UNIT 6 HOSPITAL MANAGEMENT OF

SICK YOUNG INFANT

structure
6.0 Objectives
6.1 Introduction
6.2 Management Process of the sick child
6.3 Triage Process
6.4 Danger signs in newborns and young infants
6.5 Supportive care for the sick neonate
6.5.I Thermal environment
6.5.2 Oxygen Therapy
6.5.3 Fluid management
6.5.4 Maintain normoglycemia
6.5.5 Management of Shock
6.6 Management of convulsions
6.7 Management of specific conditions
6.7.1 Perinatal Asphyxia
6.7.2 Serious Bacterial Infection
6.7.3 Meningitis
6.7.4 Pneumonia
6.7.5 Diarrhoea
6.7.6 Tetanus Neonatorum
6.7.7 Management of Jaundice
6.8 Monitoring sick young infant
6.9 Discharge from the hospital
6.10 Providing follow-up care.
6.1 1 Let Us Sum Up

6.0 OBJECTIVES
After completion of this section the participant should be able to-
e Carry out ETAT (Emergency Triage, Assessment and Treatment) for all sick young
infants when they arrive at a health facility into the following categories:
--Those with emergency signs
- Those with priority signs
- Those who are non-urgent cases.

Identify sick young infants requiring hospitalization

Provide supportive care to sick young infants
Treat serious bacterial infections, post-asphyxia1 and jaundiced babies.

6.1 INRODUCTION
Many deaths in hospital occur within 24 hours of admission. Some of these deaths can be
prevented if very sick young infants are quickly identified on their arrival and treatment is
started without delay.
I and ETAT guidelines help in identifying infants with life-threatening conditions which are most
frequently seen in developing countries. While a dedicated team should continue to run the
emergency department twenty-four hours, it is very important that new doctors and nurses
are taught the skills and are fully supervised. This unit describes a sequential process for
managing sick young infants as soon as they arrive in hospital. The unit contains
guidelines for triage, emergency treatment and inpatient care in small hospitals where basic
laboratory facilities and inexpensive essential drugs are available.

6.2 MANAGEMENT PROCESS OF THE SICK CHILD

The first step in assessing infants referred to a hospital should be triage- the process of
rapid screening to decide which of the following groups a sick infant belongs to (Fig. 6.1):

TRIAGE
Check for emergency signs EMERGENCY TREATMENT
until stable

+I
Check for priority signs or conditions

HISTORY AND EXAMINATION

LABORATORY AND OTHER INVESTIGATIONS, if required

1
List and consider DIFFERENTIAL DIAGNOSES

Select MAIN DIAGNOSES (and secondary diagnoses)

1
Plan and begin INPATIENT TREATMENT (including supportive care)

MON I'I'OR for

Complications
Response to treatment

(Not improving or new . (Improving)

problem (complication)

COUNSEL and
TREAT COMPLICATIONS
(Refer if not possible)

DISCHARGE HOME
Arrange continuing care or FOLLOW-UP at hospital or in community

Fig 6.1: Steps in the management of the sick child admitted to hospital: Summary of
key elements
 First assess every sick young for emergency signs. Those with emergency signs Hospital Management o f
require immediate emergency treatment. Sick Young Infant

If emergency signs are not present look for priority signs. Those with priority signs
should alert you to a patient who is seriously ill and needs immediate assessment and
treatment.
lnfants with nb emergency or priority signs are treated as Non-~~rgent
cases
1. Once emergency signs are identified, prompt emergency treatment needs to be
given to stabilize the condition of the child.

b
2. A detailed history is taken and examination should be performed relevant to the
presenting problems of the child.
3. Perform relevant laboratory investigations.
4. A list of possible diagnoses should be made. A sick child often has more than
one diagnosis or clinical problem requiring treatment.
5. After deciding the main diagnosis and any secondary diagnoses or problems,
treatment should be started (Specific and Supportive).
6. Monitor and reassess the sick child.
7. Plan the discharge after improvement. At discharge, teach the mother all
treatments at home and advise when to return immediately and arrange a follow-
UP.

6.3 TRIAGE PROCESS

i The word "triage" means sorting. Triage is the process of rapidly examining all sick
I
children when they first arrive in hospital in order to place them in one of the following
I categories:
I

Those with EMERGENCY SIGNS who require immediate emergency treatment

I
lfyou find any emergency signs, do the following immediately:
I
- Start emergency treatment
- Call other health workers for help
- Draw samples for emergency laboratory investigations
Those with PRIORITY SIGNS, indicating that they should be given priority in the
queue, so that they can rapidly be assessed and treated without delay.

I Those who have no emergency or priority signs and therefore are NON-URGENT
cases. These children can wait their turn in the queue for assessment and treatment.

Categories after triage Action required

Emergency cases Need emergency treatment
Priority cases Need assessment and rapid action

Non-urgent cases Can wait their turn in the queue

('are of New born and The triaging process
\oung Infant
Triaging should be quick and you must learn to assess several signs at the same time.
When and Where Should Triaging Take Place?
Triage should be carried out as soon as a sick infant arrives in the hospital, well before any
administrative procedure such as registration. This may require reorganizing the flow of
patients in some locations. Triage can be carried out in different locations - e.g. in the
outpatient queue, in the emergency room, or in a ward if the child has been brought
directly to the ward at night. In some settings, triage is done in all these places.
How to Triage?
Keep in mind the ABCD steps: Airway, Breathing, Circulation, Coma, Convulsion, and
Dehydration.
Assessing emergency signs: The ABCD concept
To quickly assess the patient for serious illness or injury, assess emergency signs which
relate to the Airway-Breathing-Circulation/ Consciousness-Dehydration. You can easily
remctnber them as "ABCD". Fig 6.2 shows the flowchart for triaging sick young infant
coming to hospital.
TRFA4T:
ASSILSS I O R EhIF,R(:iICN(.:YSI<;SS k;YII.:H<;I.:XC:YSI<;\S: Il';ui! \ign
(In all Cases) p)sitiw:gikc trcatr~wnt(s).(.:ill k)r-llclp.
d~awbltxd li)r c-lnc.l.y!lcy lalx)rAol)

Not Breathing or Gasping or

Central cyanosis or I I Manage airway (chart 3)
AIRWAY AND Severe respiratory distress = Provide basic life support
BRI'ATHING - Unable to drink Give oxygen (chart 6 )
- Respiratory rate 2 7Olmin ANY SIGN Makc sure cliild is v,m
- Severe lower chest indrawing
- Apmic spells
- Grunt~ng

I Cold hands with: I Give oxlgen (chart 6)

Make sure baby IS v,m
'a Capillary rctill longer than 3 Insen IV and g~ve223 mllkg flu~dover
seconds. and 30 mln (chart 9)
Weak and fast pulse

I
Colnla or Manage airway (chart 3)

CONVULSIN
Convulsing (now)
IF COMA/
CONWLSMG
' 1
If convulsing, give phenobarbitone
(if < 2 weeks) OR diazepam(if > 2
weeks) (ehart l I)
Give lV glucose (Chart 12)

SEVERE Dianhoea plus any two ofthese: Make sure child is wmn.
DEHYDRATION Insert lV line and begin giving
(IN INFANT Lethargy fluids rapidly tbllowing (Chart 13)
MTH ( Sunken eyes
DIARRHOEA) Very slow skin plnch I r i i ~ ~ s I
Pos~trve
1
IF THERE ARE NO EMERGENCY SIGNS U)OK FOR PRIORITY SIGNS:
'Thew neonaces need ommot assessnent and treatment

Priority signs
Respiratory distress (Respiratoryrate > 60/mn) Abdonunal distention
Bulging anterior fontanelle Ycllov, p;ilna a~xlsoles
Lharrlm Von~iting
Blwi~ng Ultxd III sttxd
Il)potherm~a Fever
<:IR(Klgm

Proceed with assessment and further treatment according to the child's priority
NON-URGENT:

Fig. 6.2: Flow diagram for Triaging Sick Young Infant

 Hospital Management of
Emergency signs Sick Young Infant

Not breathing at all or gasping

Central cyanosis
Severe respiratory distress
Shock: Cold hands and
Capillary refill>3seconds and
Weak and fast pulse
Coma
Convulsions
Diarrhea with severe dehydration
Any two signs:
Lethargy
Sunken eyes
Very slow skin pinch

6.4 DANGER SIGNS IN NEWBORNS AND YOUNG

INFANTS
Neonates and young infants often present with non-specific symptoms and signs which
indicate severe ~llness.These signs might be present at or after delivery, or in a young
infant presenting to hospital or develop during hospital admission. Initial management of
the neonate presenting with these signs is aimed at stabilizing the child, preventing
deterioration and subsequent mortality.
I
Emergency signs needing emergency treatment a s learnt earlier are:

Not breathing o r gasping

Severe respiratory distress
Central cyanosis
Signs of shock
Coma and convulsions
Severe dehydration
The Young Infants with emergency signs after stabilization a r e to be referred to a
specialized newborn care unit.

Priority signs indicating need for admission that can be managed in newborn unit
are;

Unable to feed
~ e s ~ i r a t bdistress
ry (Respiratory rate 60lmin or more)
Abdominal distention
Bulging anterior fontanelle
Yellow palms and soles
Diarrhea
Vomiting
Bleeding
Blood in stool
Care of Newborn and Hypothennia
Young infant
Fever
4800g
History
Review the referral notes or records of the birth, if available. Take relevant history related
to the problems of the baby, birth details including gestation and weight, details of
treatment given. Also review the mother's medical, obstetric, and social history and details
of pregnancy including duration, any chronic diseases during the pregnancy and any
complications and their treatment during pregnancy.

6.5 SUPPORTIVE CARE FOR THE SICK NEONATE

Before instituting specific therapy it is important to cany out supportive care to all sick
young infant i.e. keeping them warm, provision of oxygen, maintenance of normoglycemia
& initiating intravenous access and managing shock if present.

6.5.1 Thermal Environment

Keep the young infant dry and well wrapped.
A cap is helpful to reduce heat loss.
Keep the room warm (at least 25OC) making sure that there is no heat source directed
straight at the newborn
Keep the baby under a radiant warmer ad rapidly rewarm if there is severe
hyp0thermia(temp<32~C)
<ay special attention to avoid chilling the infant during examination or investigation.
Regularly check that the infant's temperature is maintained in the range 36.5-37.4OC.
Do not use antipyretic agents such as paracetamol for controlling fever in young
infants. As it can lead to hypothermia and hepatic toxicity if correct dose is not
administered Control the environment. If necessary, undress the child.
6.5.2 Oxygen Therapy
Provide oxygen therapy to all sick young infant with emergency signs and those
having respiratory rate more than 60 per minute.
Give oxygen by nasal catheter, nasal prongs or by head box

Table 6.1: Methods for administering oxygen

Method Nasal catheter Head box

Flow & Concentration Low = 0.5 L per minute Low = 3 L per minute
Moderate = 0.5 to 1 L per min Moderate = 3 to 5 L per min
High = more than 1 L per min High = more than 5 L per min

NASAL PRONGS

These are a useful means of delivering oxygen. Use appropriate size prongs, which fit the
neonate well, should be used. These could be used with an oxygen source directly or with a
CPAP machine. There are specific indications for the use of CPAP in respiratory distress in
neonates.
NASAL CATHETER

Use a 6-8 French catheter.

Determine the distance the tube should be passed by measuring the distance from the
nostril to the inner margin of the eyebrow.
 Gently insert the catheter into the nostril. bspital Management of
Sick Young Infant
Ensure that the catheter is correctly positioned.
- Look into the baby's mouth;
- The catheter should not be visible at the back of the mouth;
- lfthe catheter is visible at the back of the mouth, pull the catheter out slowly
until it is no longer visible.
Adjust the flow of oxygen to achieve the desired concentration.
Change the nasal catheter twice daily. Give oxygen using a face mask while cleaning
and disinfecting the catheter if necessary.
HEAD BOX
Place a head box over the baby's head.
Ensure that the baby's head stays within the head box, even when the baby moves.
Adjust the flow of oxygen to achieve the desired concentration.
lfthe baby's breathing difficulty worsens or the baby has central cyanosis:
Give oxygen at a high flow rate
If breathing difficulty is so severe that the baby has central cyanosis even in 100%
oxygen, organize transfer and urgently refer the baby to a tertiary hospital or
specialized centre capable of assisted ventilation, if possible

6.5.3 Fluid management

Encourage the mother to breastfeed frequently to prevent hypoglycemia. If unable to feed,
give expressed breast milk by nasogastric tube.
Withhold oral feeding if there is bowel obstruction, necrotizing enterocolitis or the
feeds are not tolerated, e.g. indicated by increasing abdominal distension or vomiting
everything.
Withhold oral feeding in the acute phase in babies who are lethargic or unconscious,
having frequent convulsions, apnea in shock or having moderate-to severe respiratory
distress.
Give I V fluids

Intravenous fluids

The fluid requirements of LBW neonates are summarized in Table 6.2.

Table 6.2: Fluid requirement of neonates (muper kg body weight)

Days of life Birth weight

> 1500g 1000 tom1500g

1 60 80
2 75 95
3 90 110

7 onwards 150 150

Note:
(i) On the first day the fluid requirements range from 60 to 80 mllkg.
(ii) The daily increment in all groups is around 15 ml per kg till day 7
Care of Newborn and Type of fluid
Young Infant
First 2 days : 10% dextrose in water

After 2 days: Isolyte-P OR 10% dextrose in water with sodium chloride and
Potassium chloride (dose of 2 mmollkg each)
Monitor the IV infusion very carefully.
Use a monitoring sheet.

CalcuIate drip rate

Check drip rate and volume infused every hour

Check for edemalpuffiness of eyes (could indicate volume overload)

Weigh baby daily to detect excessive weight gain (excess fluid) or loss (insuficient
fluid); adjust IV fluids appropriately.
Introduce milk feeding by nasogastric tube or breastfeeding as soon as it is safe to do so.
Reduce the IV fluid rates as the volume of milk feeds increases.

6.5.4 Maintain normoglycemia

Maintain normoglycemia by either intravenous fluid or by provision of breast milk.
Insert IV line and draw blood rapidly for emergency laboratory investigations

Check blood glucose: if low (< 45 mgldl) or if dextrostix is not available:

Give 2 mlkg of 10% glucose solution rapidly by IV injection. In case of convulsion
give 5 mlkg of 10% dextrose.
Neonatal Hypoglycemia:
Start infusion of glucose at the daily maintenance volume according to the baby's age
so as to provide 6 mgkglmin of glucose in all cases of neonatal hypoglycemia
Recheck the blood glucose in 30 minutes. If it is still low, repeat the bolus of glucose
(above) and increase infusion rate of glucose to 8 mglkglmin and then to 10 mglkgl
min. Table 6.3 depicts the volume of 10% and 25% dextrose to be added to get
appropriate glucose concentration. Do not discontinue the glucose infusion abruptly.
It can cause rebound hypoglycemia.
Glucose infusion rates > IOmgkglmin can result in glucose concentration > 13% in the
infused fluid. Under such circumstances infusion through peripheral veins is not
recommended. It would require infusion through umbilical vein. If you cannot
cannulate the umbilical vein refer the baby to a higher health facility.

Table 6.3: Normogram for appropriate glucose concentration

Volume Glucose infusion rate

(mllkgld) 6 mg/kg/min 8 mg/kg/min 10 mglkglmin
Dl0 D25 Dl0 D25 Dl0 D25
(ml/kg) (mllkg) (mllkg) (mllkg) (mllkg) (m/kgl)
60 42 18 24 36 0 60

70 54 11 40 30 20 50
80 76 4 56 24 36 44

90 90 76 16 54 36
100 90* 90 10 70 30

*Add 10 mllkgld of Isolyte-P

. .
If hypoglycemia is persisting at 10 mgtkgimin of glucose infusion, give one dose of H o s p i t a l .Management
Hydrocortisone: 5 mglkg and refer to a higher health facility for management of refractory I o f Sick Young I n f a n t
persistent hypoglycemia.
Now we will learn through following example to calculate glucose infusion rate.
Example: Calculating glucose infusion rate for treating hypoglycemia

A 2.5 kg hypoglycemic infant requires 6 mglkgimin of glucose infusion and daily fluid
volume at 70 mlkg.

Step 1: Total fluid needed in a day: 70 (mVkg) x 2.5 (kg) = 175 ml

Step 2: Look at chart to check composition of fluid

For 70 mllkgld @ 6mglkgimin we need 59mllkg of Dl 0 and 1 Imllkg of D25.

Amount of D I0 neededlday: 59 ml x 2.5 = 148 ml

Amount of D25 neededlday: 11 ml x 2.5 = 27 ml

Step 3: Writing fluid order

58 ml(9ml D25 + 49 ml DlO) in 8 hours @ 7-8 udropslmin*

In Micro infusion burette set 1 ml = 60 drops; so dropslmin = mllhr of fluid

6.5.5 Management of shock

Clinical Features of shock
Poor peripheral pulses
Pallor
Mottling of skin
Cold extremities
Increased capillary refill time (>3 seconds)
Tachycardia
Treatment

Shock is an emergency and outcome depends on early diagnosis and management.

Oxygen, airway and breathing are to be maintained. Restoring perfusion is the
cornerstone in shock management.
Fluid resuscitation Infuse fluid bolus of 10 mllkg ofnormal saline over 20-30 minutes.
e.g. in a baby weighing 3 kg, 30 ml of normal saline should be infused over 20-30
minutes. If no or partial improvement (i.e tuchycurdiu and CRT stillprolonged),
repeat a bolus of 10 m l k g of normal saline.
If the signs of poor perfusion persist despite 2 fluid boluses, start vasopressor
support. The most commonly used vasopressor in neonatal practice is dopamine.
Dose Usual starting dose is 5 -10 pkglrnin and if no improvement occurs, the dose can be
-
increase by increments of 5 plkglmin every 20 30 minutes to a maximum of
20 gkglmin.

How to give Dopamine 1 ml of commercially available dopamine contains 40 mg of

dopamine. In a baby weighing 2.5 kg if we want to start dopamine at a rate of 10 pgikgl
min:

= 36 mg of dopamine in 24 hours
It means if we add 0.9 ml of dopamine in 24 ml of fluid and give @ rate of 1 mll hr with
syringe pump or 60 micro drops per min with the micro drip set, we will give dopamine at
the desired rate i.e. @ 10 pglkglmin
Care of Newborn and
Young Infant 6.6 MANAGEMENT OF CONVULSIONS
Manage emergency signs as per emergency management guidelines by maintaining airway,
breathing and circulation. Table 6.4 describes the management of convulsion in neonates
(up to 2 weeks) and in neonates who are older than 2 weeks of age.
Check for hypoglycemia, if blood glucose <45mg/dl then treat for hypoglycaemia. If
not possible to check for blood sugar, give intravenous SmlIKg of 10% dextrose.

If blood sugar is normal or no response to I N glucose then give 2mllKg of Inj.

Calcium gluconate diluted with equal amounts of water for injection. Precaution
should be taken to give calcium slowly over 5-10 minutes while monitoring the heart
rate since bradycardia can occur with calcium infusion.

Anti-epileptic drugs (AEDs) should be given if seizures persist even after correction
of hypoglycemia & hypocalcaemia. Phenobarbitone is the drug of choice to be given,
20 mglkg IV slowly over 20 min, If seizures persist after completion ofthis loading
dose repeat doses of phenobarbitone 10 mglkg may be used every 20-30 min till a total
dose of 40 mg/kg has been given. Once convulsions are controlled the drug is given
in maintenance dose of 3-5 mglkglday in 1-2 divided dose, started 12 hrs after the
loading dose.
We should be careful of potential respiratory depression with higher doses of
phenobarbitone.

lf convulsions are still not controlled: Give Phenytoin in a dose of 20 mglkg IV over 20 - 30
minutes.

Caution: Phenytoin should only be mixed with saline and not in dextrose as it precipitates
in Dextrose.

Monitor: breathing and circulation because infants may become apneic and hypotension
can occur specially with phenytoin.

Table 6.4: Management of convulsions

Neonates (up to 2 weeks)

Identify and characterize the seizure
Secure airway and optimize breathing, circulation and temperature
Start oxygen if seizures continue
Secure IV access
If blood sugar < 45 mgldl, give 5 mlkg 10% dextrose
If seizures continue: IV phenobarbitone 20 mglkg over 20 min
If no control: Rpt phenobarbitone 10 mgkg till a total of 40 mglkg
If seizures continue: Give phenytoin 20 mglkg over 20 min
After control of seizures initiate maintenance doses
Beyond 2 weeks period: Give Diazepam rectally

Draw up the dose From an ampoule of diazepam into a tuberculin ( 1 ml) syringe. Base
the dose on the weight of the child, where possible. Then remove the needle.
Insert the syringe into the rectum 4 to 5 cm and inject the diazepam solution.
Hold buttocks together for a few minutes.
 Hospital Management
Diazepam given rectally (10 mg / 2 ml solution). Dose 0.1 mlkg o f S i c k Young Infant

2 weeks to 2 months (<4 kg)- 0.3 ml

If convulsion continues after 10 minutes, give a second dose of diazepam rectally lor
give diazepam intravenously (0.05 mlkg) if IV infusion is running]
If convulsion continues after another 10 minutes, give a third dose of diazepam
rectally (or Phenobarbital 1V of IM).
Caution
- Do not use Diazepam for control of convulsions in Young infant < 2 wks

- Continue Supportive Care and Treat Underlying Cause e.g. Meningitis

6.7 MANAGEMENT OF SPECIFIC CONDITIONS

Sick young infants not only require supportive care but also require specific management
for different conditions.

6.7.1 Perinatal asphyxia

Lack otloxygen supply to organs before, during or immediately after birth results in
asphyxib which is recognized by either delayed onset of breathinglcry with or withbut need
for assigted ventilation. These babies can present with multiple problems in first few days
of life.
Probleds in the postnatal period

Inbbility to suck

Poor muscle tone.

Management

1. Check for emergency signs and provide emergency care

2. Provide warmth to prevent hypothermia as these babies are unable to maintain

temperature

3. Check blood sugar and treat if hypoglycaemia detected

4. Fluids: If a baby has emergency signs, give maintenance I/V fluids after stabilization.
If there is no fluid loss in first few days or if there is weight gain restricts the fluid to 21
3rd or 50% of maintenance fluid.

5. If baby has no emergency signs or abdominal distension, consider feeding using

appropriate method.

6. Manage seizures as per the guidelines mentioned earlier. Before starting

anticonvulsants one should ascertain that metabolic derangements that may
complicate asphyxia and cause seizures (hypoglycemia, hypocalcaemia,
hyponatremia) have been taken care of. Stop anticonvulsants on the basis of
neurological examination, clinical condition and EEG if facilities are available. Primary
...
aims are to abort the clinical seizures.
Care of Newborn and Prognosis can be predicted by recovery of motor function and sucking ability. A baby who
Young Infant
is normally active will usually do well. A baby who, a week after birth, is still floppy or
spastic, unresponsive and cannot suck has a severe brain injury and will do poorly. The
prognosis is less grim for babies who have recovered some motor function and are
beginning to suck. The situation should be sensitively discussed with parents throughout
the time the baby is in hospital.

6.7.2 Serious Bacterial Infection

Serious bacterial infections include sepsis, pneumonia and meningitis and all these
present alike.
The various risk factors for serious bacterial infections are:
Maternal fever (temperature >37.9OC) before delivery or during labour
Membranes ruptured more than 24 hours before delivery
Foul smelling amniotic fluid
Etiology
Most cases of neonatal sepsis in the community are caused by Escherichia coli and
Staphylococcus aureus. In hospitals, Klebsiella pneumoniae is also a common organism.
Early-onset (72 hrs) infections are caused by organisms prevalent in the maternal genital
tract or in the delivery area. The associated factors for early-onset sepsis include low birth
weight, prolonged rupture of membranes; foul smelling liquor, multiple per vaginal
examinations, maternal feyer, difficult or prolonged labour and aspiration of meconium.
Early onset sepsis manifedts frequently as pneumonia and less kommonly as septicemia or
meningitis.
Late-onset septicemia is caused by the organisms thriving in the external environment of
the home or the hospital. The infection is often transmitted through the hands of the care-
providers. The onset of symptoms is usually delayed beyond 72 hours after birth and the
presentation is that of septicemia, pneumonia or meningitis. The associated factors of late-
onset sepsis include: low birth weight, lack of breastfeeding, superficial infections
(pyoderma, umbilical sepsis), aspiration of feeds, disruption of skin integrity with needle
pricks and use of intravenous fluids.
Possible serious bacterial infection in a young infant is us'ually suspected by the presence
of one or more of the following signs:
Convulsions or
Fast breathing (60 breaths per minute or more) or
Severe chest indrawing or
Nasal flaring
Gruntingor
Bulging fontanelle or
Axillary temperature 37.5OC or above (or feels hot to touch) or temperature less than
35.5OC (or feels cold to touch), or
Lethargic or unconscious, or
Less than normal movements
Unable to feed
Many of these symptoms may be present in other neonatal conditions eg perinatal
asphyxia, hypoglycemia or hypothermia. In such situation take the help of risk factors and
sepsis screen.

More specific localizing signs of infection which indicate serious bacterial infection
include:

Painful joints, joint swelling, reduced movement, and irritability if these parts are
handled
i a Many skin pustuleslbig boil (abscess) Hospital hlanagement
o f Sick Young I n f a n t
Umbilical redness extending to the periumbilical skin or umbilicus draining pus

Treatment of serious bacterial infections

Admit to hospital

Where blood cultures are available, obtain blood cultures before starting antibiotics
--
a Sepsis screen: A practical positive "sepsis screen" takes into account two or more
positive tests as given below:
*.
- TLC <9000lcumm (age <72 hrs); 4 0 0 0 or > 20,000lcumm (age > 72hrs)

- Neutropenia (ANC <I 800lcmm)

-- Immature neutrophil to total neutrophil (IIT) ratio > 0.2

Micro ESR (if < 14 days, then ESR = age in days + 2; after 14 days, ESR> 15mm
I st hour)

C-Reactive Protein (CRP) -positive

Start antibiotics; give Injection ampicillin (or penicillin) and gentamicin as per table 6.5
a Give cloxacillin (if available) instead of penicillin if extensive skin pustules or
abscesses as these might be signs of Staphylococcus infection
a Most serious bacterial infections in neonates should be treated with antibiotics for at
least 7-1 0 days
a If not improving in 2-3 days the antibiotic treatment may need to be changed, or the
baby referred
a Supportive care for the sick neonate (see section 6.5)
Vit K: All sick neonates < 2 weeks should be given 1 mg vitamin k IIM

Table 6.5: Antibiotic therapy of serious bacterial infection

Antibiotic Each Dose Frequency Route Duration

(mglkgldose) <7days age >7days age (Days)

Inj. Ampicillin or 50 12 hrly 8 hrly r ~IM, 7-10

Inj. Cloxacillin 50 12 hrly 8 hrly N 7-10

AND
Inj. Gentamicin or 2.5 12 hrly 8 hrly IV, IM 7-10

Inj. Amikacin 7.5 12 hrly 8 hrly IV, IM 7-10

6.7.3 Meningitis
In a infant with suspected serious bacterial infection if any one of the following signs are
present, suspect meningitis
Drowsiness, lethargy or unconscious
a Persistent irritable
a High pitched cry
a Apnoeic episodes
Care o f Newborn and Convulsion

Bulging fontanelle
To confirm the diagnosis of meningitis a lumbar puncture should be done immediately
unless the child is convulsing actively or is hemodynamically unstable.
Treat meningitis
Give antibiotics

Give ampicillin and gentamicin or a third generation cephalosporin, such as

ceftriaxone (50 mg/kg every 12 hours (use with caution in infants with jaundice) or
cefotaxime (50 m g k g every 6 hours) for 3 weeks. The dose, frequency and duration as
per table 6.6
Alternative antibiotics are penicillin and gentamicin. Chloramphenicol is an alternative
but should not be used in premature/low weight neonates.

Table 6.6: Antibiotic therapy of meningitis

Antibiotic Each Dose Frequency Route Duration

(mgkg/dose) <7days >7days (Weeks)

Inj. Ampicillin and 100 12 hrly 8 hrly N 3 weeks

Inj. Gentamicin 2.5 12 hrly 8 hrly N 3 weeks

OR Inj Cefotaxime 50 12 hrly 8 hrly N 3 weeks

Inj. Gentamicin 2.5 12 hrly 8 hrly N 3 weeks

Manage convulsions

See management of convulsions as discussed under section 6.6

Supportive care for the sick neonate

Provide supportive care discussed earlier in section 6.4

6.7.4 Pneumonia
Manage as for serious bacterial infection. Most of these babies have history of sepsis risk
factors in mother in case of early onset infection.

6.7.5 Diarrhoea
The normally frequent or loose stools of a breastfed baby are not diarrhoea. If the stools
have changed from usual pattern and are many and watery, it is diarrhoea. Diarrhea is
uncommon in breastfed babies and is seen in formula feed babies with poor hygiene.

Assess for:

Signs of dehydration

Duration of diarrhoea

Blood in the stool

Dehydration assessment

Assess for signs of dehydration and choose the appropriate plan of management. Also
assess for signs of possible sepsis and also determine if the young infant is low weight for
age.
 Hospital Management
Severe dehydration Two of the following signs: Manage severe o f Sick Young Infant
dehydration (Plan C)
Lethargic or
unconscious Start antibiotics
a Admit or refer
a Sunken eyes
Manage dehydration
Skin pinch very slow (Plan B)
Sonic dehyd~ation Two of the following signs: a Start antibiotics if signs
of sepsis or low weight
a Restless, irritable
Admit or refer
a Sunken eyes
a Plan A (Home care)
Skin pinch slow
No dehydration Not enough signs to classify a Advise mother when to
as severe or some return immediately
dehydration
a Follow up in 5 days if
not improving

A) Treatment of severe dehydration: Ayoung infant with severe dehydration needs IV

dehydration as described in Plan C (table 6.7). Start Inj Ampicillin and Gentamicin as for
cases of sepsis, as diarrhoea is generally a manifestation of systemic infection.
Table 6.7: How to treat severe dehydration in an emergency setting (Plan C)
Start 1V fluid immediately. If the child can drink, give ORS by mouth while the drip is
set up. Give 100 mllkg Ringer's lactate solution (or, if not available, normal saline),
divided as follows :

AGE First give 30 mllkg in Then give 70 mllkg in

Infants (under 12 months) 1 hour* 5 hours
* Repeat once ~frad~alpulse is still very weak or not detectable
Reassess the infant every 15-30 minutes. If hydration status is not improving, give the
1V drip more rapidly.
a Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4
hours.

Weight Volume of ORS solution per hour

<4 kg 15 ml
4 - <6 kg 25 ml
6 - < I 0 kg 40 ml
I0 - <14 kg 60 ml
14 - 19 kg 85 ml
a If IV treatment not possible, give ORS 20 ml/kg/hour for 6 hours(l20 mllkg)
by NG tube
a Reassess an infant after 6 hours. Classify dehydration. Then choose the appropriate
plan (A, B, or C) to continue treatment.
If possible, observe the infant for at least 6 hours after rehydration to be sure that the
mother can maintain hydration by giving the child ORS solution by mouth.

B ) Treatment of some dehydration: Manage dehydration as Plan B. In addition to ORS,

encourage the mother to breastfeed during first 4 hours of dehydration. If baby has low
Care of Newborn and weight or signs of sepsis, give antibiotics as for cases of sepsis table 6.8 provides the
loung Infant
detail of plan B treatment.

Table 6.8: Diarrhoea Treatment Plan B: Treat Some Dehydration with ORS
Give in clinic recommended amount of ORS over 4-hour period

DETERMINE AMOUNT OF ORS TO GlVE DURING FIRST4 HOURS

AGE* ZJp to 4 months I months up to l k 12 months up to 2 years up to
months 2 years 5 years

WEK;Hr < 6 Kg 6 -110 Kg 10-<I2 Kg 12-19 Kg

In ml 200-400 400 -700 700-900 900-1 400

-
Use the child's age only when you do not know the weight. The approximate amount of ORS required

(in ml) can also be calculated by multiplying the child's weight (in kg) times 75
- If the child wants more ORS than shown, give more.
- For infants under 6 months who are not breastfed, also give 100-200 ml clean
water during this period.
SHOW THE MOTHER HOW TO GlVE ORS SOLUTION.
- Give frequent small sips from a cup.
- If the child vomits, wait 10 minutes. Then continue, but more slowly
- Continue breastfeeding whenever the child wants.

AFTER 4 HOURS:
- Reassess the child and classify the child for dehydration
- Select the appropriate plan to continue treatment.
- Begin feeding the child in clinic.

IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:

- Show her howto prepare ORS solution at home.
- Show her how much ORS to give to finish 4-hour treatment at home.
- Give her enough ORS packets to complete rehydration.Also give her 2 packets as
recommendedin PlanA.
- Explain the Four Rules of Home Treatment:
Give extra fluid, Give zine sulphate, Continue feeding, and When to return

C) Treatment of no dehydration: Tell the mother to continue breastfeeding and teach the
mother danger signs to return immediately.

Severe persistent diarrhoea

If the young infant has diarrhoea for 14 days or more, manage as case of severe persistent
diarrhoea.

Treat severe persistent diarrhoea

Admit the young infant

Manage dehydration if present

Investigate and treat for sepsis: Start Inj. ampicillin & gentamicin
Encourage exclusive breastfeeding. Help mothers who are not breastfeeding to re-
establish lactation. If only animal milk must be given, give a breast milk substitute that
is low in lactose.
Give supplement vitamins and minerals for at least 2 weeks.

Loose stools with blood

Dysentery in young infant may be often due to surgical cause and more common in bottle
fed babies with poor hygiene
 Assess Hospital Management
o f Sick Young Infant
a Signs of dehydration
a Signs of possible bacterial infection
a Abdominal mass
a History of attacks of crying with pallor

Active baby Manage as hemorrhagic disease

1st week of age of newborn. Give Inj. Vitamin K

Loose stools with No signs of sepsis

blood a Signs of possible sepsis - Manage as sepsis / NEC
a Abdominal mass - Urgent referral
a Attacks of crying with
pal lor

Treat loose stools with blood

o Young infants less than 1 week of age, active and showing no signs of sepsis usually
have Hemorrhagic disease of newborn as cause of blood in the stools. Give Inj. Vit. K
1-2 mg stat. usually these babies do not have loose stools.

a The diagnostic possibilities in sick young infant having signs of sepsis are septicemia
and/or NEC. Get an X-ray abdomen. Manage as sepsis.
L
a Suspect a surgical cause like acute intussusception in a sick young infant with
abdominal distension or having attacks of crying with pallor. Get a urgent surgical
referral.

6.7.6 Tetanus Neonatorum

Tetanus Neonatorum occurs in babies whose mother's are not completely immunized
during the pregnancy or there is history of unclean cord cutting practice at birth

Diagnosis

Neonatal tetanus is diagnosed by the presence of

a Onset at 3-14 days
a Irritability
a Difficulty in breast feeding usually the first symptoms due to trismus
a Trismus
a Convulsions or spasms

Treatment
Tetanus immunoglobulin (TIC)

TIG is given to neutralize the circulating toxin. A single dose of 250-300 units IM is given at
admission.

Antibiotics
Crystalline penicillin is given in dose of 100,000 unit/kg/day 12 hourly 1V to eliminate the
source of toxin i.e. Clostridium tetani. An alternative antibiotic is oral erythromycin (by
nasogastric tube) in a dose of 40 mg/kg/day 12 hourly. Antibiotic therapy is given for 7-10
days.
Control of Spasms
This is the most importatit part of management as most deaths occur due to uncontrolled
spasms resulting in hypoxic damage. Diazepam is the drug of choice initiated at a dose of
Care of Newborn and 0.1-0. 2 mglkgldose every 3-6ho~11.s.Initially it is given IV intermittently and later as the
\'w~ngInfant
spasms are controlled it can be given orally. If spasms are not controlled then the dose of
diazepam can be increased up to 0.4 -0.6 mg/kg/dose.

If spasms are not controlled with diazepam then phenobarbitone in a dose of 10-15rnglkgl
day orally by NG tube 6 hourly can be added. Chlorpromazine can also be added at a dose
of I-2mglkglday 6 hourly orally by NG tube.

Once spasms are controlled, diazepam is decreased by 10% of its dose every third day.

Thermal Environment

Keep the infant warm, dry and well wrapped. Put a cap to reduce heat loss. As the infant's
condition improves keep the infant close to the mother ("kangaroo mother care")

Regularly check the infant's temperature (at least 4 hourly) to maintain an axillary
temperature in the range of 36.5 to 37.SC

If there is experience in the use of radiant heaters or incubators they can be used.

Care of airwajl: The neonate would require frequent suction of the mouth to clear the
airway. Oxygen therapy may be rzquired initially.

Fluids arid nutrition: Initially the neonate should be provided intravenous fluids as given
in section 6.4 on treatment of sepsis and meningitis. As soon as possible nasogastric
feeding of expressed milk should be started to finally provide about 120-150 ml/kg/day 3
hourly. When spasms are not well controlled nasogastric feed volumes should be kept low
to prevent aspiration.

Immunization: The neonate at discharge should be advised the standard immunization

schedule of DPT at 6, 10 and 14 weeks.

6.7.7 Management of jaundice

More than 50% of normal newborns, and 80% of preterm infants, have some jaundice.
Jaundice can be divided into physiological or pathological.

Pathological (Non-physiological) Jaundice

Characteristics Jaundice started on the first day of life

Jaundice lasting longer than 14 days in term, 2 1 days in preterm
infants
Deep jaundice: palms and soles of the baby deep yellow
Serious bacterial infection
Causes Haemolytic disease due to blood group incompatibility or
G6PD deficiency
Congenital syphilis or other intrauterine infection
Liver disease such as hepatitis or biliary atresia
Investigations Hypothyroidism
Serum bilirubin
Haemoglobin or PCV
Sepsis screen
Blood type of baby and mother, and Coombs test
Syphilis serology such as VDRL tests
G6PD screen, thyroid function tests, liver ultrasound (where
possible)

Treat jaundice:
The following charts will guide you to manage jaundice using either phototherapy or
exchange transfusion.
 Hospital Management o f
Sick Young Infant

0 0
Bfrth 24 h 48 h 72 h 96 h 5 Days 6 Days 7 Days

U s e lotal bflirubin. Do not subtract direct reacting or conjugated b~lirubin.

Risk factors = isoimmune hemolytic disease. G6PD deficiency, asphyxia, signiffcant lethargy, temperature instability.
sepsis, acidosis, or albumin -z 3.0~fdL(if measured)
F o r well infants 35-37 Bn wk can adjust TSB levels tor interventionaround the medium risk Itne. It is an option to
intervene at l w r TSB levels for infants closer to 35 wks and at higherTSB levels tor those closer to 37 617 wk.
It is on oplmn to provide colwentional phototherapy In hospital or at home at TS6 levels 2-3mgidL (35-50mmol!L)
below those shown but home phototherapy should not be used in any infant with risk faaors.

Fig. 6.3:Guidelines for initiating Phototherapy in Neonatal Hyperbiiirubinemia as per A A P Guidelines

2004

5-37 6I7'wk. and we

10 171
Birlh 24 h 48 h 72 3 96 h 5 Days 6 Days 7 Days

Age
T h e dashed lines tor the first 24 hours indicate uncertainty due l o a wide range of clinical circumstances

.and a range of responses to phototherapy

lmmediale exchange transfusiori IS recommended 11intant shows slgns ol acute bitirubfn encephalopathy
(hypertonia. arching, retrocollis, opisthotonos, lever, high pitched cry) or it TSB is 25 rngiddi ((85pmol!L)
above these lines.
Risk factors - !soimmune henrolyt~cdisease. G6PD deficiency, asphyxia, significant letharyy, temperature
instability, sepsis, acidosis.
Measure serum albumin and talculate BiA ratio (See legend)
Use total bilirubin. Do not subtract direct reacting or conjugated bilirubin
If infant is well and 35-37 617 wk (median risk) can individualizeTSB levels for exchange based on actual
gestational age.

Fig 6.4: Guidelines for Exchange Transfusion in Neonatal Hyperbilirubinemia as per A A P Guidelines
2004

Exchange transfusion is not described in this manual. These serum bilirubin levels are
included in case exchange transfusion is possible or in case the baby can be transferred
quickly and safely to another facility where exchange transfusion can be performed.
Prolonged Jaundice
Jaundice lasting longer than 14 days in term or 21 days in preterm infants is abnormal. If
the baby's stools are pale or the urine is dark, refer the baby to a specialized centre for
further evaluation.
Care of Newborn and
6.8 MONITORING OF SICK YOUNG INFANT
All sick young infants should be regularly monitored to detect improvement or worsening.
The table 6.8 given below provides a checklist for monitoring. The record should mention
the parameters to be monitored, frequency of monitoring, with date & time.

Table 6.8: Checklist for monitoring sick young infant

S. No. CHECKLIST ASSESSMENT ACTION

1. Temperature Mild hypothermia Rewarm by KMC

Hypothermia Rapid Rewarming by radiant
(Moderate!Severe) warmer

Fever Removal of excess clothing,

change environment, Sepsis
screening

2. Airway Obstructed Open the airway (Position and

suction)
3. Breathing ApnoeaIGasping PPV with Bag and Mask
Respiratory Distress Oxygen

4. Circulation Shock Give 10 ml/Kg

Normal salineIRL
In 30 min
5. Fluids No shock Maintenance Fluid

6. Medication Suspected sepsis Antibiotics

7. Feeding As per wt & age guidelines
8. Monitor Temperature, Respiration,
Colopr, Heart Rate, CRT,
Danger Signs
9. Communication For Home care:
a Exclusive Breast Feeding
a Maintain Temperature
a Cord & Eye Care
a Danger Signs
a Maternal Health
Care during referral

10. Follow Up

6.9 DISCHARGE FROM THE HOSPITAL

Careful monitoring of the infant's overall response to treatment and correct planning of
discharge from the hospital are just as important as making the diagnosis and initiating the
treatment. The discharge process for all sick infants should include:
a Correct timing of discharge from the hospital
a Counseling the mother on correct treatment and feeding of the infant at home
d
a Ensuring the infant's immuniration status and record card are up-to-date
 Communication with the health personnel who referred the infant or who will be Hospital Management of
Sick Young Infant
responsible for follow-up care (discharge card or a referral note. this will lead to more
appropriate referrals to hospital and better relationship between hospital and
community health workers)

Instructions on when to return for follow-up care and signs indicating the need to
retum immediately

- - - - - - -

6.10 PROVIDING FOLLOW-UP CARE.

I) Infants who are discharged from the hospital should retum for follow-up care to the
for checking the child's condition in relation to the present problem

2) Mother should be advised to return immediately if the child develops any of the
following signs:

Breastfeeding or drinking poorly

Becomes sicker

Develops a fever or feels cold to touch

Fast breathing

Difficult breathing

~elbw
palms and soles (if infant has jaundice)

Diarrhoea with blood in stool

3) Remind the mother of the child's next immunization visit

137
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 4) Serum bilirubin, Hemoglobin/hematocrit, Blood group of infant and mother are the Hospital Management of
Sick Young Infant
investigations to be carried out in a jaundiced infant.

5) 200-300 ml of ORS over 4 hours

6) If the infant has only diarrhea with severe dehydration with no other serious
classification such as possible severe bacterial infection, dysentry, severe persistent
diarrhea, not able to feed-possible serious bacterial infection.

b 7) Total fluid needed in a day: 100 (mllkg) x 2.0 (kg) = 200 ml

For 100 mllkgld @ 6mgIkg1'min we need 90mllkg of Dl0 and 1 Omllkg of

Amount of Dl0 neededlday: 90 ml x 2.0 = 180 ml

Amount of Isolyte-p neededlday: 10 ml x 2.0 = 20 ml

Writing fluid order

66 ml(6ml Isolyte-p + 60 ml D 10) in 8 hours @ 8 dropslmin

8) For 3.0 Kg baby on day 5, total fluid requirement 140 x 3.0 kg - 420 ml

Feeds are 5 m13 hourly i.e. 8 x 5 = 40 ml

Volume to be given as IV fluids= 420 - 40=380 ml

IV Isolyte-P 127ml 8 hourly @ 16 dropslmin

4 Dear learner,
While going through this block, you might have found certain portions ofthe text to be difficult
to comprehend and some scope to improve them. We wish to know your difficulties and
suggestions in order to improve the quality of the course. We, therefore, request you to fill up
and send us the following questionnaire, which pertains to this block. If you find the space
provided insufficient, Rinldy use a separate sheet.
Please mail the filled in questionnaire to: Programme Coordinator, PGDMCH Programme,
School of Health Sciences, IGNOU, Maidan Garhi, New Delhi-110 068.
Questionnaire
Enrolment No.
Section A: Unit Specific Comments
Unit I : ~ssentiulNewborn Cure
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Unit 2: Munugement of Low Birth Weight Babies

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Unit 3: introduction to ZMNCI
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Unit 4: Assess and CIassify Zffness

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Unit 5: Treat and Counsel
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I Unit 6: Hospital Management of Sick Young Infont

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lease list the sectionlsub-section.

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Section B: Block Specific Comments
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