INTEGRATED MANAGEMENT OF CHILDHOOD

ILLNESS (IMCI)
Part II)

SICK YOUNG INFANT (AGE 1WEEK UP TO 2 MONTHS)

 ASSESS

 CHECK FOR VERY SEVERE DISEASE & LOCAL INFECTION

• Ask:
♦ Is the infant having difficulty in feeding?
♦ Has the infant had convulsions (fits)?
• Look, Feel & Listen:
 Count the breaths in one minute; repeat count if 60 or more breaths per
minute
 Look for severe chest indrawing
(Note: For the first two, young infant must be calm)
 Measure axillary temperature
 Look at the umbilicus; is it red or draining pus?
 Look for skin pustules
 Look at the young infant’s movements. If infant is sleeping, ask the mother
to wake him/her.
 Does the infant move on his/her own?
 If the infant is not moving, gently stimulate him/her.
- Does the infant move only when stimulated but then stop?
- Does the infant not move at all?

 CHECK FOR JAUNDICE

• Look for jaundice (yellow eyes or skin)
• Look at the young infant’s palms & soles. Are they yellow?

 THEN ASK: DOES THE YOUNG INFANT HAVE DIARRHEA?

• If yes,:
 For how long?
 Is there blood in the stool?
• Look & Feel:
 Look at the young infant’s general condition; is the child abnormally sleepy
or difficult to awaken?; restless & irritable?
 Look for sunken eyes
 Pinch the skin of the abdomen; does it go back very slowly (longer than 2
seconds) or slowly?
NOTE: What is diarrhea in a young infant?
 A young infant has diarrhea if the stools have changed from usual pattern &
are watery (more watery than fecal matter)
 The normally frequent or semi-solid stools of a breastfed baby are not
diarrhea.

 THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN

BREASTFED INFANTS
 If an infant has no indications to refer urgently to hospital:
• Ask:
 Is the infant breastfed? If yes, how many times in 24 hours?
 Does the infant usually receive any other foods or drinks? If yes, how
often?
 What do you use to feed the infant?
• Look:
♦ Determine weight for age
♦ Look for ulcers or white patches in the mouth (thrush)
• Assess breastfeeding:
 Ask: Has the infant breastfed in the previous hour?
  If the infant has not fed in the previous hour, ask the mother to put her infant
to the breast
 Observe the breastfeeding for 4 minutes
 If the infant was fed during the last hour, ask the mother if she can wait &
tell you when the infant is willing to feed again
 LOOK, FEEL, LISTEN:
♥ Is the infant able to attach? (could be no attachment at all, not well
attached or good attachment)
 To check attachment, look for:
 Chin touching breast
 Mouth wide open
 Lower lip turn outward
 More areola visible above than below the mouth
(All of these signs should be present if the attachment is good)
♥ Is the infant sucking effectively that is slow, deep sucks, sometimes
pausing? (could be not suckling at all, not suckling effectively or
suckling effectively)
♥ Clear a blocked nose if it interferes with breastfeeding

 CHECK YOUNG INFANT’S IMMUNIZATION STATUS & VITAMIN A

STATUS
• Birth: BCG, HEPA-B1
• 6 weeks: DPT1, OPV1, HEPA-B2
• 10 weeks: DPT2, OPV2
• Vitamin A 200,000 to the mother within four weeks of delivery
• Give all missed doses on this visit
• Include sick infants unless being referred
• Advise the caretaker when to return for the next dose

 CLASSIFY & TREAT

 VERY SEVERE DISEASE & LOCAL INFECTION:

CLASSIFICATION SIGNS TREATMENT

VERY SEVERE Any one of the ff signs: *Give 1st dose of IM antibiotics
DISEASE  Not feeding well *Treat to prevent ↓ blood sugar
 Convulsions *Refer urgently to the hospital++
 Fast breathing (60 bpm or more) *Advise mother how to keep the
 Severe chest indrawing infant warm on the way to the
 Fever (37.5°C or above)+ hospital
 Low body temperature (less
than 35.5°C)+
 Movement only when
stimulated or no movement at
all
LOCAL BACTERIAL Umbilicus red or draining pus or *Give an appropriate oral
INFECTION Skin pustules antibiotic
*Teach the mother to treat local
infections at home
*Advise mother to give home
care for the young infant
*Follow up in 2 days
SEVERE DISEASE None of the signs of very severe *Advise mother to give home
OR LOCAL disease or local bacterial infection care for the young infant
INFECTION
UNLIKELY

+ These thresholds are based on axillary temperature. The thresholds for rectal
temperature readings are approximately 0.5°C higher.
++ If referral is not possible, see Integrated Management of Childhood Illness
Management of the sick young infant module Annex 2 “Where referral is not
possible.”
 JAUNDICE

CLASSIFICATION SIGNS TREATMENT

SEVERE Any jaundice if age less than 24 *Treat to prevent low blood sugar
JAUNDICE hours or *Refer urgently to hospital
Yellow palms & soles at any age * Advise mother how to keep the
infant warm on the way to the
hospital
JAUNDICE Jaundice appearing after 24 hours *Advise the mother to give home
of age & care for the young
Palms & soles not yellow *Advise mother to return
immediately if palms & soles
appear yellow.
*If the young infant is older than
14 days, refer to a hospital for
assessment.
*Follow up in 1 day
NO JAUNDICE No jaundice *Advise the mother to give home
care for the young infant.

 DIARRHEA:

CLASSIFICATION SIGNS TREATMENT

SEVERE Two of the ff signs: *If infant does not have possible
DEHYDRATION Abnormally sleepy or difficult to serious bacterial infection nor
awaken dysentery – give fluid for
Sunken eyes severe dehydration (Plan C)
Skin pinch goes back very slowly *If infant also has possible
serious bacterial infection or
dysentery – refer urgently to
hospital with mother giving
frequent sips of ORS on the
way; advise mother to continue
breastfeeding; advise mother to
how to keep the baby warm on
the way to the hospital.
SOME Two of the ff signs: *Give fluid & food for some
DEHYDRATION Restless, irritable dehydration (Plan B)
Sunken eyes *If infant also has possible
Skin pinch goes back slowly serious bacterial infection or
dysentery – refer urgently to
hospital with mother giving
frequent sips of ORS on the
way; advise mother to continue
breastfeeding
NO DEHYDRATION Not enough signs to classify as *Give fluid & food to treat
some or severe dehydration diarrhea at home (Plan A)
SEVERE Diarrhea lasting 14 days or more *If young infant is dehydrated,
PERSISTENT treat dehydration before
DIARRHEA referral unless the infant has
also possible serious bacterial
infection
*Refer to hospital
DYSENTERY Blood in the stool *Refer urgently to hospital with
mother giving frequent sips of
ORS on the way; advise
mother to continue
breastfeeding

 FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN BREASTFED

INFANTS

CLASSIFICATION SIGNS TREATMENT

FEEDING PROBLEM Not well attached to breast or  If not well attached or not
OR LOW WEIGHT FOR Not sucking effectively sucking effectively, teach
AGE correct positioning &
attachment
 If not able to attach well
immediately, teach the mother
to express breast milk & feed
 by a cup.
 If breastfeeding less than 8x a
day, advise to ↑ frequency of
feeding. Advise mother to
breastfeed as often & for as
long as the infant wants, day &
night.
 If receiving other foods or
drinks, counsel mother about
breastfeeding more & reducing
other foods or drinks using a
cup.
 If not breastfeeding at all, refer
for breastfeeding counseling &
possible relactation; advise
about correctly preparing
breastmilk substitutes & using
a cup
 Advise the mother how to feed
& keep low weight infant
warm at home.
 If with 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
NO FEEDING Not low weigh for age & no *Advise mother to give home
PROBLEM other signs of inadequate care for the young infant
feeding *Praise the mother for feeding the
infant well

TREAT THE YOUNG INFANT & COUNSEL THE MOTHER

 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 & wrap the infant
in a dry cloth & cover with blanket.

 GIVE AN APPROPRIATE ORAL ANTIBIOTIC FOR LOCAL INFECTION

• For local bacterial infection
• 1st line Antibiotic: AMOXYCILLIN
• 2nd line Antibiotic: COTRIMOXAZOLE

AMOXYCILLIN COTRIMOXAZOLE
Give 3x daily for 5 days (trimethroprim + sulphamethoxazole)
Give 2x daily for 5 days
AGE OR WEIGHT Tablet Syrup Adult Tablet Pediatric Tablet Syrup
250mg 125mg/5ml Single Strength 20mg trimethoprim (40mg trime. +
(80mg trime. + +100mg sulpha. 200mg sulfa)
400 mg sulfa.)
Birth – 1mo (4kg) ¼ 2.5ml ½* 1.25ml*
1-2mos (4-<6kg) ½ 5ml ¼ 1 2.5ml
* Avoid Cotrimoxazole in infants less than 1 month of age who are premature or
jaundiced.

 GIVE FIRST DOSE OF INTRAMUSCULAR ANTIBIOTICS

• Give first dose of both Benzylpenicillin & Gentamicin IM
• Referral is the best option for a young infant classified with VERY SEVERE
DISEASE; if referral is not possible, continue to give ampicillin & gentamicin for
at least 5 days. Give ampicillin two times daily to infants less than one week of age
& 3 times daily to infants one week or older. Give gentamicin once daily.
 AMPICILLIN GENTAMICIN
WEIGHT Dose: 50mg per kg Undiluted 2ml OR Add 6 ml sterile
To a vial of 250mg vial containing water to 2ml vial
Add 1.3 ml sterile water 20mg=2ml at containing 80 mg =
= 250mg/1.5ml 10mg/ml 8ml at 10mg/ml

AGE < 7days AGE >7days

Dose: 5mg per kg Dose: 7.5mg per kg
1-<1.5kg 0.4ml 0.6ml 0.9ml
1.5-<2kg 0.5ml 0.9ml 1.3ml
2-<2.5kg 0.7ml 1.1ml 1.7ml
2.5-<3kg 0.8ml 1.4ml 2.0ml
3-<3.5kg 1.0ml 1.6ml 2.4ml
3.5-<4kg 1.1ml 1.9ml 2.8ml
4-<4.5kg 1.3ml 2.1ml 3.2ml

 TREAT THE YOUNG INFANT & COUNSEL THE MOTHER

 To treat Diarrhea, see TREAT THE CHILD chart
 Immunize every sick young infant as neede

 TEACH MOTHER TO TREAT LOCAL INFECTIONS AT HOME

• Explain how the treatment is given
• Watch her as she does the first treatment in the health center
• Tell her to do the treatment twice daily; she should return to the health center if the
infection worsens

 TO TREAT SKIN PUSTULES

 Wash hands
 Gently wash off pus & crusts with soap & water
 Dry the area
 Paint with gentian violet
 Wash hands

 TO TREAT UMBILICAL INFECTION

 Wash hands
 Clean with 70% ethyl alcohol
 Paint with gentian violet
 Wash hands

 TO TREAT THRUSH
 Wash hands
 Wash mouth with clean soft cloth wrapped around the finger & wet with salt
water
 Paint the mouth with half-strength gentian violet
 Wash hands

 TEACH CORRECT POSITIONING & ATTACHMENT FOR

BREASTFEEDING

 Show the mother how to hold her infant

 With the infant’s head & body straight
 Facing her breast with infant’s nose opposite her nipples
 With infant’s body close to her body
 Supporting infant’s whole body not just the neck & shoulders

 Show her how to help the infant to attach

 She should touch her infant’s lips with her nipple
 She should wait until her infant’s mouth is opening wide
 She should move her infant quickly onto her breast, aiming the infant’s lower
lip well below the nipple

 Look for signs of good attachment & effective sucking; if the attachment or
sucking is not good, try again
 ADVISE MOTHER TO GIVE HOME CARE FOR THE YOUNG INFANT

 Food & Fluid: Breastfeed frequently, as often & for as long as the infant wants,
day or night, during sickness or health

 Make sure the young infant stays warm at all times; in cool weather, cover the
infant’s head & feet & dress the infant with extra clothing

 Follow-Up Visit

IF THE INFANT HAS: RETURN FOR FOLLOW-UP IN

Local Bacterial Infection
Any Feeding Problem 2 days
Thrush
Low Weight for Age 14 days

 When to Return Immediately

 Breastfeeding or drinking poorly
 Becomes sicker
 Develops a fever
 Fast breathing
 Difficult breathing
 Blood in stool
 Palms & sole appear yellow

 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 milk himself. DO NOT pour the milk into the infant’s
mouth.

 Teach the Mother How to Keep the Low Weight Infant Warm at Home
 Keep the young infant in the same bed with the mother
 Avoid bathing the low weight infant. When washing or bathing, do it in a very
warm room with warm water, dry immediately & thoroughly after bathing &
clothe the young infant immediately.
 Change clothes (eg. Diapers) whenever they are wet
 Provide skin to skin contact as much as possible, day & night. For skin to skin
contact:
• Dress the infant in a warm shirt open at the front, a nappy, hat & 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 (& 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 & socks, loosely wrap the young infant in a soft dry cloth & cover
with a blanket.
 Check frequently if the hands & feet are warm; if cold, re-warm the baby using
skin to skin contact
 Breastfeed (or express breast milk by cup) the infant frequently

 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-
25ml (10ml/kg) expressed breastmilk before departure. If not possible to give
expressed breastmilk, give 20-50ml (10ml/kg) sugar water. (To make sugar
 water: dissolve 4 level teaspoons of sugar (20grams) in a 200ml cup of clean
water).
 If the young infant is not able to swallow: Give 20-25ml (10ml/kg) of expressed
breastmilk or sugar water by nasogastric tube.

GIVE FOLLOW-UP CARE FOR THE SICK 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 at the skin pustules – Are then many or severe pustules?
 Treatment:
 If the pus or redness remains or is worse, refer to the hospital
 If pus & redness improve, tell the mother to continue giving the 5 days of
antibiotic & 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 & continue treating the local infection
at home.

 JAUNDICE
 After 1 day:
 Look for jaundice. Are palms & soles yellow?
 If palms & soles are yellow, refer to the hospital
 If palms & soles are not yellow, but jaundice has not decreased, advise the
mother home care & ask her to return for follow up in 1 day
 If jaundice has started decreasing, reassure the mother & ask her to continue
home care. Ask her to return for follow up at 2 weeks of age. If jaundice
continues beyond two weeks of age, refer the young infant to a hospital for
further assessment.

 DIARRHEA
 After 2 days:
 Ask: Has the diarrhea stopped?
 Treatment:
• If the diarrhea has not stopped, assess & treat the young infant for diarrhea.
See “Does the young infant have diarrhea?”
• If diarrhea has stopped, tell the mother to continue exclusive breastfeeding

 FEEDING PROBLEM
 After 2 days:
 Reassess feeding – > See “Then check for feeding problem or low weight”
 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 is low weight for age, ask the mother to return after 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 the young infant has
lost weight, refer the child

 LOW WEIGHT
 After 14 days:
 Weigh the young infant & determine if the infant is still low weight for age
 Reassess feeding – > See “Then check for feeding problems or low weight”
 If the infant is no longer low weight for age, praise the mother & encourage her to
continue
 If the infant is still low weight for age but is feeding, praise the mother; ask her to
come again within a month or when she returns for immunization
  If the infant is still low weight for age & 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 2 weeks). Continue to see the
young infant every few weeks until the infant is feeding well & gaining weight
regularly or is no longer low weight for age
 Exception: If you do not think that feeding will improve, or the young infant has
lost weight, refer to hospital

 ORAL THRUSH
 After 2 days:
 Look for ulcers or white patches in the mouth
 Reassess feeding > See “Then check for feeding problem or low weight”
 If thrush is worse or if the infant has problem with attachment or sucking, refer to
the hospital
 If thrush is the same or better & if the infant is feeding well, continue the
treatment of half-strength gentian violet for a total of 5 days

IMCI COLOR-CODED SYSTEM

COLOR PRESENTATION CLASSIFICATION OF LEVEL OF

DISEASES MANAGEMENT
Green Mild Home Care
Yellow Moderate Manage at the RHU
Pink Severe Urgent Referral to Hospital