IMNCI
SICK YOUNG INFANTS
(Referral,Treatment,Oral
Drugs)
Presented by: Tanvi Kundra
M.Sc Nursing ,1st year
Child Health Nursing
TREATMENT OF SICK YOUNG INFANTS
• The first step is to IDENTIFY TREATMENT required for the young
infant according to the classification. All the treatments required are
listed in the "Identify Treatment" column of the ASSESS & CLASSIFY
THE SICK YOUNG INFANT chart.
• Referral may mean admission to the inpatient department of the
same facility where the young infant has been examined as an
outpatient.
ASSESS,CLASSIFY AND TREAT THE SICK
YOUNG INFANT
Assess,Classify & Identify Treatment
• Check for Possible infection
• Check for Possible Neonatal Infection
• Check for Jaundice
• Then ask: Does the young infant have diarrhea?
• Then check for feeding problem,Low birth weight,Low weight
• Then check the young infant’s Immunization status
• Assess other problems
Check for Possible Infection
ASK:-
•Does the child have diarrhea?
• IF YES THEN , FOR HOW LONG?
LOOK AND FEEL:-
• Look at the general conditions. Is he/she
-lethargic or unconscious? -restless and irritable?
• Look for sunken eyes
• Pinch the skin of abdomen , and notice how it goes back:
-very slowly(longer than two seconds)
-slowly (skin stays up even for a brief instant)
-immediately
It is a sign commonly used by health care workers to assess the degree of fluid
loss or dehydration.
It is Known as Turgor’s sign.
• Locate the area on the child's abdomen halfway between the
umbilicus and the side of the abdomen; then pinch the skin using
your thumb and finger.
• Place your hand in such a way that when the skin is pinched, the
fold of skin will be in a line up and down the child's body and not
across the child's body.
• It is important to firmly pick up all of the layers of skin and the
tissue under them for fifteen to thirty seconds and then release it.
Signs Classify Treatment
Two of the SEVERE If infant has low weight or another severe
following signs: DEHYDRATION classification:
Lethargic or Give first dose of intramuscular ampicillin and
unconscious gentamicin
Sunken eyes Refer URGENTLY to hospital with mother
Skin goes back giving frequent sips of ORS on the way
very slowly Advise mother to continue breast feeding
Advise mother to keep the young
infant warm on the way to the hospital
OR
If infant does not have low weight or any
other severe classification:
Give fluid for severe dehydration (Plan
C) and then refer to hospital after
rehydration
Two of the SOME If infant has low weight or another severe
following signs: DEHYDRATION classification:
• Restless, Give first dose of intramuscular ampicillin
irritable and gentamicin
• Sunken eyes Refer URGENTLY to hospital with mother
• Skin pinch giving frequent sips of ORS on the way -
goes back slowly. Advise mother to continue breast feeding
-Advise mother to keep the young infant warm
on the way to the hospital
If infant does not have low weight or another
severe classification:
Give fluids for some dehydration (Plan B)
Advise mother when to return, immediately
•Not enough signs to NO -Give fluids to treat diarrhea at
classify as some or DEHYDRATION home
severe dehydration -Advise mother when to return
immediately
-Follow up in 5 days if not
improving
<PLAN A>
•Diarrhea lasting 14 days or SEVERE -Give first dose of intramuscular
more PERSISTENT Ampicillin and Gentamicin if
DIARRHOEA infant
has low weight if the young infant
has low weight, dehydration or
another severe classification.
-Refer to hospital
-Advise to keep the baby warm
-Treat to prevent low blood sugar
DIARRHOEA TREATMENT
PLAN A: TREAT DIARRHOEA AT HOME
• COUNSEL THE MOTHER ON THE 4 RULES OF HOME TREATMENT
1. GIVE EXTRA FLUID( AS MUCH AS THE CHILD WILL TAKE ) Breastfeed
frequently and for longer at each feed. Give ORS and clean water in
addition to breast milk
2. GIVE ZINC SUPPLEMENTS (Not for infant below 2 months)
3. CONTINUE BREAST FEEDING
4. TELL HER WHEN TO RETURN
• Tell the mother to:
* Wash the hands with soap & clean water first.
* In a clean container, first empty the entire packet of mixture and go
on adding water while stirring with a clean spoon to not allow lumps to
be formed * If the child vomits, wait 10 minutes. Then continue, but
more slowly. * Up to 2 years 50 to 100 ml after each loose stool
• Give from a clean bowl/ cup with a clean spoon from the angle of the
mouth to < 2 yrs age child.
• * Make fresh daily & use within 24 hrs.
PLAN B:SOME DEHYDRATION WITH ORS
• Give in clinic recommended amount of ORS over 4-hr period (which is
200-400 ml for a child whose age is < 4 months or whose weight is
<6 kgs.)
• If the child wants more, give more.
• After 4 hrs, reassess the child and classify for dehydration & select the
appropriate plan to continue treatment.
• Begin feeding the child at the clinic.
• If mother has to leave before 4 hrs, show her how to prepare ORS, tell
& ask how much to give in 4 hrs, explain the above mentioned 4 rules
of home treatment.
• Start I. V. Fluid immediately
• Give 100 ml/kg of Ringer’s Lactate
• Age- Under 12 months
• First give 30ml/kg in 1 hour Then give 70 ml/kg in 5 Hours
• Age-12 months and older
• First give 30ml/kg in 1/2 hour Then give 70 ml/kg in 2 1/2 Hours
• Use intravenous or intraosseus route
Ringers Lactate with 5% dextrose or ½ normal saline with 5% dextrose at 15 ml/kg/hour
for the first hour
Continue monitoring every 5-10 min.
Assess after 1 hour
If no improvement or worsening If improvement(pulse slows/faster
capillary refill /increase in blood
pressure)
Consider septic shock Consider severe
dehydration with shock Repeat Ringers
Lactate 15 ml/kg over 1 h
Switch to ORS 5-10ml/kg/hr orally or by nasogastric
tube for up to 10 hrs
Assessment Of Feeding Problem And Malnutrition
• Ask the mother:-Is there any difficulty in feeding?
• Is the infant breastfed?
• If yes - how many times in 24 hours? Does the infant usually receive
any other food or drinks?
• If yes - how often?
• What do you use to feed the infant?
Look ,Listen, Feel:-
• Determine weight for age
REFERRAL OF YOUNG INFANTS UP TO 2
MONTHS OF AGE
• Infants and children with a severe classification (pink) are referred to a
hospital as soon as assessment is completed and necessary pre-referral
treatment is administered.
• Note: If an infant only has severe dehydration and no other severe
classification ,and IV infusion is available in the outpatient clinic, an
attempt should be made to rehydrate the sick infant.
• Successful referral of severely ill infants to the hospital depends on
effective counselling of the caretaker. If s/he does not accept referral,
available options (to treat the infant by repeated clinic or home visits)
should be considered. If the caretaker accepts referral, s/he should be
given a short, clear referral note, and should get information on what to do
during referral transport, particularly if the hospital is distant.
REFERRAL OF YOUNG INFANTS UP TO 2
MONTHS OF AGE
• The Referral Note Should Include:
• Name and age of the infant;
• Date and time of referral;
• Description of the child's problems;
• Reason for referral (symptoms and signs
• leading to severe classification);
• Treatment that has been given;
• Any other information that the referral
• health facility needs to know in order to
• care for the infant, such as earlier
• treatment of the illness or any
• immunizations needed
REFERRAL OF YOUNG INFANTS UP TO 2
MONTHS OF AGE
• The first step is to give urgent pre-referral treatment(s). Possible pre-referral treatments
• include:
• First dose of intramuscular or oral antibiotics
• Keeping the infant warm on the way to the hospital
• Prevention of hypoglycemia with breastmilk or sugar water
• Frequent sips of ORS solution on the way to the hospital
Non-urgent treatments, e.g., wicking a draining ear or applying gentian violet paint on
skin pustules, should be deferred to avoid delaying referral or confusing the caretaker.
• If an infant does not need urgent referral, check to see if the infant needs non-urgent
referral for further assessment. These referrals are not as urgent. Other necessary
• treatments may be done before referral.
CHECKING IMMUNIZATION STATUS
• Immunization status should be checked in all sick young infants. A young infant who is
not
• sick enough to be referred to a hospital should be given the necessary immunizations
• before s/he is sent home.
• Note: Do not give OPV 0 to an infant who is more than 14 days old. If an infant
• has not received OPV 0 by the time s/he is 15 days old, OPV should be given at age
• 6 weeks old as OPV 1.
• IMMUNIZATION SCHEDULE:
• AGE VACCINE
• Birth BCG OPV 0
• 6 weeks DPT 1 OPV 1 HEP-B 1*
• * Hepatitis B to be given wherever included in the immunization schedule
• Tell the mother the reason for giving the drug to infant.
• Demonstrate how to measure a dose.
• Watch the mother practice measuring a dose by herself.
• Ask the mother to give the first dose to her infant.
• Explain that all the oral drug tablets or syrups must be used to finish
the course of treatment
• For all infants before referral:
• Prevent low blood sugar by giving breastmilk or
• sugar water.Warm the young infant by skin to
• skin contact if temperature is less than 36.5oC
• while arranging referral.
• Advise mother how to keep the infant warm on the
• way to the hospital
CONVULSIONS-TREATMENT
• If the infant is convulsing, give diazepam
• (10 mg/2 ml solution) in dose 0.2 mg/kg
• (0.05 ml/kg) IV or rectally; if convulsions continue
• after 10 minutes, give a second dose of
• of diazepam. Use Phenobarbital (200 mg/ml solution)
• in a dose of 20 mg/kg IM to control convulsions
• in infants less than 2 weeks of age.
POSSIBLE SERIOUS BACTERIAL INFECTION TREATMENT
• POSSIBLE SERIOUS BACTERIAL INFECTION Give first dose of intramuscular
• AND/OR antibiotics.
• SEVERE DEHYDRATION OR The recommended choices are
• SOME DEHYDRATION WITH LOW WEIGHT gentamicin (5 mg/kg) plus
• AND/OR ampicillin (100 mg per kg),
• SEVERE PERSISTENT DIARRHOEA / DYSENTERY OR
• WITH LOW WEIGHT OR DEHYDRATION ceftriaxone (100 mg per kg)
• AND/OR OR
• NOT ABLE TO FEED – POSSIBLE SERIOUS cefotaxime (50 mg per kg).
• BACTERIAL INFECTION OR
• SEVERE MALNUTRITION
SEVERE DEHYDRATION
TREATMENT IN OUT PATIENTS CLINIC
• The treatment instructions for a young infant are given in the chart
book (page 5 to
• 10).
ORAL DRUGS
• The first dose of oral drugs for a young infant should always be given in the
clinic.
• In addition, the mother or caretaker should be taught how to give an oral
antibiotic at
• home. That is, teaching how to measure a single dose, showing how to
crush a
• tablet and mix it with breastmilk, and teaching the treatment schedule.
• Note: Avoid giving cotrimoxazole to a young infant less than 1 month of
age who
• is premature or jaundiced. Give this infant amoxycillin or ampicillin instead
ASSESSING OTHER PROBLEMS
• All sick young infants need to be assessed for other potential
problems mentioned by the mother or observed during the
examination. If a potentially serious problem is found or there is no
means in the clinic to help the infant, s/he should be referred to
hospital.
• CASE: Jatin is 6 weeks old. He weighs 4.5 kg. His temperature is 37°C. The
physician asked
• “What are the infant’s problem?” The mother said “Jatin has diarrhea and
a skin rash for the last 3days”. This is the initial visit for this illness.
• The physician checks the young infant for signs of possible bacterial
infection/jaundice. His mother says that Jatin has not had convulsions. The
physician counts 55 breaths per minute. He finds no chest indrawing or
nasal flaring. Jatin has no grunting. The fontanelle does not bulge. There is
no pus in his ears. The umbilicus is normal. The body temperature is
normal. There are 6 skin pustules. Jatin is not lethargic or unconscious, and
his movements are normal. He does not have jaundice.
• When the physician asks the mother about Jatin’s diarrhoea, the mother replies
that it began 3days ago, and there is no blood in the stool. Jatin is crying. He
stopped once when his mother put him to the breast. He began crying again when
she stopped breastfeeding. His eyes look normal,not sunken. When the skin of his
abdomen is pinched, it goes back slowly.
Jatin’s mother says that she has no difficulty feeding him.He breastfeeds about 5
times in 24 hours.
• She gives him other foods and drinks. The physician uses the Weight for Age chart
and determines that Jatin’s weight (4.5 kg.) is not low for his age (6 weeks).Since
Jatin is feeding less than 8 times in 24 hours and is taking other foods or drinks,
the physician decides to assess breastfeeding. Jatin’s mother agrees to breastfeed
now. The physician observes that Jatin’s chin is touching the breast. His mouth is
wide open and his lower lip is turned outward. More areola is visible above than
below the mouth. His sucks are deep and slow. When Jatin stops breastfeeding,
the physician looks in his mouth. He sees no ulcers or white patches in his mouth
