush in 2 days. Follow-up low
weight for age in 14 days.
Advise mother to give home care for the young infant.
NO FEEDING Praise the mother for feeding the infant well.
PROBLEM
 Identify Appropriate Treatment

Urgent referral to a hospital

 Young infant with possible serious bacterial infection
 Young infant with severe dehydration (and does not
have serious bacterial infection) the infant needs
rehydration with IV fluids according to plan C.
- If IV therapy can be given, the infant can be
treated in the clinic.
- Otherwise, urgent referral is needed for IV
therapy.
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 Identify Appropriate Treatment

 Young infant with both severe dehydration

and possible severe bacterial infection (give
frequent sips of ORS and continue
breastfeeding while on the way to the
hospital)

 Preparea referral note and explain to the

mother the reasons to the referral

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 Treatment for a young infant who
does not need urgent referral

 Record treatment

 Advise mother on what to give and when to

return for a follow-up visit

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 Treatment for a young infant who
does not need urgent referral

 Follow-up visits:

If infant gets worse on follow up, refer to the

hospital. Advise follow up after 2 days in a
young infant who:

(a) receives antibiotics for local bacterial

infection or dysentery
(b) has a feeding problem or oral thrush
in 14 days in an infant with low weight for age
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 Treatment for a young infant who
does not need urgent referral

 Pre-Referral Treatment:

(1) give first dose of intramuscular antibiotics

(2) give an appropriate oral antibiotic, e.g. first dose of
an oral antibiotic for local bacterial infection or dysentery
(3) keep the infant warm on the way to the hospital
( advise the mother to wrap the infant next to her body)
(4) treat to prevent low blood sugar
(5) give frequent sips of ORS and continue
breastfeeding
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 Treatment with appropriate oral or
parenteral antibiotic
Local Bacterial Infection
Amoxicillin
40-50 mg/kg/day q8h
for 5 days
Co-trimoxazole
8-10 mg/kg/day of Trimethoprim q 12h for
5 days

NOTE: do not give to infants < 1 month old who are

premature and jaundiced

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 Treatment with appropriate oral or
parenteral antibiotic

 Dysentery

give antibiotic recommended for Shigella in

your area for 5 days.

45
 Treatment with appropriate oral or
parenteral antibiotic

 Possible serious bacterial infection:

Needs coverage for gram-negative and

gram-positive organisms (E. coli and Grp. B
Strep): combination of gentamicin and
Penicillin IM

46
 Treatment with appropriate oral or
parenteral antibiotic
 Referral is the best option for a young infant
classified with possible serious bacterial
infection. If referral is not possible, give
benzylpenicillin & gentamicin for at least 5
days. Give Benzylpenicillin every 6h and
gentamicin every 8h.

For infants in the first week of life, give

gentamicin every 12h.
Benzylpenicillin 50,000 units/kg/dose
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Gentamicin 2.5 mg/kg/dose
 Treatment of Diarrhea

 Emphasize to continue breastfeeding

 Ifan infant is exclusively breastfed, do not

introduce any food-based fluid but may give
additional ORS solution or clean water.

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 Treatment of Diarrhea

 To treat some dehydration, during the first 4

hours of rehydration, encourage the mother
to pause to breastfeed whenever the infant
wants, then resume giving ORS.

 Give a young infant who does not breastfeed

an additional 100-200 ml clean water.
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 Immunization of the Sick Young Infant

 Administer any Immunization that the young

infant needs

 Tellthe mother when to bring the infant for

the next immunization

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 Treatment of local infections at home

Skin pustules or umbilical infections

 wash hands before and after treating the

infection
 gently wash off pus and crusts with soap and
water
 dry the area
 paint with gentian violet

51
 Treatment of local infections at home

Oral thrush-ulcers or white patches in mouth

 wash hands before and after

 wash mouth with clean, soft cloth wrapped
around the finger and wet with salt water
 paint the mouth with half-strength gentian
violet
 stop using gentian violet after 5 days

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 Oral Thrush

53
 Correct positioning and attachment
for breastfeeding

Reasons for poor attachment and ineffective

suckling:

previous non-breastfeeding especially in the first

few days after delivery

inexperienced mother

54
 Correct positioning and attachment
for breastfeeding
Good positioning is recognized by the
following signs:

infant’s neck is straight or bent slightly back

infant’s body is turned towards the mother

infant’s body is close to the mother

infant’s whole body is supported

55
 Correct positioning and
attachment for breastfeeding

Poor positioning is recognized with any of the

following:

infant’s body is twisted or bent forward

infant’s body is turned away from mother
infant’s body is not close to mother
only the infant’s head and neck are supported

56
 Correct positioning and
attachment for breastfeeding

 Positioning is important because poor

positioning often results in poor attachment,
especially in younger infants

57
 Teaching correct positioning and
attachment for breastfeeding

Show the mother how to hold her infant:

 with the infant’s head and body straight

 facing her breast, with infant’s nose opposite her
nipple
 with infant’s body close to her body
 supporting infant’s whole body, not just neck and
shoulders
58
 Teaching correct positioning and
attachment for breastfeeding

Show her how to help the infant 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
59
 How we can help a baby suckles

Baby well attached at breast Peristaltic wave moving along

Lacteal sinuses inside mouth tongue and removing milk

60
How we can see differences in good and bad
attachment: observing a mother to breastfeed

61
 Good Attachment

62
 Poor or Bad Attachment

63
 Examples of Good and Poor Positioning

64
 Counseling about other feeding
problems

 Breastfeed as often and for as long as the

infant wants, day and night

 Feed the infant any other drinks from a cup,

and not from feeding bottle

 Breastfeed for 8 times or more in 24h

65
 Counseling about other feeding
problems

 Refer
a mother who does not breastfeed for
counseling and relactation

 Advise a mother who does not breastfeed

about choosing and correctly preparing an
appropriate breast milk substitute to be given
with a cup and not from a feeding bottle

66
 Home care for the sick young
infant

 Breastfeed frequently, as often and for as

long as the infant wants, to provide
nourishment and help prevent dehydration

 Tell the mother when to return for follow up

visit and when to return immediately

67
 Home care for the sick young
infant
Return immediately if the young infant has any of these signs:
 breastfeeding or drinking poorly
 becomes more sick
 develops fever
 fast breathing
 difficult breathing
 blood in stool
Keep the infant warm at all times
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