Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

78
Dr. Dhruvendra Pandey

description

Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months, Difference between IMCI and IMNCI, Objective, Elements, Management of Diarrhea, Bacterial Infections, Jaundice, Hypothermia, Feeding problem, counseling of mothers, followup

Transcript of Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

Page 1: Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

Dr. Dhruvendra Pandey

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INTRODUCTION

Almost 19,000 children under 5 yrs of age, died everyday across the world. 50% of it occurs in just five countries i.e. India, Nigeria, Congo, Pakistan and China.

In India, there are nearly 16.55 lakhs child deaths during 2011 and we rank top among the countries with highest child mortality.

India IMR - 42/1000 live births. (46 – Rural, 28 - Urban)

M.P. IMR - 56/1000 live births (60 – Rural, 37 Urban)

(SRS 2013)

2/3rd children of M.P. are malnourished.

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WHO and UNICEF recognized the need to strengthen child-health activities in the country and decided to launch IMCI.

The generic IMCI guidelines were adapted and the Indian version was named Integrated Management of Neonatal and Childhood Illness (IMNCI).

IMNCI strategy is one of the main interventions under RCH-II/NRHM, that focuses on preventive, promotive and curative aspects of program.

Every year more than 10 million children die in developing countries before they reach their fifth birthday. Perinatal conditions, acute respiratory infections (ARI), diarrhea, measles and malnutrition are the commonest causes of morbidity in young children.

(Textbook of PSM, Park’s 22nd edition)

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Inclusion of 0-7 days age group (as against 1 week to

5 years in IMCI) to address the neonatal mortality challenge.

The order of training was reversed, starting from the young infant (0-2 months) to the older child (2 months-5 years).

The total duration of training was reduced from 11 days to 8 days out of which, half of the training time was earmarked for the management of the young infants, 0 to 2 months.

Incorporating National guideline on Malaria, Anemia, Vit. A supplementation and Immunization schedule.

Home-based care of newborns and young infants was included.

(Textbook of PSM, Park’s 22nd edition)

The major highlights of Indian adaptations were as follows:

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Difference B/w IMCI and IMNCI

Features Generic IMCI India IMNCI

Coverage of 0 – 6 days No Yes

Basic health worker module

No Yes

Home visit module by provider for care of newborn and young infants

No Yes

Home visit training No Yes

Duration of training on newborn and young infants

2 to 11 days 4 to 8 days

Sequence of training, behavior change communication

Child first than young infants

Newborn/ young infants than child

(National health programs of India, J Kishore 11th edition)

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Malnutrition*54%

MAJOR CAUSES OF NEONATAL AND CHILDHOOD MORBIDITY

43%

27%

17%

13%

Malnutrition

Fever

ARI

Diarrhoea

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What is IMNCI ?

• IMNCI is an integrated approach to child health that focuses on the well-being of the whole child. IMNCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age.

• IMNCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities.

•The strategy includes three main components:Improving case management skills of health-

care staff Improving overall health systems Improving family and community health

practices. (Textbook of PSM, Park’s 22nd edition)

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• In health facilities, the IMCI strategy promotes the accurate identification of childhood illnesses in outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counseling of caretakers, and speeds up the referral of severely ill children.

• In the home setting, it promotes appropriate care seeking behaviors, improved nutrition and preventative care, and the correct implementation of prescribed care.

• (Textbook of PSM, Park’s 22nd edition)

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IMNCI Plus(National health programs of India, J Kishore 11th edition)

New born and child health

CARe at BIRTh

IMmUNIZAT

ion

Home and community

levelPreventive, Promotive

careManagement

of mild illness

Facility careOut patient

careInpatient

care

IMNCI

Health system strenthening

BCC & community participation

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Why is IMNCI better than single condition approaches?

• Children brought for medical treatment are often found suffering from more than one morbid condition, making a single diagnosis impossible. These children require a combined therapy for successful treatment. Thus, the need of the hour is an integrated strategy that combines the treatment of major childhood illnesses.

•Cost effective

•Emphasizes on -Prevention of disease -Promotion of Child health and development -Provision of Standard Case management

(Textbook of PSM, Park’s 22nd edition)

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Objectives

1) Reducing infant mortality. 2) Reducing the incidence and seriousness of

illnesses and health problems. 3) Improving growth and development during

the first five years of a child's life

(Textbook of PSM, Park’s 22nd edition)

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Components of integrated approach

IMNCI includes both preventive and curative interventions. The strategy has the following three components:

1.Health-worker component: Improvements in the case-management skills of health staff through the provision of locally adapted guidelines

2.Health-service component: Improvements in the overall health system required for effective management of neonatal and childhood illness

3.Community component: Improvements in family and community health care practices.

(National health programs of India, J Kishore 11th edition)

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Work distribution

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Case Management Process

In IMNCI, only a limited number of carefully-selected clinical signs are considered, based on their sensitivity and specificity, to detect the disease. A combination of these signs helps in arriving at the child's classification, rather than a diagnosis.

Classification(s) also indicates the severity of the condition. The classifications are color coded:

A. PINK CLASSIFICATION: suggests hospital referral or admission (Child needs urgent referral)

B. YELLOW CLASSIFICATION: indicates initiation of treatment (Child needs specific medical treatment and advise)

C. GREEN CLASSIFICATION: calls for home treatment (Child needs no medicine, advise home care)

(National health programs of India, J Kishore 11th edition)

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A sick young infant up to 2 months of age is assessed for

Possible bacterial infections, diarrhoea , jaundice

Children of age 2 months to 5 years: Cough or difficult breathing, diarrhoea, fever &ear

problems

Active participation of caretakers in the treatment

Use of limited number of essential drugs

(National health programs of India, J Kishore 11th edition)

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ELEMENTS:-

Assess Danger signs, nutrition and immunization status Other problemsClassify as per Color CodingIdentify Specific TreatmentProvide Treatment Pre referral Medical treatment Home ManagementCounsel Feeding problems Mother’s healthFollow-up care(

Textbook of PSM, Park’s 22nd edition)

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CHECK FOR POSSIBLE DIARRHOEA

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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?

-immediately? (IMNCI Module 2 WHO, UNICEF, MOHFW)

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TURGOR’S SIGN

it is a sign commonly used by health care workers to assess the degree of fluid loss or dehydration.

I. Locate the area on the child's abdomen halfway between the umbilicus and the side of the abdomen; then pinch the skin using the your thumb and finger.

II. 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.

III. 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.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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TURGOR SIGN

When released, the skin pinch goes back either • very slowly (longer than 2 seconds),• slowly (skin stays up even for a brief

instant),• immediately.

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SIGNS OF DIARRHOEA

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Classification:

Signs Classify treatment

Two of the following signs:Lethargic or unconsciousSunken eyesSkin goes back very slowly

SEVERE DEHYDRATION

If infant has low weight or another severe classification:Give first dose of intramuscular ampicillin and gentamicin- Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way- Advise mother to continue breast feeding- Advise mother to keep the young infant warm on the way to the hospitalOR If infant does not have low weight or any other severe classification:- Give fluid for severe dehydration (Plan C) and then refer tohospital after rehydration(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Two of thefollowing signs:• Restless, irritable• Sunken eyes• Skin pinch goesback slowly.

SOMEDEHYDRATION

If infant has low weight or another severe classification:- Give first dose of intramuscular ampicillin and gentamicin- Refer URGENTLY to hospital with mother givingfrequent sips of ORS on the way- Advise mother to continue breast feeding-Advise mother to keep the young infant warm on theway 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- Follow up in 2 days

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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•Not enough signs to classify as some or severe dehydration

NODEHYDRATION

Give fluids to treat diarrhea at homeAdvise mother when to return immediately Follow up in 5 days if not improving <PLAN A>

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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•Diarrhea lasting 14 days or more

SEVERE PERSISTENT DIARRHOEA

Give first dose of intramuscular ampilicin and gentamicin if infant has low weight if the young infant has low weight, dehydration or another severe classification.Refer to hospitalAdvise to keep the baby warmTreat to prevent low blood sugar

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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•Blood in the stools SEVEREDYSENTERY

Give first dose of intramuscular ampilicin and gentamicin if infant has low weight if the young infant has low weight, dehydration or another severe classification.Refer to hospitalAdvise to keep the baby warmTreat to prevent low blood sugar

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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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

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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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. Taste of tears (not more

salty than that).

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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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. (IMNCI Module 2 WHO, UNICEF, MOHFW)

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Plan C:Treat severe dehydration Quickly

Start iv fluid immediately. If child can drink give ORS by mouth while the drip is set up.

Give 100ml/kg ringer lactate solution(if not available then N.saline) in dose divided as:

30ml/kg in first hour And rest 70ml/kg in 5 hour ..Reassess the child in every 15-30 mins .

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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FOLLOW UP :

After two days

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Assessment Of Feeding Problem And Malnutrition

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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?

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Look , Feel:-

Determine weight for age -Mid Upper Arm Circumference(MUAC) MUAC TAPE

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Assess Breast Feeding :-

•Has the infant breastfed in previous hour?•Is the infant able to attach?

To check attachment , look for:Chin touching breastMouth wide openLower lip turned outwardMore areola visible above than below .

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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If the infant has not feed in the previous hour, ask the mother to put her infant to the breast. Observe her breastfeed for 4 minutes.

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.

Is the infant able to attach?no attachment at all , not well attached , good attachment

Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?

not suckling at all not suckling effectively suckling effectively (IMNCI Module 2 WHO, UNICEF, MOHFW)

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Clear a blocked nose if it interferes with breastfeeding

Look for ulcers or white patches in the mouth(thrush)If yes, look and feel for:Flat or inverted nipples, or sore nipplesEngorged breasts or breast abscess

• Does the mother have pain while breastfeeding?(IMNCI Module 2 WHO, UNICEF, MOHFW)

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SIGNS

CLASSIFY AS

TREATMENT

•Not able to feed or•No attachment or•Not suckling at all or•Very low wt for age

Not able to feed –Possible serious bact. infection or Severe malnutrition

Give first dose of intramuscularampicillin and gentamicin Treat to prevent low blood sugar Warm the young infant by skin to skin contact if temperature less than 36.5oC (or feels cold to touch) whilearranging referral Advise mother how to keep the young infant warm on the way to the hospital Refer URGENTLY to hospital

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Not well attached tobreast or• Not suckling effectively or• Less than 8 breastfeedsin 24 hours or• Receives other foodsor drinks or• Moderately underweight(< -2SD to -3SD) or• Thrush (ulcers orwhite patches in mouth) or• Breast or nipple problems

Feeding problem or low weight for age

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 breastfeeding more, reducing other foods or drinks, and using a cup and spoon.• If not breastfeeding at all advise mother about giving locally appropriate animal milk and teach the mother to feed with a cup and spoon. If thrush, teach the mother to treat thrush at home.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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If breast or nipple problem, teach the mother to treat breast or nipple problems. If low weight for age, teach the mother how to keep the young infant with low weight warm at home Advise the mother to give home care for the young infant Advise mother when to return immediately Follow up any feeding problem or thrush in 2 days Follow up low weight for age in 14 days

•Not low weight for age and no signs of inadequate feeding

No feeding problem

Advise the mother to give home care for theyoung infant Advise mother when to return immediately Praise the mother for feeding the infant well

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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FOLLOW –UP CARE

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Feeding ProblemReassess feeding Ask about any feeding problems found on the initial visit.Counsel the mother, ask her to return back again in 2 days.

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

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Teach correct positioning and attachment for breastfeeding. Show the mother how to hold her infant With the infant 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.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Show her how to help the infant to attach.Infant’s chin should touch her breastMouth should be wide open.Upper areola should be visible more than the lower areola.Lower lip should be turned outward.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Look for signs of effective suckling.The baby takes slow and deep sucks (the pauses are to allow more milk to flow into the lactiferous sinuses/ milk ducts)You can see or hear baby swallowingThe baby cheeks are not drown inwards and are rounded during feedTo treat thrush (ulcers or white patches in mouth)Apply gentian violet 0.25% paint twice daily.The mother should :•Wash hands•Wash mouth•Paint the mouth with gentian violet.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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SUMMARY:-

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CHECK FOR POSSIBLE BACTERIAL INFECTIONS/JAUNDICE

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ASK:-•Has the infant had convulsions ?

LOOK ,LISTEN ,FEEL:-•Count the breaths in one minute .repeat the count•Look for severe chest indrawing•Look for nasal flaring•Look and listen for grunting•Look and feel bulging fontanelle•Look for pus draining from the ear•Look at the umbilicus-is it red or draining pus ?•Look for skin pustules. Are there 10 or more skin pustules or a big boil•Measure axillary temp.•See if the young infant is lethargic or unconscious•Look at the young infant’s movements. Are they less than normal?•Look for jaundice. Are the palms and soles yellow?

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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SIGNS CLASSIFY AS

IDENTIFY TREATMENT

•Convulsions or•Fast breathing(60 breaths per minute or more)•Severe chest indrawing •Nasal flaring•Grunting•Bulging fontanelle•10 or more skin pustules or a big boil If axillary temp>= 37.5 or temp<=35.5 degree celsius•Lethargic or unconscious•Less than normal movements

POSSIBLESERIOUSBACTERIAL INFECTION

Give first dose of intramuscular ampicillin and gentamicinTreat to prevent low blood sugarWarm the young infant by skin to skin contact if temperature less than 36.5°C (or feels cold to touch) while arranging referralAdvise mother how to keep the young infant warm on the way to the hospitalRefer URGENTLY to hospital#

(A) CLASSIFY ALL YOUNG INFANTS

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Look for chest indrawing when child breaths IN.The child has indrawing if the lower chest goes in when the child breathes in Chest indrawing occurs when the effort required to breathe in,is much greater than normal

CHEST INDRAWING

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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•Umbilicus red or draining pus•Pus discharge from ear or•< 10 skin pustules

LOCAL BACTERIAL INFECTION

Give oral co-trimoxazole or amoxycillin for 5 daysTeach mother to treat local infections at homeFollow up in two days

Umbilicus red

Draining pus

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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SIGNS CLASSIFY AS IDENTIFY TREATMENT

•Palms &soles yellow•Age <24hrs or•Age >=14 days

SEVERE JAUNDICE Treat to prevent low blood sugarWarm the young infant by skin toskin contact if temperature less than36.5°C (or feels cold to touch) whilearranging referralAdvise mother how to keep the young infant warm on the way to the hospitalRefer URGENTLY to hospital

•Palms& soles not yellow

JAUNDICE Advise mother to give home care for the young infantAdvise mother when to return immediatelyFollow up in 2 days

JAUNDICE(IMNCI Module 2 WHO, UNICEF, MOHFW)

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•Temperature between 35.5-36.5 degree Celsius

LOW BODY TEMPERATURE

Warm the young infant by skin contact for 1 hrTreat low blood sugar

(C) IF THE TEMPERATURE IS BETWEEN 35.5- 36.5 DEGREE CELCIUS

12

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Teach the mother to give oral drugs at home

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.

Treat The Young Infant For Local Infections At Home

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Local bacterial infections

Umbilicus red or draining pus

>10 or big boil<10 and no big boil

Remains or worse refer to hospital

Improved,continue treatment

Skin pustules Ear Discharge

Refer to hospital Continue treatment

Continue wicking to dry the ear

Follow-Up Care

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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Follow up

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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CHECK FOR POSSIBLE HYPOTHERMIA

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If a baby has a temperature of less than 36.5°C the baby has ‘hypothermia’.1) Mild hypothermia (36.0°C to 36.4°C)2) Moderate hypothermia (32°C to 36.0°C)3) Severe hypothermia (<32°C)

WHAT IS HYPOTHERMIA

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Large surface area of babies compared to their weight.• Limited heat generation mechanism.• Vulnerability to getting exposed.• Decreased subcutaneous fat and brown fat.• Poorer homeostatic response to hypothermia and early exhaustion of metabolic store like glucose.

CAUSES OF HYPOTHERMIA

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Axillary (standard method)• Rectal • Skin• Human touch-• abdomen, feet and hands are warm- Normal• abdomen is warm but feet and hands are cold- Cold stress•abdomen, feet and hands are cold- Hypothermia

METHODS OF TEMPERATURE MEASUREMENT

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Warm Chain- It is a sequence of ten steps- 1) Warm delivery room 2) Warm Resuscitation 3) Immediate drying 4) Skin to skin contact 5) Breastfeeding 6) Bathing postponed 7) Appropriate clothing 8) Mother and baby together 9) Professional alertness 10) Warm transportation

PREVENTION OF HYPOTHERMIA-

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Kangaroo mother care for low birth weight babies, was introduced in COLUMBIA in 1979, by Dr’s Hector Martinez and Edzar Rey.

KANGAROO MOTHER CARE

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• Skin-to-skin contact between mother and baby is called Kangaroo Mother Care.

• It is the most practical, preferred method of warming a hypothermic infant in a primary health care facility.

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PROCEDURE-•Provide privacy to the mother. If mother is not available then it may be provided by father or any other adult. •Request the mother to sit comfortably.•Undress the baby gently and place the baby prone on mother`s chest in upright and extended posture, between her breast, in skin to skin contact, turn baby`s head to one side to keep airway clear.• cover the baby with mother`s gown and wrap the baby mother duo with an added blanket or shawl.• if possible warm the room(>25 c) with a heat device.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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•Reassess after 1 hour. Look for signs of possible serious bacterial infection. Measure axillary temperature (or feel for low body temperature)• If signs present or temperature still below 36.50c refer urgently after giving pre-referral treatment.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

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1) Mild hypothermia (36.0°C to 36.4°C) Skin-to-Skin contact is the best way to keep a baby warm and the best way to ‘re-warm’ a baby who is cold to touch.

2) Moderate hypothermia (32°C to 36.0°C)Warm the young infant using Skin to Skin contact .If Skin to Skin contact is not possible, radiant warmer may be used if available.Encourage mother to breastfeed more frequently.If the baby’s temperature is not up to 36.50C or more after 2 hours of ‘rewarming’,reassess the baby for other problems.

MANAGEMENT OF HYPOTHERMIA

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3) Severe hypothermia (<32°C)Remove cold or wet clothing. Dress in warm clothes and a cap, and cover with a warm blanket.Warm immediately using a pre warmed radiant warmer.Check and treat for hypoglycemia .Treat for sepsis.Start IV fluids.Provide oxygen if indicated .Monitor temperature of the baby every ½ hourly.

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Counsel The Mother FOR HOME CARE

Advice mother to give home care for the young infant:

Food and fluids Breastfeed frequently as often and for as

long as the infant wants. Make sure the young infant stays warm at

all times.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

Page 75: Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

Follow-Up Visit

If the infant has Return for follow up in

•Local bacterial infection•Jaundice•Diarrhea•Any feeding problem•Thrush

2 days

•Low weight for age 14 days(IMNCI Module 2 WHO, UNICEF, MOHFW)

Page 76: Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

When To Return Immediately If the young infant has any of this

signs: Breastfeeding or drinking poorly Becomes sicker Develops a fever or feels cold to touch Fast breathing Difficult breathing Yellow palms and soles Diarrhoea with blood in stool.

(IMNCI Module 2 WHO, UNICEF, MOHFW)

Page 77: Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months
Page 78: Integrated management of Neonatal and Childhood illness among Infants of 0 to 2 months

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