OUTPATIENT MANAGEMENT OF CHILDREN BELOW 2 MONTHS (SICK YOUNG INFANTS)

Considering special characteristics of very young infants, e.g. non-specificity of clinical presentations, limited value of clinical signs and higher risk of rapid deterioration during an illness, separate guidelines have been recommended under IMNCI for management of children lt; 2 months (termed as sick young infants) as follows:

Step I.

Accordingly, all babies are classified in following five categories—(a) possible serious bacterial infection, (b) pneumonia, (c) local bacterial infection, (d) infection unlikely (Table 29.7).

Step II. Assessment for jaundice by—(a) asking the day on onset, and (b) checking the presence of jaundice on skin as well as on palms and soles.

TABLE 29.7: IMNCI classification for possible serious bacterial infection (Age up to 2 months)

Possible Serious Bacterial Infection or Very Severe Disease

Signs: (Any one)

(a) Not able to feed well, or (b) Severe chest indrawing, or

(c) Convulsions, or (d) Axillary temperature gt; 37.5#8725;lt;35.5°C, or

(e) No movements or movements only on stimulation Treatment:

• Give first dose of IM antibiotics

• Treat/prevent hypoglycemia

• Refer urgently, ensure warmth during transfer

Pneumonia

Sign:

Fast breathing (RR gt;60 after 7^th day)

Treatment:

If low weight or has other severe classification

• Give first dose of IM antibiotics

• Refer urgently, ensure warmth during transfer

If not low weight or has no other severe classification

• Give oral Amoxicillin for 5 days

• Advise home care

• Follow-up after 2 days or SOS

Local Bacterial Infection

Signs:

(a) Umbilical redness/pus discharge, or (b)Pustules

Treatment:

• Give oral amoxicillin for 5 days

• Advise home care

• Follow-up after 2 days or SOS

Infection Unlikely

TABLE 29.8: IMNCI classification for jaundice in young infant (Age up to 2 months)

Severe Jaundice

Signs:

(a) Jaundice lt; 24 hr of age, or (b) Yellow palm and soles

Treatment:

• Refer urgently, ensure warmth during transfer

• Treat/prevent hypothermia

Jaundice

Signs:

(a) Jaundice gt; 24 hrs age, or (b) Palms and soles not yellow

Treatment:

• Advise about home care

• Follow-up if palm/soles become yellow

• Refer if jaundice persists gt; 14 days

No Jaundice

Signs:

No jaundice

Treatment

• Advice home care

TABLE 29.9: IMNCI classification for diarrhea in young infants (Age up to 2 months)

Severe Dehydration

Signs: (Any two)

(a) Lethargic/unconscious (b) Sunken eyes,

(c) Inability to drink (d) Very low turgor

Treatment:

If any other severe classification

• Give first dose of IM antibiotics

• Refer urgently, ensure warmth during transfer

• Advice to continue ORS and breastfeeding during transfer

If no other severe classification

• Give IV fluids (WHO-Plan C) and then refer to hospital

Some Dehydration

Signs: (Any two)

(a) Restless/Irritable (b) Sunken eyes

(c) Thirsty, drinks eagerly (d) Low skin turgor

Treatment:

If low weight for age or has another severe classification

• Give first dose of IM antibiotics

• Refer urgently, ensure warmth during transfer

• Advice to continue ORS and breastfeeding during

If not low weight for age or no other severe classification

• Give oral fluids (WHO-Plan B)

No Dehydration

Signs: Not enough signs for some/severe dehydration

Treatment:

• Give ORS (WHO-Plan A)

• Continue breastfeeding

• Follow-up after 2 days

Step III.

TABLE 29.10: IMNCI classification for feeding problems (Age up to 2 months)

Very Low Weight

Signs: (a) Weight lt;1800 gm lt; 7 days or (b) Weight lt; 3 SD from 7-59 days

Treatment:

• Refer urgently, ensure warmth during transfer

• Treat/prevent hypoglycaemia

Feeding Problem or Low weight for age

Signs: (any one)

(a) Poor attachment, (b) Poor sucking, (c) lt; 8 feeds per day

(d) Fed on other food/drinks, (e) Oral thrush

(f) Low weight for age, (f) Breast and nipple problems Treatment:

• Advise to avoid other food/drinks

• Increase frequency of breastfeeding

• Advise correct position and attachment during breastfeeding

• Advise local animal milk with cup/spoon, if necessary

• Manage breast/nipple problems

• Treat oral thrush

• Follow-up for feeding problems after 2 days

• Follow-up for low weight after 14 days

No Feeding Problem

Sign: Weight for age gt;-2SD and no other signs of poor feeding Treatment:

• Advise the mother about baby care at home

• Praise mother for feeding the infant well

• Follow-up SOS

sucking, pain to mother while feeding (breast/nipple problems, e.g. sore nipples), (c) mesurment of body weight record, and (d) oral cavity examination for thrush.

Accordingly, an infant is classified as: (a) very low weight, (b) feeding problem or low weight for age, and (c) no feeding problem (Table 29.10).

Step IV. Assessment of immunization status: All due immunizations may be given to sick young infant, pro­vided s/he is not sick enough to require urgent referral.

Step V. Assessment of other problems: Mentioned by mothers or observed during examination. All young infants with potentially serious problems should be referred to higher center.

Step VI. Referral to the hospital: Following categories of cases (Pink color code) needs urgent referral—(a) possible serious bacterial infection or very severe disease, (b) pneumonia with low weight for age, (c) severe jaundice, and (d) very low weight. Cases of diarrhea with severe or some dehydration need urgent referral only if any other severe classification is present.

Some other categories of cases may also need non­urgent referral after follow-up.

A proper referral note, discussed earlier, should accompany the child.

All these cases should also receive essential pre­referral treatment, e.g. (a) first dose of antibiotics

(IM Ampicillin and Gentamycin, (b) treatment/ prevention of hypoglycemia by giving breast milk or sugar water, (c) treatment/prevention of hypothermia by skin to skin contact, i.e. Kangaroo mother care, etc.

Step VII. Treatment at the outpatient clinic: IMNCI guidelines provide specific treatment recommendations for cases with less severe classifications (yellow or green code) or those with severe classification but referral not possible, which must be administered at the clinic under supervision or at home after proper counseling of mother or caretaker (see relevant tables). These interventions also include teaching the mother about correct feeding practices, temperature care and administration of oral drugs at home. Mother should also be trained to recognise signs that need urgent follow-up.

Step VIII. Follow-up: All cases with less severe classifications (Yellow/Green) must be asked to follow­up immediately if—(a) unable to accept breast-feeds or drink liquids, (b) become sicker or (c) develop fever, fast breathing, difficult breathing or blood in stools. IMNCI guidelines recommends specific follow-up periods in other cases, as specified in tables.

Advantages: IMNCI approach has huge potential for success in developing countries like India, as:

a. It addresses nearly all major health problems, responsible for gt;80% childhood deaths.

b. It is cost-effective and helps in better utilization of available resources for genuine cases.

c. It obviates the need for elaborate laboratory workup in most cases.

d. It promotes curative as well as preventive health care.

e. IMCI approach has shown major impact on health status in other countries, where it has been adopted.

Current status: IMNCI has been accepted as one of the main strategies under NRHM and RCH-II program, to prevent and manage common childhood illnesses. It has been also included as an essential component of training in medical curriculum. However, these guidelines include most, but not all, common childhood conditions, excluding conditions, e.g. trauma and chronic illnesses, e.g. HIV. Wider acceptance of these guidelines by medical fraternity is still not up to the mark. Further, operational aspects of this approach also need collaboration with other health programs and strengthening of referral care services.

BIBLIOGRAPHY

1. World Health Organization. Integrated Management of Childhood Illness (IMCI) (revised). Geneva: World Health Organization/The United Nation Children's Fund (UNICEF); 2014.

2. Ministry of Health amp; Family Welfare, Govt. of India. Integrated management of neonatal and childhood illness. Chart Booklet for medical officers 2023. Available at https: / / nhm.gov.in/images/pdf/programmes/child-health/guidelines/ imnci_chart_booklet.pdf (accessed on 13th July 2023).