f Imnci Manual

Ministry of Health & Family WelfareGovernment of India New Delhi 2009 Facility Based IMNCI (FIMNCI) Participants Manual Ministry of Health & Family Welfare Government of India New Delhi 2009 Facility Based (FIMNCI) Participants Manual Module1: Emergency Triage Assessment and Treatment (ETAT) Module 2: Facility Based Care of Sick Young Infant Module 3: Facility Based Care of Sick Child MESSAGE Effective Sick Newborn and Child Care is a crucial challenge that is faced by every health care setting dealing with sick Newborn and Child. Training of Doctors, Nurses and ANMs in low resource settings is an urgent need. A key component is to equip the staff with appropriate knowledge and skills to improve the quality of service delivery. The Ministry of Health and Family Welfare is addressing this through launch of the Facility Based Integrated Neonatal and Childhood illness (FIMNCI). A simple and scalable training module on F-IMNCI has been developed for this programme. This training will enhance the multi-skills missing at facilities to manage newborn and childhood illness. This programme provides evidence-based knowledge in improving newborn and child health care at facilities. The health provider after training will furnish all the required care for a newborn and child, identify and manage common complications, stabilize newborns and child needing additional interventions. I am sure that this programme will act as an enabiling tool for newborn and child survival in the country and also help address the acute shortage of Pediatricians at facilities. Ghulam Nabi Azad Union Minister for Health and Family Welfare Government of India FOREWORD The National Population Policy Goals aims at achieving an Infant Mortality Rate of 30/1000 live births by the year 2010. The National Rural Health Mission launched in April 2005 reiterates this commitment. The Ministry of Health and Family Welfare is implementing the Integrated Management of Neonatal and Childhood Illness (IMNCI) as a key child health strategy within the National Reproductive Child Health Programme II and the National Rural Health Mission. The aim of the strategy is to implement a comprehensive newborn and child health package at the household and the community level through medical ofcers, nurse and LHVs. However this excludes the skills required at facilities to manage new born and childhood illness. The long term program needs therefore can only be met if the health personnel and workers possess optimum skills for managing newborn and children both at the community level as well as the facility level. The FIMNCI training manual would be able to provide the optimum skills needed at the facilities by the Medical ofcers and Staff Nurses. According to the Bulletin on Rural Health Statistics 2007, there is an acute shortage of Pediatricians in the country; as against the required number of 4045 there are only 898 pediatricians in position. The introduction of F-IMNCI will help build capacities of the health personnel at facilities to address new born and child hood illness and thus help bridge this acute shortage of specialists. The Child Health Division, Department of Health and Family Welfare have prepared these operational guidelines to enable States to roll out F-IMNCI in their States. I congratulate the Division and the other Professional Bodies, Development Partners and Field Experts who have given their whole hearted assistance for the development of this Operational Manual. I am sure that this manual, when implemented in word and spirit, will go a long way in reducing the enormous burden of newborn and child mortality in our country. Naresh Dayal. IAS Secretary (Health & Family Welfare) Ministry of Health and Family Welfare Government of India . This package will also help address the acute shortage of pediatricians at facilities. I would also like to place on record my appreciation for the hard work and untiring efforts put in by the Child Health Division in developing these operational manual. Referrals include the most common childhood conditions responsible for over 70 per cent of all deaths in children under the age of 5 years in resource poor setting. F-IMNCI is the integration of the Facility based Care package with the IMNCI package. NNF. Amit Mohan Prasad. The critical element of this strategy is the evidence-based integrated approach with a focus on new born and child hood illness. IAS Joint Secretary (RCH) Ministry of Health and Family Welfare Government of India . It helps to build capacities to handle referrals taking place from the community.PREFACE The Government of India is committed to achieve a reduction in infant and child mortality to achieve the National Population Policy and National Rural Health Mission Goal of Infant mortality of 30 per thousand live births. It would not have been possible to bring out these guidelines without their active interest and support. The implementation of F-IMCI strategy will help improve the performance and quality of health workers. I thank them all.IMNCI in States has been developed with inputs form various professional bodies such as Indian Academy of Pediatrics. WHO and UNICEF and Field level experts. An operational manual for implementation of F. to empower the Health personnel with the skills to manage new born and childhood illness at the community level as well as the facility. The Integrated Management of Neonatal and Childhood Illness (IMNCI) is the Indian adaptation of the WHO-UNICEF generic Integrated Management of Childhood Illness (IMCI) strategy and is the centrepiece of newborn and child health strategy under Reproductive Child Health II and National Rural health Mission. ................................... Circulation .................................... ......................................................................................2 2......... Exercise 1 ................................................................................................................................................................................................ Assessment and Treatment of Emergency Signs ..................................... Give Oxygen to a Child with Respiratory Distress ................................................................................................................6 3.... .................................. Manage Airway and Breathing ... .....17 8............................................................................................................ Emergency Triage Assessment and Treatment ............................. ............ Exercise 2 ................10 5........................ Check and Treat Hypoglycaemia .................................................................................... .....10 7...........................................................................................................................................................................................................8 4...........19 9................................10 6.................................................................................................25 ................................................... Introduction ....................................................CONTENTS Module 1 1........................................................................................ ...................................................................... ...........................10........................................................................................................................................... ............................. Exercise 3 ...........................................................................................................................................................................26 11.....36 14. Coma and Convulsions ..................................37 ... .................................................................................................................. Dehydration .................................................... .........................30 12................................................31 Module 2 13............................................................................................................................................................. ............................................................... Care at Birth ......... Introduction .............. ............................ ..................................................................... ..........................................................................84 24...............................................................89 26. Care of Newborn in Postnatal Ward ...................................................... Case Recording Forms .. Case Studies........72 19.........................................................................................................................................................................78 20...............................................................91 27.......................................................................... Exercise 4 ................ ............................ Annexure3 ................................................................................................................15....................................................................................................................................................................................... ................................................. ...........................................................82 23..................81 22....................................................................................... Annexure1 ............71 18..................................... Management of Low Birth Weight Babies ......................................... Annexure5 .......................... ........................................................................98 28...... .............................................56 16................................ .................................................................................................................. ...................................................................................................................................................................................................................................................................................... ......................................... Exercise 5 ........................................................................................................................................................................................................................................................................................ Neonatal Transport .. Exercise 6 .......... Annexure2 .......79 21................... Annexure4 ............. Management of a Sick young infant ........................................... 59 17..........................87 25............................................................................................................................ ....................................................................... .............. ............................. Exercise 7 ....................................................................... Exercise 8 ..................................129 34... ....... Case Management of Children Presenting with Diarrhoea ............................................................................................................................... .................... Case Management of Children Presenting with Fever ........................................................................................................................................122 32..........123 33.....................................................................................................................145 ...................105 Module 3 29....................... Introduction ............110 30......................... ...................................................................................................................................................................... Case Management of Children Presenting with Cough or Dif?cult Breathing .......130 35............... Exercise 9 ..................................... ............................................................................................................................................................................111 31......... ..........................................................................................................................................................................................................................................................202 46............ Annexure: 8 .175 42......... .............................................................................................................................. Annexure: 6 ............................................................................... Case study ...... ....................... Case Management of Children with Severe Acute Malnutrition .......... Annexure: 12....................................................................186 43........................................................................................................................................................... ..... ................................................ ...........................................210 48.....................................................................................................................................174 41............................................................... .................................................................... Annexure: 10.................................................................................................................. ............................149 38..............................206 47........................36......................................................................................................172 40.................................... Annexure: 7 ........... .. Drill ............... ......................................................................................................................... ........211 ........197 44..................146 37................................................................................................................. Annexure: 11....................................... Management of Children with Severe Anaemia .............................. Case recording form . ..........................................................................................................................................................................................169 39......................................... Exercise: 10 .................................................................................................................................. Annexure: 9 ...................................................201 45......................... MODULE-1 Emergency Triage Assessment and Treatment PARTICIPANTS MANUAL . 1 . sick newborn and all children 1. • If emergency signs are not present. Those with emergency signs require immediate emergency treatment . Perform relevant laboratory investigations. c. take a detailed history and perform examination relevant to the presenting problems. 1. emergency treatment. look for priority signs. and inpatient care of all children including newborn babies in small hospitals where basic laboratory facilities and inexpensive essential drugs are available.1 Management process of the sick child (Chart 1) a. . Assessment sick young infants and children when they • Understand the management process of referred to a hospital. Those with priority signs should alert you to a patient who is seriously ill and needs immediate assessment and treatment. The ?rst step in assessing children referred to a hospital should be triage ? the process of rapid screening to decide to which of the following group(s) a sick child belongs: • First assess every child for emergency signs. d.0 Learning objectives At the end of the course the participants will be able to: • Carry out ETAT (Emergency Triage. The module contains guidelines for triage. prompt emergency treatment needs to be given to stabilize the condition of the child. Once emergency signs are identi?ed. b. After the child with emergency signs is stabilised. • Children with no emergency or priority signs are treated as non-urgent cases. 1 INTRODUCTION This module describes a sequential process for managing sick young infants and children as soon as they arrive in hospital. and Treatment) of arrive at a health facility.SECTION. 2 . h. frequency of severity of the chart record to . After deciding the main diagnosis and any secondary diagnoses or problems. • Maintaining children with warmth in the severe malnutrition are area in which young infants or being looked after in order to prevent hypothermia. teach the mother all treatments needed to be carried at home. Key aspects in monitoring The key aspects in monitoring the progress of a sick child are: • Making a plan at the time the to monitor the child regularly.Laboratory investigations needed at small hospitals Essential • Hemoglobin • Blood smear and RDT • Blood glucose • Microscopy of CSF. f. A list of possible diagnoses should be made. • The monitoring. urine and stool • Blood grouping and • • for malaria cross-matching Serum bilirubin X-rays Desirable • CBC (Complete • Routine urine. g. • Arranging the paediatric ward so that the most seriously ill children get the closestattention.2 Principles of in-patient care for sick children a. spread of nosocomial infection by to wash hands regularly. A sick child often has more than one diagnosis or clinical problem requiring treatment. treatment should be started (Specic and Supportive). Basic Principles of Child Care Basic principles of child care for providing good in-patient care should include following practices: • Communicating with the parents. 1. stool • Blood and CSF blood counts including examination culture platelet count) e. Those who are admitted should be closely monitored for response to treatment. Plan the discharge after improvement. advise her when she must return to hospital with child immediately. b. depend on the nature • a standard Using and child enters hospital. children ?t enough to be discharged with treatment and follow-up advice can be sent home. providing water and soap and other measures. and arrange follow-up. At discharge. • Allowing the • Keeping • Preventing encouraging the mother to the the staff stay with the child. child comfortable. child’s which will clinical condition. Once the diagnosis is made. change the treatment. • Bringing doctors or these problems other senior staff to who the have attention of the experience the and authority to act on these ndings and.essential that information to facilitateprompt identifcation of any problems require change in treatment. 3 . if necessary. In a child with diarrhoea: blood in stool or drinking poorly. • Mothershould be advised to return immediately if the child develops any of the following signs: Young infant: . Discharge from the hospital Careful monitoring of the child’s overall response to treatment and correctplanning of discharge from the hospital are just as important as making the diagnosis and initiating the treatment. . Sick child: .In a child with cough or cold: fast or dif?cult breathing. . . • Counseling the mother on correcttreatment and feeding of the child at home.Breastfeeding or drinking poorly.Becomes sicker. . providing equipment for a child with disability). . • Ensuring the child’s immunization status and record card are up-to-date.Dif?cult breathing.Fast breathing. . about the • Remind child’s next the mother immunization visit. this will lead to more appropriate referrals to hospital and better relationship between hospital and community health workers). .Not able to drink.c. d. • Assisting the family with specialsupport (eg. The discharge process for all sick children should include: • Correct timing of discharge from the hospital. . • Communicating with the health personnel who referred the child or who will be responsible for follow-up care (discharge card or a referral note.Diarrhoea with blood in stool.Yellow palms and soles (if infant has jaundice). • Instructing mother on when to return for follow-up care and signs indicating the need to return immediately.Develops a fever.Develops a fever or feels cold to touch. . . Providing follow-up care • Children who are discharged from the hospital should return for follow-up care to the hospital or if this is not possible then to a frst-level referral facility for checking the child’s condition in relation to the present problem. .Becomes sicker. 4 . Chart 1: Steps in the management of sick young infants and children admitted to hospital TRIAGE • Check for emergency EMERGENCY TREATMENT (Absent) (If present) until stable • Check for priority • • HISTORY AND LABORATORY AND signs signs or conditions EXAMINATION OTHERINVESTIGATIONS. if required List and consider DIFFERENTIAL DIAGNOSES Select MAIN DIAGNOSES (and secondary diagnoses) Plan and begin INPATIENT TREATMENT (including supportive care) MONITOR for • Complications • Response to NOT IMPROVING OR • • treatment IMPROVING NEW COMPLICATION REVISE TREATMENT TREAT COMPLICATIONS (Refer if not possible) • CONTINUE TREATMENT • COUNSEL and • PLAN DISCHARGE DISCHARGE HOME • Arrange continuing care and FOLLOW-UP at hospital or in community 5 . 1 How to Triage Keep in mind the ABCD steps: Airway. • Those with priority signs. that the Circulation. Convulsion. and Dehydration. coma. Besides the medical staff other helping and non-clinical staff can also be trained to recognize some of the life-threatening situations. it is very important that new doctors are taught the skills and are fully supervised. Hence. • Assess the status of circulation and level of consciousness.SECTION. Make sure This is described in Chart 2. . 2.0 Learning objectives After completion of this section the participant should be able to: • Triage all sick young infants and children when they health facility into the following categories: • Those with emergency signs. Manage shock. Breathing. • Those who are non-urgent cases. 2. it is equally important that they are well trained in important life saving procedures and their skills are renewed at frequent intervals. Coma. Assess and manage severe dehydration in a child with diarrhoea. child is warm at all times. Nurses are the most important personnel in any emergency department since they are involved in the emergency care at all stages. 2 EMERGENCY TRIAGE ASSESSMENT AND TREATMENT ETAT guidelines help in identifying children with life-threatening conditions that are most frequently seen in developing countries. While a dedicated team should continue to run the emergency department 24 hrs.\ Categories after Triage Action Emergency cases (E) Priority cases (P) Non-urgent cases (N) • • • arrive at a Emergency treatment Rapid assessment and action Can wait Assess airway and breathing and give emergency treatments. and convulsions. 6 . insert an umbilical or intraosseous line IF SEVERE ACUTE MALNUTRITION (Age 2 months) If lethargic or unconscious: • Insert I/V line and IV glucose and fuids 5) If not lethargic or unconscious: • Give glucose orally or NG tube give (Chart by COMA IF COMA CONVULSING • Coma • or • Convulsing Proceed immediately to full assessment treatment (now) OR CONVULSING Manage and • airway • Position the child • Check correct and hypoglycaemia • • If I/V infants convulsions calcium in If convulsions continue. and •Weak acute pulse and fast sure child is warm* • Insert I/V and begin giving fuids rapidly (Chart 4) If not able to insert peripheral I/V. Do not use a tourniquet • Give oxygen • Make CIRCULATION Cold extremities with: IF longer POSITIVE • Capillary refll Check for severe than malnutrition 3 sec.Hb) gasping or • Manage airway • Provide basic life support (Not breathing/gasping) (Chart 3) • If the child has any bleeding.Chart 2: Triage TREAT: •Checkforhead/necktraumabeforetreatingchild (do not move neck if cervical spine injury possible) ASSESS FOR EMERGENCY SIGNS (In all cases) •Giveappropriatetreatmentfor+veemergencysigns •Callforhelp AIRWAY AND BREATHING Any Sign • Not • breathing or Central cyanosis or • Severe respiratory Positive distress •Drawbloodforglucose. apply pressure to stop the bleeding.malariasmear. give anticonvulsants • Make child SEVERE DEHYDRATION (ONLY IN CASES WITH DIARRHOEA) Diarrhoea plus any two of these: • Lethargy • Sunken Very eyes • is slow continuegive young sure warm* skin pinch D I A . I/V if baby rapidly ACUTE MALNUTRITION (Age 2 months) following • Do not start I/V PLAN immediately • Proceed immediately C to full assessment IF SEVERE and treatment is cold to touch. get surgical help or follow surgical guidelines 7 .RRHOEA plus TWO SIGNS • Insert line and begin giving fuids POSITIVE Check for severe acute malnutrition * Check temperature. both feet and further treatment Note: If a child has trauma or other surgical problems.5ºC or • • (severe) visible severe (major) NON-URGENT: according • > Respiratory 38. rewarm IF THERE ARE NO EMERGENCY SIGNS LOOK FOR PRIORITY SIGNS: These children need prompt assessment and treatment • Tiny baby Temperature • Bleeding • Pallor • Malnutrition: • Burns (<2 months) <36.5ºC Trauma or other Referral (urgent) wasting • distress (RR urgent Oedema of Proceed with assessment to child’s priority > 60/min) • surgical condition • • PoisoningRestless. Place priority patients at the front of the queue. Have blood specimens taken for laboratory analysis. Call a senior health worker to see any emergency.Summary Triage is the sorting of patients into priority groups according to their need. • Treat any emergency signs you fnd. 1. Look for emergency signs. • Look for any priority signs. • Check for head/neck trauma. All children should undergo triage. • Place patients with priority signs at the front of the queue. EXERCISE . Start treatment emergency signs you nd. of any . Move on to the next patient.1 Indicate the correct chronological order of the following actions: Ask about head or neck trauma. • Move on to the next patient. Look for any priority signs. • Call for Help • Draw blood for emergency samples. The main steps in triage are: • Look for emergency signs. 8 . On the basis of the triage chart. An 8-day-old baby fed on top milk is brought to a health facility with complaints of diarrhoea. Monu. His temperature is 36. skin pinch takes more than 3 sec. and he has a weak and fast pulse. categorize the child. categorize the child. He has central cyanosis. . On the basis of the triage chart. breathing normally.2. On the basis of the triage chart. three weeks old. one year old. his hands are eyes are cold and capillary refll is < 3 sec. List the signs on the basis of which you assigned the category. The eyes and skin pinch are normal and baby is alert. He became unconscious. had a seizure outside the hospital. His breathing sounds very wet and noisy and there is drooling from his mouth. 4. List the signs on the basis of which you assigned the category. List the signs on the basis of which you assigned the category. categorize the child. The normal. Mayank.2ºCand he is lethargic. is brought to you with complaints of 4 days of diarrhea and vomiting. 3. 9 . in the dose of 2 ml/kg for young infants. • the baby under a radiant warmer and re-warm as to bring the child’s temperature to 36. • If you can not measure blood . give I/V bolus dose of 10% dextrose.5ºC. Efforts should be made to maintain euglycemia and euthermia while managing ABCD. Thermal environment • • • • Keep the infant dry and well wrapped.SECTION. 3 ASSESSMEN T AND TREATMENT OF EMERGENCY SIGNS All sick children are assessed for Airway. As soon as a sick child is brought with temperature below 35. Keep the room warm (at least 25ºC) making sure that no heat source directed straight at the newborn. and 5 ml/kg for older children.5ºC or who is cold to touch (where thermometer is not available). for example with shock or with severe acute malnutrition (SAM). gloves and stockings are helpful to reduce heat loss. there is Keep so Pay and then Check and Treat Hypoglycaemia Check for blood glucose in all children presenting with emergency sign. Cap. the management of these is detailed here before ABCD. Coma. those with severe acute malnutrition and all sick young infants: • If hypoglycaemia detected (defned as < 45 mg/dl for young infants and < 54 mg/dl in older sick children beyond 2 months). maintain thermal environment as given below. • specialattention to avoiding chilling the infant during examination or investigation. Monitor temperature every half hourly for frst 2 hrs every 2 hourly. Circulation. In view of the poor outcome in many small infants and severely malnourished children due to co-existent hypothermia and hypoglycaemia. Convulsions and severe Dehydration (ABCD). Maintaining Temperature Maintaining temperature is an essential step in managing sick newborns and sick children. Breathing. you should look for signs in the areas represented by C. If there is no problem with the airway or breathing. Details of management of hypoglycaemia in young infants are given in section 6.To assess if the child has an airway or breathing problem you need to know: • Is the child breathing? • Is the child blue (centrally cyanosed)? • Does the child have severe respiratory distress? 10 .1 Managing Airway and Breathing The letters A and B in ABCD represent airway and breathing. give bolus dose as above.2. 3.glucose. ASSESS AIRWAY • Manage airway AND • Central cyanosis or Not breathing or gasping or • • Provide basic life support . A bluish or purplish discoloration of the tongue and the inside of the mouth indicates central cyanosis.1. feeding or breastfeeding? Is the child breathing very fast. - Signs of severe respiratory distress Respiratory rate 70/min Severe lower chest in-drawing Head nodding Grunting Apnoeic spells Unable to feed due to respiratory distress Stridor in a calm child 11 .1. 3.1. Stridor in a calm child and grunting are signs of severe respiratory distress. look at the mouth and tongue.1 Is the Child Breathing? To assess whether or not the child is breathing. If none of these. Is there difculty in breathing while talking.BREATHING distress • Severerespiratory 3. look again to see whether the chest is moving. or crying. Is there any harsh noise with while lower breathing abnormal The chest wall in-drawing.youneedtomanagetheairwayandsupportthebreath ingartifcially by ventilating the child with a bag and mask and continue further steps as given in Chart 3.3 Does the Child have Severe Respiratory Distress? Observe whether the child has signicant discomfort from not getting enough air into the lungs. which cause the latter is particularly noises heard when head or using to nod seen in breathing? A breathing in is called stridor. the child is obviously breathing. have severe the accessory muscles for or bob every inspiration? young infants. talking.2 Does the Child Show Central Cyanosis? Cyanosis occurs when there is an abnormally low level of oxygen in the blood. 3. Are they normal? • Feel: Can you feel the breath at the nose or mouth of the child? Ifthechildisnotbreathing. • Listen: Listen for any breath sounds. a short noise when breathing out in young infants is called grunting. there are three things you must do: • Look: If active. To assess for central cyanosis. This sign may be absent in a child who has severe anemia. listen.4.2 and quickly continue the assessment for other emergency signs.4 Basic Life Support Basic Life Support for a young infant is different from that of an older child because of differences in anatomy and physiology. ventilation 1 breath every 3sec • Pulse • (3:1<1year of age) • Rate of about 100 compressions per min Reassess 2 for pulse minutes Palpable • every D r u g Still No Pulse • Continue resuscitation as above • Start s B r e a t h i n g .If the child is breathing adequately. refer to the Module-2. and feel Give position • Oxygen • Continue Reassess further e assessment If no chest rise: • Reposition airway Not breathing or gasping Deliver 2 effective breaths with bag and mask with oxygen 2 minutes • Reattempt breaths If chest rise present • Assess for signs of • Check pulse for no seconds circulation more than . Suspect Foreign body aspiration 2. CHART 3: Providing basic life support Open airway • Head tilt and or • Jaw thrust (in chin lift suspected neck trauma) If breathing: • Recovery Check breathing Look.If no success: 1. The following sections refer to children older than 2 months. go to section 3. Seek appropriate help 10 No Pulse Palpable No or poor respiration: • Continue Bag and mask Compress chest and continue ventilation • 15 compressions to 2 ventilation with Oxygen.1. For young infants. 3. Section 4. spontaneously: • Stop compression and ventilation • Put in 12 Give position • recovery Oxygen • Continue further assessment . as this will determine how much a child can be moved.3.5 Management of airway in a child with gasping or who has just stopped breathing Always ask and check for head or neck trauma before treating. a. It is also important to know the child’s age because you will position an infant (under 12 months of age) differently from an older child. If a child has trauma you must avoid further injury during assessment or treatment. Positioning to Improve the Airway when no neck trauma suspected Child conscious No neck trauma is suspected Child unconscious .1. and feeling for breath 13 . open the airway with a jaw thrust while you immobilize the cervical spine. listening breath sounds. • Inspect mouth and remove • Let child assume position foreignbody. • Check the airway by looking Head tilt-chin lift maneuver (Fig 1) The neck is slightly extended and the head is tilted by placing one hand on to the child’s forehead. Infant Older Children Fig 1: Position for opening airway b. Positioning to Improve the Airway when neck trauma suspected To limit the risk of aggravating a potential cervical spine injury.• Inspect mouth and remove • Open the airway by Head foreignbody. It is safe to use in cases of trauma for children of all ages. • • • • for Neck trauma suspected (possible cervical spine injury) Stabilize the neck. suction catheter. • Clear secretions from throat • Give Oxygen. tilt and Chin lift • Clear secretions from throat using method. if present of maximal comfort. Lift the mandible up and outward by placing the nger tips of other hand under the chin. Inspect mouth and remove foreignbody. if present. as shown in fgure 2. if present Clear secretions from throat by suction catheter Check the airway by looking for chest movements. may need padding under the that occurs when shoulder their to prominent preventexcessive fexion of occiput rests the on the surface on neck which the child lies. mask ventilation it may and neck gently through be a necessary range of to move the positions to determine the optimum position for airway patency and effectiveness of ventilation.Jaw thrust maneuver (Fig 2) The jaw thrust is achieved by placing two or three ngers under the angle of the jaw on both sides.1. 3. In children older than 2 years you may need to give padding under the occiput to obtain optimal airway position. In correct snifng position. hyperextension of the infant neck can produce airway obstruction (Fig 3). The jaw thrust maneuver is also used to open the airway when bag-mask ventilation is performed. Fig2: Using Jaw thrust without head tilt If after any of these maneuvers the child starts breathing.6. The bag together with a facemask. an oropharyngeal airway should be put and start oxygen. Extreme . Ventilate with Bag and Mask If the child is not breathing even after the above maneuvers or spontaneous ventilation is inadequate (as judged by insuffcient chest movements and inadequate breath sounds). instead. Infants. and lifting the jaw upwards and outward. the opening of the external ear canal should be in line with or in front of (anterior to) the anterior aspect of the shoulder. A snifng position without hyper-extension of the neck is usually appropriate for infants and toddlers. is used During bag and child’s head ventilate with a self-infating bag and mask. Fig 3: Difference in padding for an infant and older child 14 . Fig 4: Bag and mask ventilation It is important for the mask to be the correct size for the child. Use Reservoir and oxygen (5-6 should connected infating bag during resuscitation. . to the of tidal self minimum volume volume 450-500ml just enough to should be cause the used. Fig 5: Choosing the correct mask size Self-infating force bags and rise visibly. L/min) be chest to Call for help in any child who needs Bag and mask since some of these children may additionally need chest compression.Bags and masks should be available in sizes for the entire pediatric range (size 0. 1 and 2). it must completely cover the mouth and nose without covering the eyes or overlapping the chin. The correct size and position are shown in the g u r e 4 & 5. thesecondpersonshouldstartchestcompression. These techniques are: 15 .brachialorcarotid)for nomorethanten seconds.7 Chest compressions The techniques for chest compression vary for a child under 1 year and those between 1-8 years and are detailed below: a.checkthepulse(femoral.1.Ifpulseisabsent. Chest compression in the infant (less than 1 year of age) There are two techniques for performing chest compression.Aftertwoeffectiveventilations. 3. where the 2 thumbs are used to depress the sternum. chest compressions must always be accompanied by positive-pressure ventilation. compress the lower half of the sternum but do not compress over the xiphoid.posterior of approximately diameter of the chest. • “Push fast”: push at a rate compressions per minute. avoid pressing on the ribs. • Minimize interruptions in chest compressions . This corresponds to 1 to 1-½ inches. • Using either method to give chest compressions. for the 2 activities must be ventilation interposed after a total of 30 breaths and 90 compressions per minute b. • Depress the sternum 1/3 to 1/2 of the of the chest. while the other hand is used to support the baby’s back (unless the baby is on a very rm surface). with one every third compression. After each compression allow the chest to recoil fully because complete chest re-expansion improves blood fow into the • “Push hard”: push chest approximately heart. while the hands encircle the torso and the ngers support the spine (Figure: 6 ) 2-�nger technique. • at the rate approximately depth heel of lower half Lift your Compress of one of fngers a . Therefore. • Release completely to the chest by completely releasing 100 allow a complete the pressure but recoil of maintaining contact with the compression site.Thumb technique. because one will decrease the efcacy of the other. where the tips of the middle nger and either the index nger or ring nger of one hand are used to compress the sternum. Fig 6: Thumb technique • During cardiopulmonary resuscitation. Chest to 8 years of age) (Fig 7) compressions for the child (1 • hand the to Place the over the sternum. Avoid giving a compression and ventilation simultaneously. coordinated. with one suffcient third to force one to half depress the the anterior. 100 times per minute. Fig 7: Chest compression for the child 16 . Adrenaline 0. If a child is upset by one method of oxygen support. An airway may be placed if the child is unable to maintain airway. Oxygen Delivery Give oxygen to a child in a non-threatening manner as anxiety increases oxygen consumption and possibly respiratory distress. Sources of oxygen to treat hypoxemia There are two possible sources of oxygen: Oxygen concentrators and Oxygen-lled cylinders. 3. In these children begin oxygenation with a head box (8-10 L/min) or a face mask (5-6 L/min). to provide rescue breathing) . which drops with each pause (eg.Two effective breaths should be given after every 15 chest compressions. If the child improves.3.• The ratio of chest compressions and ventilation should be 15:2.9 Giving Oxygen to a child with respiratory distress A child with cyanosis or severe respiratory distress should be allowed to take a comfortable position of his choice and should be given oxygen. where needed. 3. It is important to have the proper equipment to controloxygen fow rates. (s) he can be given oxygen and fuids according to the assessment and underlying condition should be managed. etc. pneumothorax. An unconscious patient should be placed in recovery position as mentioned in section 3.1.8 Setting up of IV access and Use of drugs: Set up an intravenous access preferably using a large peripheral vein. As it takes a number of chest compressions to raise coronary perfusion pressure. You should call for help or more trained hands by this time. catheter/prongs can be used for oxygen delivery. Setup an intravenous or an intraosseous line for use of any drugs. Two such doses can be used 3-5 minutes apart. Bag and mask ventilation is a very effective way of ventilation if done correctly.1. The outcome of babies who do not respond to 2 doses of adrenaline is generally poor but the continuation of therapy may be done in situations where expertise is available or condition is potentially reversible like poisoning. you should attempt to deliver the oxygen by an alternative technique. in case the patient does not have an intravenous line in place. hypothermia. Some children may require intraosseous access in case IV access is not possible.000) intravenous can be used in a child who does not respond to initial ventilation and chest compressions and his pulses are absent. If the health care provider has the necessary skills and equipment airway can be secured by endotracheal intubation. time from arrest to CPR and co-morbid disorders. The decision to terminate resuscitation rests with the treating physician which is usually based on assessment of etiology. . When the child improves.1 ml /kg (1:10. 17 . NASAL PRONGS short tubes inserted into the sizes for adults and children. with low fow the expired emergency settings of air oxygen is dangerous. of oxygen nasal catheter to These are different have only adult-size prongs. and to ft into child’s nostrils. • Place a head box over the baby’s head. • Place them just with a piece of nose. of mucus. litres/min in child shall deliver concentration in the inspired air. which of HEAD BOX AND FACE MASK • Face Mask (need fow rates 5-6 litres/min) or Oxygen hood (need fow rates 8-10 lit/min). • litres/min • Nasal delivering A fow in an prongs are oxygen rate of 0. • Gently insert the • Ensure that the • A fow rate infants and 1-2 litres/min 30-35% oxygen • Adjust the fow concentration • Change the catheter catheter of in an into is 0. the the the desired twice daily. • Take inside the tape on nostrils and the cheeksnear secure the care that the nostrils are kept clear could block the fow oxygen. are good devices to achieve oxygenation in severely distressed and in emergency situations. distance the tube from the nostril to should be passedby the inner marginof the eyebrow. outlet tubes are cut the outlet Prongs come • If you too far apart tubes off and direct the jet of the oxygen into the nostrils.• • measuring Use a 8 Determine the the distance NASAL CATHETER French size catheter. correctly positioned. organize is the use can lead has transfer and urgently refer the baby to a tertiary hospital or specialized centre capable of assisted . and Ifthebaby’sbreathingdiffcultyworsensorthebabyhascentralcyanosis: • Give oxygen at a high fow rate(5-10 litres/ min) • If breathing diffculty is so severe that the baby centralcyanosis even with high fow oxygen. if available.5-1 litres/min older child preferred over nasal catheter to young infants and children in infants and for with severe 1-2 croup or pertussis as catheters can provoke paroxysms of coughing. • However.5-1 older the nostril. • of • to An alternative a face Using Head box rebreathing of method in mask. • in achieve nostrils. even when the baby moves. oxygen delivery the head box and should not is a rather wasteful be used routinely for mannerof permanent oxygen delivery on the wards. Ensure that the baby’s head stays within the head box. ventilation. Duration of oxygen therapy Continue giving oxygen continuously until the maintain a SaO2 >92% in room air. the duration of oxygen therapy is guided by clinical signs. but check again 1/2 hour later. Where pulse oximetry is not available. Any child who has been successfully resuscitated or any unconscious child who is breathing and keeping the airway open should be placed in the recovery position. It should only be used in children who have not been subjected to trauma. discontinue oxygen. and 3 hourly thereafter on the rst day off oxygen to ensure the child is stable. which are less reliable. child is When the able child to is stable and improving. A child with cyanosis or severe respiratory distress should be allowed to take a comfortable position of his choice. take the child off oxygen for a few minutes. If the SaO2 remains above 92%. This position helps to reduce the risk of vomit entering the child’s lungs. if possible.3 18 . The recovery position is detailed later in the section 3. • And is been opened.2 Circulation The letter C in ABCD stands for Circulation. and (Age 2 months) .1 Assess the circulation for signs of shock After the airway has you need to know: • • If not. 3. to assess if a child has a circulation problem Does the child have is the the capillary pulse weak and warm extremities? refll fast? time longer than 3 seconds? InsertI/Vandbegingivingfuidsrapidly • If the bleeding.2. Do not use a tourniquet • Give oxygen • Make sure child ASSESS Cold extremities with: • Capillary severe acute is warm Insert IV and be If POSITIVE giving fuids rapidly (C Check for If not able to insert periphera umbilical or intraosseous line • refll longer than 3 malnutrition IF SEVERE ACUTE MALNUTRITION CIRCULATION seconds. child has any apply pressure to stop the bleeding.ComaandConvulsions.3. to assess the capillary rell. It should be less than 3 seconds. If it is more than 3 seconds the child may be in shock. take feels warm. In such a situation check the pulses and decide about shock. If the need to assess capillary refll or feet feel cold. problem and pulse. It is carried out by applying pressure to the pink part of the nail bed of the thumb or big toe in a child and over the sternum or forehead in a young infant for 3 seconds.• Weak and pulse fast a. you need b. 19 . The capillary rell time is the time from release of pressure to complete return of the pink color. This sign is reliable except when the room temperature is low. Are the Child’s Extremities Warm? To assess the If it circulation. the the child you not do child’s hands and If lethargic or unconscious • Insert IV line an IV glucose & (Chart 5) If not lethargic or unconsci • Give glucose or by NG tube • Proceed immediat child’s hand has no and feet circulation in your own.IstheCapillaryRefllTimeLongerthan3Seconds? Capillary rell is a simple test that assesses how quickly blood returns to the skin after pressure is applied. as cold environment can cause a delayed capillary rell. Lift the limb slightly above heart level to assess arteriolar capillary rell and not venous stasis. if central pulses (femoral or carotid) are also weak it is an ominous sign. An intravenous line must be inserted and fuids given rapidly in shocked children without severe malnutrition. Ifthechildhascoldextremities. no further assessment is needed.2 Shock The most common cause of shock in children is due to loss of fuid from circulation. it is important to replace this fuid quickly. and b. Low blood pressure is a late sign in children and may not help identify treatable cases. Treatment of Shock Treatment of shock requires teamwork. In all cases. Is the pulse weak and fast? Evaluation of pulses is critical to the assessment of systemic perfusion. The correct size BP cuff necessary for children of different age groups may not be available 3. Applying pressure to the nail bed for 3 seconds B. In an infant (less than one year of age) the brachial pulse may be palpated in the middle of upper arm. The radial pulse should be felt. or through capillary leak in a disease such as severe Dengue fever. Note that blood pressure is not required for identifying shock because: a. Check the time to the return of the pink colour after releasing the pressure Figure8:Checkingcapillaryrefll c.2.andafastweakpulse. The following actions need to be started simultaneously: .A. then he or she is in shock. either through loss from the body as in severe diarrhoea or when the child is bleeding.acapillaryreflltimemorethan3seconds. In a child with weak peripheral pulses. If it is strong and not obviously fast (Rate > 160/min in an infant and > 140/min in children above 1 year). the pulse is adequate. 20 . 60 ml of normal saline should be infused over 20-30 minutes. • If the signs of poor perfusion persist despite 2 fuid boluses. the dose can be increased by increments of 5 μg/kg/min every 20 30 minutes to a maximum of 20 μg/kg/min.5 ml Add 1. • The most commonly used vasopressor in practice is dopamine.5 ml dopamine(mg) to this dose amount of dopamine into be to added = 10 x6 =60 to ml of dopamine: 98. apply pressure to stop the bleeding. except in infants with severe dehydration who should be treated as per Plan C of diarrhoea management. repeat a bolus of 20 ml/kg of normal saline. in a baby weighing 3 kg.• • • • • • • If the child has any bleeding. If no or partial improvement (i.5 ml to make 100 . How to give Dopamine • • of to amount ml of amount total fuid gives 1 to ml of dopamine = of dopamine • For giving 1 mcg/kg/minute Amount of dopamine(mg) x6 To convert this dose into dopamine divide by 40 (1 mg of dopamine) • Add this to make 100 ml of 1 ml/hour of this fuid • To give give 10 ml/hour 10 microdrops/minute 60 microdrops • 10 mcg/kg/minute ( as dopamine be added = Weightin kg 40 (ml) mcg/kg/minute or = 1ml) Example: Giving 10 mcg/kg/minute for a 10 kg child • • • Amount of mg To convert 60/40 =1.e tachycardia and CRT still prolonged). Do not use a tourniquet • Give oxygen Make sure the child is warm Select an appropriate site for administration of Establish IV or intraosseous access Take blood samples for emergency laboratory tests Begin giving fuids for shock. Usual starting dose is 5 -10 μg/kg/min and if no improvement occurs. e. Young Infants Fluid resuscitation: Infuse fuid bolus of 20 ml/kg of normalsaline over 20-30 minutes.g. Assessment of shock in severe acute malnutrition (SAM) diffcultand the fuid therapy is also different • of shock in Dengue (DHF/DSS) is detailed specifcsection of module 3 fuids is Treatment in the Givingfuidsandothertreatmentforshock. a. start vasopressor support. a different rate of very closely. 10 on the and child 21 .• ml of 10 ml/hour microdrops/minute total of fuid this fuid b. Therefore a different gives 10 mcg/kg/minute or of fuids to treat shock depending are shown in Chart 4 . Children above 2 months of age The recommended volumes the age/weight of child child has severe malnutrition. If you must use a different fuid administration and monitor the regime is used for these children. No improvement • fuid evidence if YES: of give blood 20 ml/kg over 30 minutes • If profuse diarrhoea another bolus of Ringer’s lactateor Normal saline ( Fourth Bolus Reassess after fourth Bolus give ) a n d o v e r 2 * Signs of volume improvement:Good and slowing pulse ½ . Estimate weighed or the weight if child weight not known • child have • Give Oxygen • Make sure child does not is warm severe acute Check malnutrition Insert an intravenous line and draw blood for emergency laboratory investigations • Give Ringer’s lactate or Normal saline • Infuse First Bolus -20 ml/kg as rapidly as possible in a child & over 20-30 minutes in a young infant Reassess child No improvement: If improvement with any stage:* Fluid responsive shock • Observe fuids (70 ml/ Repeat Second Bolus of 20 ml/kg and kg continue over 5 h o u r s i n Repeat Third Bolus of 20 ml/kg i n f a n t s No improvement Look for blood loss. bolus at rate and faster capillary rell.Chart 4: Management of shock in a child without severe acute malnutrition • Weigh the cannot be that the child. give IV Hydrocortisone 1.2 mg/kg fuids if up mcg/kg/min deterioration (features of fuid over load any stage): • Stop and fuid bolus observe • Check Urine Dopamine resistant output at .hours in a • Give losses If child) additional if no improvement with boluses in sick 3 child fuid 2 young fuid boluses in & infant Fluid refractory shock Manage as septic shock • min • Add antibiotics • Start dopamine infusion at 10 mcg/kg/min and Increase by 5 no response • to 20 • If no response: Continue same treatment and consider referral to higher center If assess every 15 mcg/kg/min Titrate initial dose broad spectrum If still no response: 22 shock : • If you suspect adrenal insuffciency. Stop the infusion and reassess • Repeatsame fuid IV 15 ml/kg over 1 hour more. Estimate the weight not known Oxygen sure child is warm weight if child cannot be weighed Insert an IV line and draw blood for emergency laboratory investigations Give IV Glucose Give IV fuid 15 either Half-normal saline with lactate ml/kg over 5% 1 glucose hour of or Ringer’s Measure the pulse and breathing rate at the start and every 5-10 min minutes Signs of improvement (PR and RR fall) If the child fails to improve after the rst 15 ml/kg IV If the child deteriorates during the IV rehydration (RR increases by 5 /min or PR by 15 beats/min). then • Switch to oral or nasogastric rehydration with ORS. 10 Assume The child has septic shock ml/kg/h up to 10 hours.Chart 5: Management of shock in a child with severe acute malnutrition Give this treatment only if the child has signs of shock AND is lethargic or has lost consciousness • Weigh or • Give • Make the child. • Initiatere-feeding starter formula with • • Give (4 Start maintenance IV fuid ml/kg/h) antibiotic treatment • Start dopamine re-feeding possible as • soon Initiate as . 23 . ml/Kg If the over I hour the child fails child has septic . but monitor carefully. to improve after the frst 15 ml/Kg assume shock and per guidelines manage as IV IV. use glucose or Ringer’s tube and ½-strength possible. Stay with the child and check the pulse and breathing rate every 5 minutes. Discontinue the intravenous infusion if either of these increase (pulse by 15. vomiting). It is important to follow the standard guidelines for caring for a child with severe malnutrition. you must use different rate of administration a and different monitor fuid the child very closely. avoid or oral fuids. give repeat and then switch to oral or nasogastric ORS. but have sepsis rather than hypovolemia. If IV fuids – use a if the child is lethargic or nasogastric unconscious (NG) an NG tube (e. Sometimes children with severe malnutrition have circulatory signs suggesting shock.Management of shock in a child with severe acute malnutrition If the and child a has severe malnutrition. respiratory rate by 5/min). Only cannot swallow or tolerate normal saline with 5% Lactate at 15 ml/kg in 1 hr. If the child shows signs of improvement.g. 15 in Chart 5. 24 . bpm. Weight 5 kg. Sunita four-month old baby is brought to hospital with fever. There is no chest indrawing and there are no abnormal respiratory noises. The child is very lethargic and extremities are cold with capillary rell of more than 3 seconds. Write the initial steps of management.EXERCISE . Vijay 12 months old is brought to you with loose stools and vomiting. 2. List the emergency signs. List the emergency signs.2 1. The femoral pulse is palpable but fast and weak. Her hands are cold. A 7 days old baby weighing 2 kg is admitted with refusal to feeds. He weighs 5. 3. How will CRT you is still proceed? 4 seconds . The capillary rell is more than 3 seconds. The pulses are weak and fast and has mild respiratory distress. She has had 2 episodes of vomiting and watery diarrhoea.0 kg and has visible severe wasting. a) What are the steps of initial management? b) with After HR giving 2 of 190 fuid challenges. fast and weak pulse with mottling of skin. Write the initial steps of management. cold extremities and a CRT of 5 seconds. respiratory rate of 60/min. 25 . A little shake to the arm or leg should be enough to wake a sleeping child. is lethargic. ask the mother if the child is just sleeping. Assess the child for coma and convulsion To • • assess the Is the Is the child’s neurological status you child in coma? child convulsing? need to know: 3. give I/V CONVULSING Calcium in young infants • If convulsions continue. apply a rm squeeze to the nail bed.2 Is the Child Convulsing Now? This assessment depends on your observation of the child and not on the history from the parent. enough to cause some pain. but responds to voice. call his/her name loudly. An unconscious child may or may not respond to pain. To help you assess the conscious level of a child is. e. Children who have a history of convulsion.g. The following signs indicate impaired neurological status: coma.3.3.3 Coma and Convulsion C also represents Coma and Convulsion.3. Do not move the child’s neck. 3. V Is the child responding to Voice? If not. need a complete . give anticonvulsants Try to wake the child by talking to him/her.1 Is the Child in Coma? A child who is awake is obviously conscious and you can move to the next component of the assessment. and convulsions. but are alert during triage. you need to assess the level of consciousness: • Manage airway • • Coma or • Convulsing • now Position the child Check and correcthypoglycaemia • If convulsions IF COMA OR continue. If there is any doubt. a simple scale (AVPU) is used: A Is the child Alert? If not. If this is unsuccessful. A child with a coma scale of “P” or “U” will receive emergency treatment for coma as described below. A child who is not alert. lethargy. P Is the child responding to Pain? U The child who is Unresponsive to voice (or being shaken) AND to pain is Unconscious. If the child is asleep. A child who does not wake to voice or being shaken or to pain is unconscious. A child who does not respond to this should be gently shaken. clinical history and investigation. but no emergency treatment for convulsions. There is stiffening of the child’s arms and legs and 26 . The child must be seen to have a convulsion during the triage process or while waiting in the outpatient department. You can recognize a convulsion by the sudden loss of consciousness associated with uncontrolled jerky movements of the limbs and/or the face. in infants. The child may lose control of the bladder. hands or feet. Do not try to insert anything in the mouth to keep it open. Sometimes. b. Put the Child in Recovery Position Any unconscious child who is breathing and keeping the airway open should be placed in the recovery position.3 Treatment of coma and convulsion Treatment of coma and convulsions are similar and will be described together • Manage the airway • Manage the airway • Position the child (if there • Position the child is a history of trauma. It should only be used in have not been subjected to trauma. This has been discussed in earlier.3. the jerky movements may be absent. • Check the blood sugar stabilize the neck rst) • Check the blood sugar • Give IV glucose a. and is unconscious during and after the convulsion. This position helps to reduce the risk of vomit entering the children who child’s lungs. but there may be twitching (abnormal facial movements) and abnormal movements of the eyes. If neck trauma is not suspected (Fig 9) • Turn the child on the side to • Keep the neck slightly extended the cheek on one hand • Bend one the body reduce risk of and stabilize aspiration by placing leg to position Fig 9: Position of unconscious child (no trauma) stabilize . You have to observe the infant carefully. 3. Give oxygen for the emergency setting.uncontrolled movements of the limbs. Convulsion To manage the airway of a convulsing child gentle suction of oropharyngeal secretions should be done & child put in recovery position and oxygen started. Manage the Airway Coma Managing the airway is done in the same way as treating any child with an airway or breathing problem. 27 . a sandbag placed on each side or a cervical collar can splint the neck. An appropriate sized airway goes from the centre of the teeth (incisors) to the angle of the jaw when laid on the face with the convex side up. should assume responsibility for the neck. hold the angle of mandible the patient’shead. He should stand at the top end the patient. Insertion of an oropharyngeal (Guedel) airway (Fig 12) The oropharyngeal or Guedel airway can be used in an unconscious patient to improve airway opening. When the patient is not being moved. . Move a patient with a suspected cervical spine injury carefully. Avoid rotation and extremes of fexion and extension. with and place the the palm over fngers under of the the ears and parietal region and maintain gentle traction to keep the neck straight and in line with the body. One person.If trauma is suspected (Fig 10) Stabilize the child while lying on the back. Patient then can be rolled to one side with the help of two more persons simultaneously moving the torso and lower limbs on instructions from the senior attendant. Fig 11: Log roll c. It may not be tolerated in a patient who is awake and may induce choking or vomiting. Fig 10: Position of unconscious child (trauma suspected) Use the log roll technique to turn the child on the side if the child is vomiting (Fig 11). Use bottles or rolled towels in case sandbags are not available as shown in the gure 10 below. Guedel airways come in different sizes (Guedel size 000 to 4). usually the most senior attendant. Fig12: Inserting an oropharyngeal airway in an infant: convex side up 28 . Age/weight 2 2 4 1 3 weeks (<4 <6 <10 <14 19 to kg) <4 kg) <12 kg) <3 kg) <5 kg) 2 Table 2: Dosage of diazepam Diazepam given rectally 10mg/2mlsolution Dose0. In an emergency it is easier and quicker to give it rectally than intravenously.2 ml 2 to 4 kg 0.5 ml . Use a different sized airway or reposition Give oxygen the child to not to move a tongue convex side if necessary.Phenobarbitoneintravenousdose(200mg/ml) Weight of Infant Initial dose 2 kg or less 0. The dose is 0.5mg/kg (0.05 ml/kg) intravenously. insert the oropharyngeal airway the up. d.• • • • Select an appropriate sized airway • Position open the airway as described above.0.1 ml/kg) rectally (Table 2) or 0. This is a useful guideline in an emergency situation when you may not have a chance to weigh the child. unless an intravenous line is already running.1. Re-check airway opening.25 ml years (14 – 1.1 ml 0. give 2 ml/kg If seizures continue: IV 10% Calcium over 10 minutes while monitoring heart rate If seizures continue: IV phenobarbitone min (Table 1) If no control: Repeatphenobarbitone 10 of 40 mg/kg If seizures continue: Give phenytoin 20 Table 1: Dose of Phenobarbitone for young infants Inj. An estimated dose of rectal diazepam is shown below. taking care the neck if trauma suspected • Using depressor.1ml/ kg months 0. Rectal diazepam acts within 2 to 4 minutes.3 ml 10% dextrose gluconate 2ml/kg (in young infants). if the child is convulsing in front of you.0 ml years (10 - 1. How to manage convulsions? Infant up to 2 weeks of age with seizures: • • • • • Secure IV access If blood sugar < 45 mg/dl.25mg/kg (0. • 20 mg/kg over 20 mg/kg till a total mg/kg over 20 min convulsions in Repeat dose 0.3 ml months (4 .5 ml months (6 . Diazepam can be given by the rectal or intravenous route. It may be helpful to put it on the wall in your department.15 ml Caution Do Neonates not < use 2 Diazepam weeks for controlof Managing convulsions beyond 2 weeks of age: Diazepam is the rst drug used to stop convulsions (anticonvulsant). No drug should be given if the convulsion has stopped. where possible. If you already have intravenous access. 29 . Give 0.Base the dose on the weight of the child. Hold the buttocks together for a few minutes.5mg/kg diazepam injection solution per rectum by a tuberculin syringe or a catheter. • Do not give been controlled child so breathing with oral (danger it is important Diazepam to regularly. If convulsions do not stop after 10 minutes of second dose of diazepam. If still convulsing. (or diazepam intravenously slowly over 1 minute if an IV infusion is running). Alternatively phenobarbitone can be used in a dose of 15. room-temperature water to medication until of aspiration) the reduce the convulsion EXERCISE – 3 1. seek help of a senior or more experienced person. the airway and If there is high fever: • Sponge the fever. appropriate List the emergency measures? 12 days old infant weighing 3 kg is brought to the facility with generalized tonic has . give a second dose of diazepam. Inj Phenytoin can be given intravenously if access has been achieved. He has no chest weighs 11 3. He weighs 12 kg. His extremities are warm and there is no history of diarrhoea. if available. The respiratory rate is 72 /min and temperature is 38º C. rectally. in at least one full minute. can affect reassess the child’s breathing. but slowly. 15 . Reassess the child after 10 minutes.20 mg/kg Phenytoin is diluted in about 20 ml of saline and given slowly (not more than 1 mg/kg Phenytoin per minute). Sunil two-year old boy is carried in by his grandmother. Anil is an 18 month old boy who has fever for two days. How would you manage the child? 2. The child is breathing normally and the CRT is < 3seconds. What are His airway is clear. He is febrile and having a seizure.20mg/kg IV (in 20 ml 5% dextrose or saline) or IM. However. the most being examined. His mother has noticed that he has fast breathing. At this stage.you can give the correct volume of drug directly. and he indrawing. kg. the boy started to convulse while signs. The child 30 warm extremities.seizures with refusal to feed. How will 60 . Baby’s blood you manage this case? is breathing normally and has sugar is mg/dl. Assess for severe dehydration To assess if the child • Is the • Does the • Does a is severely dehydrated you need to know: child lethargic? child have sunken eyes? skin pinch take longer than 2 seconds • Diarrhoea plus any to go back? Make sure child is warm. • Insert IV line and begin giving . If the child is severely malnourished these signs are not as reliable.3. In this section we will look at the assessment of severe dehydration in the child with diarrhoea or vomiting.4 Dehydration The letter D in the ABCD formula stands for Dehydration. if not If set the up.4. Severe dehydration (without severe acute malnutrition) • Start ORS Ringer’s IV by fuid immediately (Table 3). available. mouth while the drip is lactate solution (or.5 years) 30 minutes* * Repeatonce if radial pulse is still very 21/2 hours weak or not detectable. divided as follows: AGE Infants (under 12 months) Table3:IVfuidsforseveredehydration Firstgive30ml/kgin Thengive70ml/ kgin 1 hour* 5 hours Children (12 mo.SEVERE DEHYDRATION (ONLY IN CASES WITH DIARRHOEA) two of these : • Lethargy PLUS • Sunken SIGNS • Very slow POSITIVE pinch fuids rapidly following PLAN C eyes TWO IF SEVERE ACUTE MALNUTRITION skin (Age 2 months) • Do not start Check for severe IV acute malnutrition immediately DIARRHOEA 3. 31 . give ml/kg normal saline).1 Treatment of severe dehydration in an emergency setting a. child Give can 100 drink. • Also give ml/kg/hour) as soon as the child can drink: 3-4 hours (infants) or 1-2 hours (children). Table 4: Volume of ORS Weight Volume of ORS solution per hour <4 kg 15 ml 4 6 - <6 <10 kg kg 25 ml 40 ml . If hydration status is give the IV drip more rapidly.• Reassess the not improving. ORS (about 5 usually after child every 15-30 minutes. . • If possible. b. • Give oral antibiotic for cholera if child 2 years or older. B. give ORS 20 ml/kg/hour for 6 hours (120 ml/kg) by NG tube • Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. observe the child for at least 6 hours after rehydration to be sure that the mother can maintain hydration by giving the child ORS solution by mouth. or C) to continue treatment as you have learned in IMNCI.10 - <14 kg 60 ml 85 14 19 kg ml If IV treatment not possible. Then choose the appropriate plan (A. Severe dehydration with severe acute malnutrition • This has been detailed later in the section Video demonstration on ETAT 32 on SAM. 5ºC • • Bleeding Restless. Apnoeic spells.ASK: Case Recording Form Age-----------. Continuously or lethargy .5ºC or > 38. Hb) AIRWAY • AND Not breathing gasping BREATHING or or • Central cyanosis or • Severerespiratory distress (Respiratory rate  70/min.Proforma for Emergency Triag Assessment and Treatment (ETAT) Name-------------------------. Severe lower chest in-drawing. Stridor in a clam child) CIRCULATION Cold hands with: • Capillary refll longer than 3 seconds. and • Weak and fast pulse IF POSITIVE Check for severe acute malnutrition COMA CONVULSING • Coma (AVPU) or • Convulsing (now) SEVERE DEHYDRATION (ONLY IN CHILD WITH DIARRHOEA) Diarrhoea plus any two of these: • Lethargy • Sunken eyes • Very slow skin pinch If two signs positive check for severe acute malnutrition PRIORITY SIGNS · • Tiny baby (<2 months) • Respiratory distress (RR>60/min) • Temperature <36. Grunting. Head nodding.Sex---------Wt------What are the Date Temp infant’s problems? ASSESS (Circle all signs present) Emergency treatments • Check for head/neck trauma before treating child do not move neck if cervical spine injury possible· • EMERGENCY SIGNS: (If any sign positive: give treatment(s). irritable. call for help. Unable to feed due to respiratory distress. draw blood for emergency laboratory investigations (glucose. malaria smear. rewarm 33 .• • • • • • • Check Trauma or other surgicalcondition urgent Referral (urgent) Pallor (severe) Malnutrition: Visible severe wasting Oedema of both feet Poisoning Burns (major) temperature if baby is cold to touch. 34 . MODULE-2 Facility Based Care of Sick Young Infant PARTICIPANTS MANUAL . the rst few days of life and sick young infants with important priority conditions which are likely to be encountered in a health facility. through primary health facilities to hospitals. through neonatal period and early infancy.the rst from pregnancy. This manual will deal with care of newborns at birth. The guidelines in this manual are consistent and support the IMNCI (Integrated Management of Neonatal and Young Infanthood Illness) training materials for outpatient management of sick Young Infants. India contributes about a quarter of all neonatal deaths in the world. It is well known that majority of neonatal deaths can be prevented with low technology. Because of its large population and relatively high neonatal mortality rate. Young infants (up to 2 months) referred with severe classications based on IMNCI strategy are assessed and investigated based on guidelines given in the manual for making a more precise diagnosis. birth. It has been estimated that optimal treatment of neonatal illness can avert up to half of all preventable neonatal deaths. Some of them are extremely sick and need emergency life saving treatments. low cost interventions delivered across two continua of care. A health facility in addition to providing care to newborns at birth also receives sick young infants with diverse clinical presentations. Learning Objectives After completion of this module the participant should be able to• Provide care at birth for all newborns • Manage sick young infants in a health facility • Understand principles of transporting sick young infants needing referral • Use essential equipments for providing care to young infants .INTRODUCTION Neonatal mortality contributes to over 64% of infant deaths and more than two thirds of these deaths occur during rst week of life. and the second from home. 36 . To be warm 2. . This area is mandatory for all health facilities where deliveries take place.SECTION. Effective care at birth is needed for anticipation of problems with this transition and to provide support to ensure stabilization.0 Learning Objectives After completion of this section the participant should be able to• Prepare newborn corner for providing care • Provide care at birth for all newborns • Identify and manage newborns who may at birth need specialcare 4. To be protected (prevent infection) 4. 4 CARE AT BIRTH Introduction This section gives guidelines for care of the newborn at the time of birth. 4. To be fed 4.2 Newborn Care Corner This is a space within the delivery room for facilitating immediate care of the newborn. To breathe normally 3. The four basic needs of ALL newborns at the time of birth and for the rst few weeks of life are: 1.1 Why care at birth is important? This is the critical period of transition from intrautero dependant life to extrautero independant existence. 37 . IV cannula (24G) .Suction catheters (10F.Feeding tube (6F.Radiant warmer with bassinet . 5-10% may need assistance to establish adequate breathing and therefore will need resuscitation.Mucus extractors .Drugs (Inj.Sterile blade/scissors . Supplies: .Clean baby sheets .Wall Clock .Endotracheal tubes (3.Room thermometer A. 12F) .Self in?ating resuscitation bag (500 ml) with masks (size 0. Normal saline.Vitamin K) 4.Oxygen source . Epinephrine .Laryngoscope (straight blade. B. 8F) .Sterile cord ties .Sterile Gloves . Most babies would require routine care.1) . 38 .3 Immediate Newborn Care The immediate care needed for all babies at birth is outlined in the ow diagram. size 0. Inj.Weighing machine .1) .Equipment and supplies that should be available in the corner: Equipment: .5 mm) . 3.Suction equipment . provide Routine care • • • • • • • • • • • • If no Place the baby on the mother’s abdomen Proceed for Dry the baby with a warm clean sheet. Support initiation of breastfeeding Cover the baby’s head with a cloth.3. (see Chart 6) Wipe the mouth and nose with a clean cloth Clamp the cord after 1-3 min and cut with a sterile instrument.Immediate Newborn Care Assess by • Is • Is • Is • Does checking the baby Term gestation? the amniotic fuid clear? the baby Breathing or crying? the baby have Good muscle tone? If yes. loose heat (Figure 13) 13: Four ways a newborn loose heat to the 39 .1 Keeping the baby warm • Newborn There are baby’s temperature falls within seconds 4 ways by which a baby may Figure may environment of being born. Cover the mother and baby with a warm cloth Place an identity label on the baby Give Inj Vit K 1mg IM (0. Do resuscitation not wipe off vernix.5mg for preterm) Recordthe baby’s weight Refer if birth weight < 1500g. Tie the cord with a sterile tie Examine the baby quickly for malformations/birth injury Leave the baby between the mother’s breasts to start skin-to-skin care.has major 4. do the following.4 (resuscitation). oozing blood. hands and feet • Re-start Skin-to-skin contact as soon as mother be roomed-in at dry 25-28ºC cloth. Decide: Does the baby need any help with breathing? The babies who need immediate help to support breathing are those with apnea or gasping respiration.3 Immediate Cord Care • • • Clamp the cord sterile instrument Tie the cord the remaining Observe for second tie Do not apply stump. dry Put the cloth baby on the mother’s abdomen or on a warm surface Provide a warm. • Oxygen is needed to keep the baby’s brain and other vital organs normal.3.g exposure to draught) Radiation (e. To manage these babies follow guidelines in section 4. Convection(e.• If the temperature continues and may even die. A baby can die or suffer from hypoxic injury very quickly if breathing does not start soon after birth. • on the cut . • Wrap the baby in a clean dry warm cloth and place radiant warmer. contact with a cold surface of a weighing scale). • Cover the mother and baby with a warm and dry • Support breast feeding as soon as possible after • Delay the frst bath to beyond 24 hr period. If warmer is not available warmth by wrapping the baby in a clean dry warm cover with a blanket. Wet baby) Conduction (e. Ensure baby’s head. warm.g.3. draught free room for delivery at  25ºC Keep the room warm Keeping a newborn warm after delivery • Provide a warm. between the skin and any medication/substance cms and cut with a from the base and place a frst tie. warm. If mother and babys separation is necessary. Method of heat loss Evaporation (e. Those who are breathing normally need to be provided routine care.g. If blood oozes. When the umbilical cord is cut the placenta is no longer a source of oxygen and the baby needs to support his oxygenation through the lungs. cloth birth under a ensure cloth and are covered. after 1-3 min of delivery between 2 to 3 cord.2 The babys need to breathe normally • To ‘breathe normally’ was identifed as one of the baby’s immediate and basic ‘need’. draught free room for delivery • Dry the baby immediately after birth with a clean. and baby can 4. • Put the baby on the mother’s abdomen. 4. Cold surroundings) to fall the baby will become sick Prevention Immediately after birth dry baby with a clean.g. .• 40 Leave stump uncovered and dry. its mother whether she mother must be comfortable frst because is lying Do not give articial teats or pre-lacteal feeds to the newborn e.7 Initiate breastfeeding within 1 hour • • • Support mother to hour.4.g. 4.baby and initiatebreast feeding within the colostrum is very important against infections. omphalocele.5 Examine the baby quickly for malformations/birth injury Quick but thorough clinical screening is essential to identify any life threatening congenital anomalies e. Therefore. it also important to maintain body temperature during resuscitation.g meningomyelocele.3.2 How do you determine whether the baby requires resuscitation? To decide if the baby needs resuscitation at birth.4 Care of the eyes • • No Do routine eye not instill any care is medicine required in the eyes 4. sugar water or local foods or even water. The “ABCs”of resuscitation are the same for babies as for adults. whether spontaneous or assisted. Be sure that there is ‘Breathing’. Even mothers who deliver by Cesarean Section or Assisted delivery should be supported for early breast feeding and should not be separated from their newborns Group Discussion on Hypothermia 4. about 1% need extensive resuscitative measures to survive.3.4. Newly born babies are wet following birth and heat loss is great. 4.3. The baby’s frst feed of it helps to protect The baby can feed from down or sitting. anal atresia.1 Which babies require resuscitation? Approximately 10% of newborns require some assistance to begin breathing at birth.4 Neonatal resuscitation 4.6 Weighing the baby Weigh all babies before transfer from the delivery room 4.3. ask the following 4 questions • Term gestation? • Clear of meconium? • Breathing . Ensure that the ‘Airway’ is open and clear.4. Make certain that there is adequate ‘Circulation’ of oxygenated blood. 41 .or crying? • Good muscle tone? If answer to any of the above questions is NO. the baby would require resuscitation at birth. Chart 6: FLOW CHART of Neonatal Resuscitation BIRT H Approximate time • Term gestation • • • Clear amniotic Breathing or Good muscle ? Routine care • Provide Yes fuid ? crying? tone? No 30 secs • Provide warmth H • { Dry. and color reposition . heart rate. Evaluate respiration. stimul ate. HR>100 & Pink Give supplementary oxygen Persistent cyanosis Provide positive pressure ventilation* HR <60 • Provide positive pressure Post resuscitation Care HR >60 ventilation 30 secs • Administer chest compression* HR * Endotracheal intubation may be considered at several steps 42 <60 .Breathing. HR>100 30 secs But cyanotic Apneic or HR<100 Breathing. This will allow secretions to collect in the cheek where they can be removed easily. turn the head to the side. Care should be taken to prevent hyperextension or exion of the neck. larynx. clear airway (as necessary) • Dry. stimulate. To help maintain the correct position. If. When using suction from the wall or from a pump. all of the initial steps should be initiated within a few seconds. with the neck slightly extended in the snifng position. which will facilitate unrestricted air entry.4. The mouth is suctioned before the nose to ensure that there is nothing for the newborn to aspirate if he or she should gasp when the nose is suctioned. no suctioning of oro-pharynx or the trachea is required. This will bring the posterior pharynx. you may place a rolled cloth/ towel under the shoulders.4. Initial steps • Provide warmth • Position. Although they are listed as initial and are given in a particular order. If material in the mouth and nose is not removed before the newborn breathes. In all non-vigorous babies suctioning of oro-pharynx needs to be done.3 What are the initial steps and how are they administered? Once you decide that resuscitation is required. . •Providewarmth The baby should be placed under a radiant warmer. where you will have easy access to the baby and the radiant heat will help to reduce heat loss •Positionbyslightlyextendingtheneck The baby should be positioned on the back. oropharyngeal suction would need to be followed by tracheal intubation to clear it of meconium (if skills are available). such babies were also delivered through meconium stained amniotic uid. they should continue to be applied throughout the resuscitation process. How do you clear the airway? Secretions may be removed from the airway by wiping the nose and mouth with a towel or by suctioning with a mucus extractor or suction catheter. heart rate>100 bpm and a good muscle tone). the respiratory consequences can be serious. since either may restrict air entry (Figure 14) Figure 14: Snifng Position •Clearairway(asnecessary) In vigorous babies (a vigorous baby is one who has strong respiratory efforts. If the newborn has copious secretions coming from the mouth. the negative pressure (vacuum) reads approximately 100 mm Hg. When this occurs. the material can be aspirated into the trachea and lungs. and trachea in line. the suction pressure should be set so that when the suction tubing is blocked. 43 . If the newborn does not have adequate respirations.stimulatetobreathe.andreposition Often.Once the airway is clear. • Gently rubbing back. but also may be used to stimulate continued breathing after positive-pressure ventilation. brain damage. positioning the baby and suctioning secretions will provide enough stimulation to initiate breathing. For many newborns. It is important for you to understand the correct methods of tactile stimulation. pneumothorax. Drying will also provide stimulation. trunk. available. you should have several pre-warmed towels. There should be good chest movements. these steps are enough to induce respirations. or methods of providing stimulation include. As part of preparation for resuscitation. and fresh pre-warmed towels or blankets should be used for continued drying and stimulation. which can be used to dry most of the uid. Drying the body and head will also help to prevent heat loss. down and shaking Intraventricular bleeding. ficking the soles of the newborn’s extremities (Figure 15) Fig 15: Tactile Stimulation Certain actions of physical stimulation can harm the baby and should not be used. This towel should then be discarded.4. Stimulation may be useful not only to encourage a baby to begin breathing during initial steps of resuscitation. 4. what should be done to stimulate breathing and prevent further heat loss? •Dry. If 2 people are present. the second person can be drying the baby while the rst person is positioning and clearing the airway.4 What do you do after the initial steps? Evaluate the baby in the following order: • Respiration. additional tactile stimulation may be provided briey to stimulate breathing. What other forms of stimulation may help a baby breathe? Both drying and suctioning stimulate the newborn. The baby initially can be placed on one of these towels. death . Harmful Actions Consequences Slapping the back Bruising Squeezing the rib cage Holding upside Fractures. Safe and appropriate additional tactile • Slapping or the feet. and the rate and depth of respirations should increase after a few seconds of tactile stimulation. • Heart rate. The easiest and quickest method to determine the heart 44 . The heart rate should be more than 100 bpm. If the baby is breathing but appears blue. 4. Free-ow oxygen cannot be given reliably by a mask attached to a selfinating bag. . indicate that by itself. Cyanosis the can provide breathing and determined caused by by the looking at too little oxygen in the blood will appear as a blue hue to the lips. tongue and central trunk. How do you know when to stop giving oxygen? When the newborn no longer has central cyanosis. administration of supplement oxygen is indicated. • Colour. Counting the heart rate for 6 seconds and multiply by 10 to calculate the heart rate per minute. Acrocyanosis which is a blue hue to only the baby’s blood the hands and feet does not generally oxygen level is low and should not. be treated with oxygen. Only central cyanosis requires intervention. adequate circulation. gradually withdraw the supplemental oxygen until the newborn can remain pink while breathing room air. The baby should have pink lips and trunk. If cyanosis persists despite administration of free-ow oxygen. There should be no central cyanosis once the baby has good respiration and heart beat that indicates hypoxia. • Give free-fow oxygen Give a ow of 5 L/min with a tubing by cupped hand or a mask kept closer to the face (Figure 16). or wean the oxygen as indicated by pulse oximetry. and a trial of positive-pressure ventilation may be indicated. changing from most rapid and visible indicator blue of to pink. the baby may have signicant lung disease.4. but has central cyanosis? A baby’s skin color. best the The central part baby’s skin color is of body.5 What do you do if the baby is breathing.rate is to feel for the pulse at the base of the umbilical cord. Fig 16: Free ow oxygen delivery methods Observational Care Babies improving after initial steps of resuscitation require observational care. Demonstration on Initial Steps 45 . color and temperature every 15 minutes during the rst hour after birth. heart rate. Continue to provide warmth and initiate breast feeding. This can be provided either with the mother or in a newborn care unit. he will require additional interventions. If baby is unstable. Assess breathing. 6 Positive Pressure Ventilation Indications of • Baby is • Heart rate • Persistent Positive pressure Ventilation not breathing or is gasping. even if it is not attached to oxygen and even if its mask is not on a patient’s face. Capability to deliver a variable oxygen concentration up to 100% Babies who require positive-pressure ventilation at birth initially be ventilated with high concentration of oxygen.4. . Consideration should be given to the following: Appropriately sized masks A variety of mask sizes. centralcyanosis despite supplemental oxygen Ventilation of the lungs is the single most important and most effective step in cardiopulmonary resuscitation of the compromised newly born baby. The mask should cover the chin. while still being small enough to create a tight seal on the face. since it may be difcult to determine the appropriate size before birth. It remains infated at all times. Advantages and disadvantages of Self Inating Bag The self-inating bag is more commonly found in the hospital delivery room and resuscitation cart. Use of Self Inating bag to ventilate newborns The self-inating bag. The disadvantages of this. is that be less likely to know if the oxygen line has become or if you have not achieved a good seal between the the baby’s face-both of which are necessary you will disconnected mask and for effective resuscitation. inates automatically without a compressed gas source (Figure 17). unless being squeezed.4. This can be accomplished by attaching a 100% oxygen source to a self-inating bag with an oxygen reservoir. and nose. as it will rell after being squeezed. but not the eyes. pop of valve Fig 17: Bag and mask What are the important characteristics of resuscitation bag used to ventilate newborns? The equipment is specically designed for newborns. of course. as its name implies. should be available at every delivery. is less than 100 bpm. It is somewhat easier to learn to use. High oxygen concentration cannot be achieved with a self-inating bag without a reservoir. Peak inspiratory pressure (PIP) (or peak infation pressure) is controlledby how hard the bag is squeezed. appropriate for babies of different sizes. mouth. 46 . • Too large-may cause possible eye damage and will not seal well • Too small-will not cover the mouth and nose and may occlude the nose Be sure to have various-sized masks available. which are designed for older children and adults. resuscitation devices have certain safety features to prevent or guard against inadvertent use of high pressures. They are made to be placed on the face with the most pointed part of the mask tting over the nose. (Figure 18). Bags larger than 750mL. Masks also come in several sizes. For the mask to be of the correct size. Effective ventilation of a preterm baby with a . achievea tight seal between the mask Masks come in two shapes: round and anatomically shaped.Approximately sized bag You should use bags for newborns which have volume of 500 mL. Safety features To minimize complications resulting from high ventilation pressures. Masks suitable for small premature babies as well as for term babies should be available for use. Bags that are too small will not permit long ination times. limiting the pressure being transmitted to the newborn. What characteristics of face masks make them most effective for ventilating newborns? Masks come in a variety of shapes. sizes and materials. If peak inspiratory pressure greater than 30 to 40 cm H2O are generated. Term newborns require only 15 to 25mL with each ventilation (5 to 8mL/Kg). the mouth. The and the correct mask will newborn’s face. the valve opens. They have a pressure-release valve (commonly called pop-off valve) (Figure 17). make it difcult to provide such small volumes. Selection of a mask for use with a particular newborn will depends on how well the mask fts the newborn’s face. and the nose but not the eyes. Anatomically shaped masks are shaped to t the Contours of the face. the rim will cover the tip of the chin. which generally is set by the manufacturer at 30 to 40 cm H2O. Fig 18: Choosing correct size of the mask 47 .term-infant size mask is impossible. One way to accomplish this is to place a small roll under the shoulders (Figure 19). the baby’s neck should be slightly extended (but not overextended) into the snifng position to maintain an open airway. Be sure to attach oxygen reservoir when using self inating bag. reposition the baby before continuing. How do you position the bag and mask on the face? Place the on face so covers nose mouth. The equipment should be checked before each delivery. valves that stick or leak. the mask should cover the mouth. and for vascular access via umbilical cord should these procedures become necessary. You may nd it helpful to begin by cupping the chin in the mask and then covering the nose (Figure 19). If the baby’s position has shifted. check the bag and mask to be sure they function properly. The mask usually is held on the face with the thumb. and tip of the chin. Bags that have cracks or tears.How do you prepare the resuscitation device for an anticipated resuscitation? Assemble equipment The positive-pressure ventilation device should be assembled and connected to oxygen so that it can provide the necessary 90% to 100% concentration. nose. the tip the rests the of the mask the that it the and and of chin within rim mask. and/or middle nger encircling much . or mask that are cracked or deated must not be used. Position the babys head. You may want to suction the mouth and nose one more time to be certain there will be no obstruction to the assisted breaths that you will be delivering. or Both positions leave the chest and abdomen unobstructed for visual monitoring of the baby. What do you need to check before beginning positive-pressure ventilation? Select the appropriate-sized mask. index. Test the equipment Once the equipment has been selected and assembled. Remember. Position yourself at the bedside You also head will to need use to a position yourself at resuscitation device effectively the baby’s side (Figure 19). for chest compressions. but not the eyes (Figure 18) Be sure there is a clear airway. As described in ETAT. The operator should check it again just before its use. of the rim of the mask. Fig 19: Positing of bag and mask on the face 48 . while the ring and fth bring the chin forward to maintain a patent airway. color. or slightly less than once a second. the baby also should become pink and muscle tone should improve. and muscle tone. How often should you squeeze the bag? During the initial stages of neonatal resuscitation.. When color improves. you should look for the presence of chest movements with each positive-pressure breath and have an assistant listen to both sides of the lateral areas of the chest with a stethoscope to assess breath sounds. you should continue to administer positive-pressure ventilation and assess the 4 signs every 30 seconds. and muscle tone do not improve and babys chest is not moving during positive-pressure ventilation? .TwoThree (squeeze) (release) (squeeze) (release) How do you know if the baby is improving and that you can stop positive pressure ventilation? Improvement is indicated by the following 4 signs: • Increasing heart rate • Improving color • Spontaneous breathing • Improving muscle tone Check the 4 signs for improvement after 30 seconds of administering positive pressure. But if the heart rate is above 60 bpm. What do you do if the heart rate. breaths should be delivered at a rate of 40 to 60 breaths per minute. Monitor the movement of the chest and breath sounds to avoid overination or underination of the lungs. supplemental oxygen also can be weaned as tolerated. Rapid rise and in the muscle baby’s heart rate tone are the and best subsequent indicators improvement in color that ination pressures are adequate. With improvement. When the heart rate stabilizes above 100 bpm. color. As the heart rate increases towards normal. To help maintain a rate of 40 to 60 breaths per minute. If these signs are not improving. you need to proceed to the next step of chest compressions as described in the next lesson. reduce the rate and pressure of assisted ventilation until you see effective spontaneous respirations. How do you know how much ination pressure to deliver? The best indicator that the mask is sealed and the lungs are being adequately inated is an improvement in heart rate.Why is establishing a seal between the mask and the face so important? An airtight between the rim of the mask and the face is essential to achieve the positive pressure required to inate the lungs with the resuscitation devices. try saying to yourself as you ventilate the newborn: BreatheTwoThreeBreathe. If the heart rate remains below 60 bpm. continue ventilating the baby at a rate of 40 to 60 breaths per minute. and muscle tone do not improve.If the heart rate. 49 . it may be due to one or more of the following reasons. check to see if the chest is moving with each positive-pressure breath and ask the second person to listen with the stethoscope for breath sounds. color. If the chest does not expand adequately and there are poor breath sounds. and leaving the gastric tube in place and uncapped to act as a vent for stomach gas throughout the remainder of the resuscitation. • Check the baby’s position and extendthe neck a bit farther. increase the pressure until the valve actuates. Use a little more pressure on the rim of the mask and lift the jaw a little more forward. The most common place for a leak to occur is between the cheek and bridge of the nose. and nose for secretions. Demonstration of PPV and Practice by participants 4. The problems related to gastric/abdominal distention and aspiration of gastric contents can be reduced by inserting an orogastric tube.7 Chest Compression . color. and perceptible chest movements. • If using a bag with pressure-release valve.4. oropharynx. Blocked airway Another possible reason for insuffcient ventilation of the baby’s lungs is a blocked airway. If using a resuscitation device with a pressure gauge. Not enough pressure You may be providing inadequate inspiratory pressure.note the amount of pressure required to achieve improvements in heart rate. reapply the mask to the face and try to form a better seal. Do not press down hard on the baby’s face. • Increase the pressure. • Try ventilating with the baby’s mouth slightly open (especially helpful in extremely small premature babies with very small nares). suction the mouth and nose if necessary.• • The seal is inadequate • The airway is blocked Not enough pressure is being given Inadequate seal If you hear or feel air escaping from around the mask. Is there anything else to do if positive-pressure with a mask is to be continued for more than 2 minutes? Newborns requiring positive-pressure ventilation with a mask for longer than 2 minutes should have an orogastric tube inserted and left in place. endotracheal intubation may be required.To correctthis. • If physiologic improvements still cannot be achieved. • Check the mouth. suctioning gastric contents. breath sounds. despite stimulation and 30 seconds of positivepressure ventilation.What are the indications for beginning chest compressions? Chest compressions should be started whenever the heart rate remains less than 60 bpm despite 30 seconds of effective positive-pressure ventilation. the myocardium is depressed and unable to contract strongly enough to pump blood to the lungs to pick up the oxygen that you have now ensured is in the lungs. Therefore. As a result.(Check HR for 6 seconds) Why perform chest compressions? Babies who have a heart rate below 60 bpm. probably have very low blood oxygen levels and signicant acidosis. you will need to mechanically pump the heart while you simultaneously continue to ventilate the 50 . blood enters the heart from the veins. This technique is superior in generating peak systolic and coronary . where the 2 thumbs are used to depress the sternum. How do you position your hands on the chest to begin chest compressions? There are two techniques for performing chest compression. sometimes referred to as external cardiac massage. while the hands encircle the torso and the ngers support the spine (Figure 20). where the tips of the middle nger and either the index nger or ring nger of one hand are used to compress the sternum. 2 people are required to administer effective chest compressions-one to compress the chest and one to continue ventilation. and where should they stand? Remember that chest compressions are of little value unless the lungs are also being ventilated with oxygen. The person assistingventilation will need to be positioned at the baby’s head to achieve an effectivemask-face seal (or to stabilize the endotracheal tube) and watch for effective chest movement. Compressing the sternum compresses the heart and increases the pressure in the chest. The person performing chest compressions must have access to the chest and be able to position his or her hands correctly. Therefore. and you can generally control the depth of compression somewhat better. These techniques are •Thumbtechnique . consist of rhythmic compressions of the sternum that • • • Compress Increase Circulate the heart against the spine the intrathoracic pressure blood to the vital organs of the body The heart lies in the chest between the lower third of the sternum and the spine. When pressure on the sternum is released. What are chest compressions? Chest compressions. while the other hand is used to support the baby’s back (unless the baby is on a very frm surface) (Figure 21). • 2-fngertechnique. How many people are needed to administer chest compressions. causing blood to be pumped into the arteries.lungs until the myocardium becomes sufciently oxygenated to recover adequate spontaneous function. This process also will help to restore oxygen delivery to the brain. Fig 20: Thumb technique Fig 21: 2-nger technique What are the advantages of one technique over the other? The thumb technique is preferred because it usually is less tiring. perfusion pressure. The 2nger technique also is preferable to provide access to the umbilicus when medications need to be given by the umbilical route. However. 51 . the 2-nger technique is more convenient if the baby is large or your hands are small. You can quickly locate the correct area on the sternum by running your ngers along the lower edge of the ribs until you locate the xiphoid. Care must be used to avoid putting pressure directly on the xyphoid. The two techniques have the following things in common: • • Position of the . which lies between the xyphoid and a line drawn between the nipples.Neck slightly extended. How do you position your hands using the 2-nger technique? In the 2-nger technique. The actual distance compressed will depend on the size of the baby. one over the other (Figure 20). The thumbs will be used to compress the sternum. - baby Compressions Same location. Then place your thumbs or ngers immediately above the xiphoid. As with the thumb technique. The thumbs can be placed side by side or. and then release the pressure to allow the heart to rell. The thumbs should be exed at the rst joint and pressure applied vertically to compress the heart between the sternum and the spine. depth. How do you position your hands using the thumb technique? The thumb technique is accomplished by encircling torso with both hands and placing the thumbs on the sternum and the fngers under the baby’s back supporting the spine (Figure 20). the tips of the middle nger and either the index or ring nger of one hand are used for compressions (Figure 21).Firm support for the back .Therefore.and the press with 2-fngers the perpendicular to the fngertips. on a small baby. With the ngers and hands correctly positioned use enough pressure to depress the sternum to a depth of approximately one third of the anterior posterior diameter of the chest. while your ngers provide the support needed for the back. (Figure 22). and rate Where on the chest should you position your thumbs or ngers? Hands should be positioned on the lower third of the sternum. you should learn both techniques. apply pressure vertically to compress the heart between the sternum and the spine. chest as Position shown. . How much pressure do you use to compress the chest? Controlling the pressure used in compressing the sternum is an important part of the procedure. One compression consists of the downward stroke plus the release. 52 . • There should be (1 minute) approximately 120 “events” – 90 compressions plus 30 per 60 breaths. the 2 activities must be coordinated. heart and lungs. Avoid giving a compression and ventilation simultaneously. seconds How can you practice the rhythm of chest compressions with ventilation? . then • Time is wasted in relocating the compression area. because one will decrease the efcacy of the other. Allow the chest to fully expand by lifting the thumbs or ngers during the release phase to permit blood to re-enter the heart from the veins. with one ventilation interposed after every third compression. However. Therefore. the ribs are fragile and can to the baby. Pressure can cause laceration of the easily be broken. How often do you compress the chest and coordinate compressions with ventilation? During cardiopulmonary resuscitation. the wrong area. chest compressions must always be accompanied by positive-pressure ventilation. • Chest compressions can cause trauma Two vital organs lie within the ribcage-the applied too low. over the xiphoid. for a total of 30 breaths and 90 compressions per minute One cycle of events will consist of 3 compressions plus one ventilation. may result producing underlying organs. • • Control over Compression of the chest or the depth of compression is lost.Fig 22 : Depth of chest compression The thumbs or the tips of ngers should remain in contact with the chest at all times during both compression and release. If the thumbs or ngers are completely off the sternum after compression. Also. do not lift the thumb or ngers completely off the sternum after compression. trauma to Are there dangers associated with administering chest compressions? • • liver. squeeze your hand only when you say Breathe and 53 .Practice saying the words and compressing the chest. Remember. One-and-Two-and-Three-and-Breathe-and-One-and-Two-and-Three-and-Breathe-andOne-and-Two-and-Three-and-Breathe-and-One-and-Two-and-Three-and-Breathe-and One-and-Two-and-Three-and-Breathe-and Now time yourself to see if you can say and do these ve events in 10 seconds. One-and-Two-and-Three-and-Breathe-and-One-and-Two-and-Three-and-Breathe-andOne-and-Two-and-Three-and-Breathe-and-One-and-Two-and-Three-and-Breathe-and One-and-Two-and-Three-and-Breathe-and When do you stop chest compressions? After approximately 30 seconds of well-coordinated chest compressions and ventilation, stop compressions long enough to determine the heart rate again. Feel the pulse at the base of the cord, If the heart rate is now above 60 bpm, then Discontinue chest compressions, but continue positive-pressure ventilation now at a more rapid rate of 40 to 60 breaths per minute. Once the heart rate rises above 100 bpm and the baby begins to breathe spontaneously, slowly withdraw positive- pressure ventilation and move the baby to the nursery for postresuscitation care. Demonstration of Chest compression and practice by participants If the heart rate is now below 60 bpm, then Despite good ventilation of the lungs with positive-pressure ventilation and improved cardiac output from chest compressions, a small number of newborns (fewer than 2 per 1,000 births) will still have a heart rate below 60 bpm. These babies would require epinephrine to stimulate the heart. 4.4.8 How should you prepare epinephrine, and how much should you give? Although epinephrine is available in both 1:1,000 and 1:10,000 concentrations, the 1:10,000 concentrations is recommended for newborns, eliminating the need for dilution. Recommended concentration= 1:10,000 Epinephrine should be given intravenously, although administration may be delayed by the Recommended dose=0.1 to 0.3 mL/kg of time required to access. Give ml/kg establish intravenous 1:10,000 solution (consider 0.3 to 1mL/kg if giving 0.1 0.3 endotracheally) – of 1:10,000 solution. Calculate the dose and give in 1 ml syringe intravenously. Recommended preparation=1:10,000 solution in 1-mL syringe (or larger syringe if giving endotracheally) Recommended rate of administration=Rapidly-as quickly as possible What should you expect to happen after giving epinephrine? Check the you baby’s heart rate 30 seconds after continue positive-pressure ventilation administering epinephrine. As and chest compressions, the heart rate should increase to more than 60 bpm after you give epinephrine. If this does not happen, you can repeat the dose after 3 to 5 minutes. In addition ensure that • There is good chest movement air and exchange presence as of evidenced bilateral by adequate breath sounds. Chest are given to a depth of one third the chest and are well coordinated with compressions diameter ventilations. 54 of the • What should you do if the baby is in shock, there is evidence of blood loss, and the baby is responding poorly to resuscitation? Babies in shock appear pale, have delayed capillary rell and have weak pulses. They may have a persistently low heart rate, and circulatory status often does not improve in response to effective ventilation, chest compressions, and epinephrine. If the baby appears to be in shock and is not responding to resuscitation, administration of a volume expander may be indicated. What can you give to expand blood volume? How much should you give? How can you give it? The recommended solution for acutely treating hypovolemia is an isotonic crystalloid solution. Acceptable solutions include • 0.9% NaCl (“Normal saline”) • Ringer’s lactate. The initial dose is 10 mL/kg. However, if the baby shows minimal improvement after the rst dose, you may need to give another dose of 10 mL/kg. In unusual cases of large blood loss additional dose might be considered. A volume expander must be given into the vascular system. The umbilical vein is usually the most accessible vein in a newborn, although other routes (eg, intraosseous) can be used. • Sodium bicarbonate should be avoided in labor room 4.4.9 Post Resuscitation Care Babies requiring positive pressure ventilation, chest compressions or medicatios would require post resuscitation care. Some of these babies need to be transferred to a newborn care unit. They would require ongoing evaluation, monitoring and management (for details see section 6.3). When to terminate resuscitation? After 10 minutes of continuous and adequate efforts if there are no signs of life (no heart rate and no respiratory effort), discontinue resuscitative efforts. The prognosis of such babies must be discussed with the parents before discontinuing the resuscitation resuscitation. Remember efforts be must in continued all so-called for 10 min. ‘stillbirths’ The data suggests that in fresh stillbirths prognosis is not all that bad. Where do babies go from delivery room? health facility with a neonatal care unit. • Has birth weight less than 1500 gms • Has major congenital malformation / severe birth injury • Has severe respiratory distress • PPV  5 minutes or needing more • 1800 • closely Birth weight 1500gm Babies needing IPPV < 5 minutes and vigorous • Babies with fast breathing All babies not needing referral and short-term observation are roomed-in with the mother 55 SECTION. 5 CARE OF NEWBORN IN POSTNATAL WARD A large majority of newborns after birth would be transferred to the post-natal wards for rooming-in with their mothers. These babies need to be monitored because they are at continued risk of hypothermia and feeding difculties during the rst few days of life. These babies can also become sick and develop danger signs. The mother-infant pair would need counseling and appropriate treatment when required. 5.0 Learning Objectives After completion of this section the participant should be able to• • Examine Identify and all newborns to manage newborns detect any who need signs of specialcare illness 5.1 The postnatal environment A postnatal room should be kept warm with no draughts from open doors or windows. A temperature of 25ºC is required to help keep a baby warm. A mother and her baby should be kept together in the same bed right from birth. This helps the mother to get to know her baby and form an early close loving relationship (bonding), she can also respond quickly when her baby wants to feed, which helps establish breastfeeding and reduces breastfeeding difculties. It is important to greet the mother important reason for this is mother. Using good mother that her appropriately before starting the examination of the baby. An to open good communication with the communication helps to reassure the baby will receive good care. Review labour and birth record Review the labour and birth record to identify any risk factors or any events during the birth which may be important in the management of the mother and the baby 5.2 Ask the mother • Does says • Has hours. investigation • Has is she or the baby have any the infant passedstools?Meconium Passage after 24 hours is the NOT problems and record what should be passedby 24 NOT NORMAL and needs infant passedurine? Urine is passedby NORMAL if not passedby 48 48 hours. It hours. • she • 56 Have you started breast feeding the Is there any diffculty in feeding infant? the infant? • Do breast any the you have any pain feeding? • Have you other foods or drinks infant? If while given to Yes, what and how ? 5.3 Examine the baby • • • • • • • • • Count the breaths in one minute. Look for severe chest indrawing. Look and listen for grunting. Look at the umbilicus. Is it red or draining pus? Look for skin pustules. Are there 10 or more pustules a big boil? Measure axillary temperature (if not possible, feel for fever or low body temperature): Normal (36.5-37.4º C) Mild hypothermia (36.0-36.4º C/ cold feet) Moderate hypothermia (32.0º C – 35.9º C, cold feet and abdomen) Severehypothermia (< 32º C) Fever ( 37.5º C/ feels hot) See if young infant is lethargic Look for jaundice. Are the face, abdomen or soles yellow? Look for malformations or 5.4 Assess Breastfeeding If infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. • - Is the infant able to attach? Chin touching breast Mouth wide open Lower lip turned outward More areola above than below the mouth To check attachment, look If not well attached, help the mother to position so that the baby attaches well to the breast. • Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? If not sucking well, then look for: • ulcers or white patches in the mouth (thrush). If there is difculty or pain while feeding, then look for • Engorged breasts or breast abcess • Flat or inverted, or sore nipples for: 57 Look for Normal Phenomena There are several phenomena after birth that is normal and mothers only need reassurance. • There are a few developmental variants which may be present and be of concern to the mother. These include milia, epstein pearls, mongolian spots, enlarged breasts, capillary nevi etc. The mother needs to be reassured. stools, • Transitional yellowish-green in color stools is between day the passage of frequent, loose 3 and 14 life. day of It needs NO treatment. • • These • frst birth Vaginal white discharge/bleeding in Red rashes on the skin may be are normal Weightloss of 6-8% (10-12% few days of life is normaland female babies is seen on 2-3 in most normal days of preterms) in infants regain their the weight by 10-14 days. 5.5 Cord Care Instruct keep for 2-4 the it mother not dry. Umbilical pathogenic hours of to cord apply anything on is an important the cord portal of and entry after organism. Umbilical stump must be inspected clamping. Bleedingmay occur at this time due to shrinkage of the cord and loosening of the ligature. 5.6 Skin and Eye Care Babies are not bathed routinely in the hospital to prevent complications like hypothermia and infection, they may however be sponged with lukewarm water. No routine eye care is required. 5.7 Vitamin K Give Vitamin K 1.0 mg (0.5 mg in preterms) IM if not already received at birth. 5.8 Counsel the mother • • • Warmth. Breastfeed frequently. Advise mother to wash hands with soap toilet and after cleaning the bottom mother regarding danger signs and care and of water after using the the baby. • Advise seeking. Immunization • The baby should receive -BCG -OPV-0 -Hepatitis B (HB-1) - if included in immunization schedule Follow-up Schedule a postnatal visit within the rst week on day 3 and day 7 of delivery. Also visit on day 14, 21 and 28 if baby is LBW. In the follow up the baby should be assessed for growth and development and early diagnosis and management of illnesses. In addition, health education of parents should be done. It is preferable that every baby is seen and assessed by a health worker at least once every month for 3 months and subsequently 3 monthly till 1 year. life. Group Discussion on care in postnatal ward 58 SECTION. 6 MANAGEMENT OF A SICK YOUNG INFANT Sick young infants not only require supportive care but also require specic management for different conditions. 6.0 Learning Objectives After completion of this section the participant should be able to• • Provide Manage state, sepsis and jaundice • Monitor • Provide appropriate fuid therapy specifcconditions – Hypoglycemia, (including pneumonia and meningitis), sick newborn follow up care after post-asphyxial tetanus neonatorum discharge 6.1 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 in the acute phase in babies who are lethargic or unconscious, having frequent convulsions, apnea, shock or having moderate to severe respiratory distress. • Withhold oral feeding if there is bowel obstruction, necrotising enterocolitis or the feeds are not tolerated, e.g. indicated by increasing abdominal distension or vomiting everything. Give IV uids Intravenous uids The uid requirements of neonates are summarized in Table 5. 59 . It can cause rebound hypoglycemia. adjust IV fuids appropriately. Introduce milk feeding by orogastric tube or breastfeeding as soon as it is safe to do so.2 Hypoglycemia Check for blood glucose in all sick young infants • If hypoglycaemia detected (defned as young infants). monitor blood sugar every 4-6 hourly. • Glucose infusion rates  10mg/kg/min can result in glucose concentration > 13% in the infused fuid. • Adjust daily IV maintenance fuids appropriately if baby is receiving dopamine or any other infusions. 6. • Use a monitoring sheet • Calculate drip rate • Check drip rate and volume infused every hour • Check for edema/puffness of eyes (could indicate volume overload) • Weigh baby daily to detect excessive weight gain (excess fuid) or loss (insuffcient fuid). • Recheck still low. volume according mg/kg/min of glucose in all cases of neonatal hypoglycemia as given in Table 6. stop IV uids. Monitor the IV infusion very carefully. Do not discontinue the glucose infusion abruptly. Once normal. For babies who are able to breastfeed well.g. Under such circumstances infusion through peripheral veins is not recommended. Reduce the IV uid rates as the volume of milk feeds increases in infants on orogastric feeds. then increase to 10 mg/kg/min. Discontinue IV uids once oral intake reaches 2/3rd total requirement. give 2 ml/kg IV bolus dose • to Start infusion of glucose at the daily the baby’s so to provide 6 age as < of maintenance 45 10% mg/dl for dextrose.Table 5 : Fluid requirement of neonates (ml/per kg body weight) Day of Life Birth Weight <1500 g 1500 g 80 1 95 110 60 2 125 75 3 140 90 4 150 105 5 150 120 6 135 7 150 Type of uid • • First 2 days : After 2 days: maintenance fuid containing 10% dextrose in water Use either commercially available pediatric 25mmol/L of sodium (e. If blood sugar still remains low. If you cannot cannulate the umbilical vein refer the baby to a higher health . infusion the blood glucose repeat the bolus of in 30 glucose minutes. (above) If and it is increase rate of glucose to 8 mg/kg/min. Table 6 depicts the volume of 10% and 25% dextrose to be added to get appropriate glucose concentration. It would require infusion through umbilical vein. Isolyte-P) prepare the + 1ml otherwise Kcl+79 mL of 10% fuid by adding 20 ml NS dextrose to make 100ml uid. • After the blood sugar has concentration of glucose been by stabilized step 2 mg/kg/min down the every 4-6 hourly ensuring that blood sugar remains normal. If the baby cannot be breastfed. Allow the baby to begin breastfeeding. 60 . give expressed breast milk using an alternative feeding method.facility. higher/lower glucose infusion rate. so drops/min = ml/hr of ?uid 6-7 50 micro- . Do not discontinue the glucose infusion abruptly to prevent rebound hypoglycemia.• As the baby’s ability to feed improves. Example: Calculating glucose infusion rate for treating hypoglycemia A two day old 2 kg hypoglycemic infant requires 6 mg/kg/min of glucose infusion and daily uid volume at 75 ml/kg. you a fresh solution with the desirable Group Discussion on Hypoglycaemia management Now we will learn through the following example to calculate glucose infusion rate. Step 1: Total uid needed on day 2 of life: 75 (ml/kg) x 2 (kg) = 150 ml Step 2: Look at Table 6 to check composition of uid For 75 ml/kg/d @ 6mg/kg/min we need 68ml/kg of D10 and 7 ml/kg of D25. Amount of D10 needed/day: 68 ml x 2 = 136 ml Amount of D25 needed/day: 7 ml x 2 = 14 ml Step 3: Writing uid order ml drops/min* (5ml D25 + 45 ml D10) in 8 hours @ * In Micro infusion burette set 1 ml = 60 drops. slowly decrease (over 6 to 12 hours) the volume of IV glucose if the baby remains euglycaemic while increasing the volume of oral feeds. Table 6 : Achieving appropriate glucose infusion rates using a mixture of D10 & D25 (Babies > 1500 gm) Glucose infusion rate Volume (ml/ kg/d) 60 75 90 105 120 6 8 10 mg/kg/min mg/kg/min mg/kg/min D10 (ml/kg/d)D25 (ml/kg/d)D10 (ml/kg/d)D25 (ml/kg/d)D10 (ml/kg/d)D25 (ml/kg/d) 42 18 24 36 5 5 5 68 7 49 26 30 4 5 3 90 74 16 55 5 85* 99 6 80 2 5 1 100* 120 97 8 Note: *Add 20ml/kg of Normal saline to provide 3 meq/kg of sodium • If hypoglycemiais infusion. give one refer to a higher health facility for • To provide a would have to make glucose composition persisting at 10 mg/kg/min of glucose dose of Hydrocortisone: 5 mg/kg and further management of persistent hypoglycemia. 61 . renal failure. consider enteral feeding. section3. When to stop anticonvulsant medication? If the baby has been free of convulsions and is neurologically normal after 72 hrs.3. Feeding: If the baby has no emergency signs or abdominal distension.6. hypotonia or hypertonia. 3.5ºC (or feels cold to touch) • Lethargic or unconscious. . during or immediately after birth results in asphyxia which is recognized by either delayed onset of breathing/cry with/without need for assisted ventilation. poor suck and feeding difculty. If the baby needed an anticonvulsant drug (ACD) to control convulsions review the baby after 72 hrs. 6. shock. provide maintenance intravenous uids according to age (see section 6. Check blood sugar and if hypoglycemia is detected. 4. apnea.4 Septicemia Common systemic bacterial infections in young infants pneumonia and meningitis and all these may present alike. Fluids: In a baby with emergency signs (breathing dif?culty. Additional problems that these newborns may have include hypoglycemia. If at 72 hrs. Check for emergency signs and provide emergency care (see chart2).5ºC or above (or feels hot to touch) or temperature less than 35. Clinical features that these babies could manifest with during the rst 2-3 days of life include irritability or coma. then restrict maintenance uid to 60% of requirement.1) after initial stabilization of emergency signs. convulsions. Place these babies under radiant warmer to maintain normaltemperature as they usually have diffculty in maintaining normal body temperature.2). If the baby is sucking well. 2. then follow management guidelines in Module 1. coma or convulsions). 6. Bacterial sepsis in a young infant is usually suspected by the presence of one or more of the following signs: • Unable to feed • Convulsions • Fast breathing (60 breaths per minuteor more) • Severechest indrawing • Nasal faring • Grunting • Bulging fontanelle • Axillary temperature 37. If convulsions are present. treat it ( seesection6. the baby has hypertonia. initiate breast feeding or else initiate gavage feeding with breast milk in those with poor/no sucking. shock. After 24 hrs of hospitalization. 5. then stop the ACD.3 Post Resuscitation care of Asphyxiated newborn Lack of oxygen supply to organs before. continue ACD and refer for assesment. Management 1. if the baby has not lost weight or has gained weight. include sepsis. Initiate feeding with 15 ml/kg/day and increase by 15 ml/kg/day for next few days while gradually tapering off IV uids. • 62 Less than normalmovements . 7. Start oxygen by hood or mask. If perfusion is poor as evidenced by capillary re?ll time (CRT) of more than 3 seconds. reduced movement. manage shock as described earlier. A mik acin 710 15 24 h . In such situations take the help of risk factors and sepsis screen. duration and frequency. Inject Vitamin K 1 mg intramuscularly. • Provide supportive obtain blood cultures before care and for the sick Table 7. Provide gentle physical stimulation. Consider use of dopamine if perfusion is persistently poor. hypoglycemia or hypothermia.Many of these symptoms may be present in other neonatal conditions eg perinatal asphyxia. 5. if apneic. starting antibiotics. per (if of Staphylococcus infection. days the preferably pustules or treated with arthritis. 6. joint swelling. • neonate as for described in Give Refer cloxacillin available) instead of ampicillin if abscesses as might be signs in 7-10 neonates should be days except meningitis. deep If not improving need to be antibiotic treatment may as microbial culture reports. ensure consistently normaltemperature 2. Avoid enteral feed if very sick. 9. abscesses and staphylococcal infections which would require 2-3weeks of therapy. Provide warmth. Ampicillin or50 Inj. Where blood cultures are available. IM 7-10 Inj. Start intravenous line. 3. Infuse glucose (10 percent) 2 ml/kg stat. Start antibiotics. 8. and irritability if these parts are handled • Many skin • pustules/big boil (abscess) Umbilical umbilicus redness draining extending pus to the periumbilical skin or Treatment of Septicemia • • • • Admit to hospital. 4. 10. give Injection ampicillin and gentamicin. give maintenance ?uids intravenously Table 8 : Antibiotic therapy of sepsis AntibioticEach Dose Frequency (mg/kg/dose) Inj. More specic localizing signs of infection which indicate serious bacterial infection include • Painful joints. Most bacterial antibiotics for these infections at least extensive monitoring 2–3 changed. IM 8 hrly 710 IV AND Inj. Table 8 dose. Provide bag and mask ventilation with oxygen if breathing is inadequate. Cloxacillin50 Route Duration <7days 12 hrly age 12 hrly  7days age (Days) 8 hrly IV. • in skin to Table 7 : Supportive care of a septic neonate 1. Gentamicin or5 24 hrly24 hrlyIV. if cyanosed or grunting. IM 7-10 63 .rly 24 hrly IV. Table 9 : Antibiotic therapy of meningitis Each Dose Frequency RouteDuration (mg/kg/dose) <7days 7days Inj. Gentamicin OR 12 hrly8 hrly 50 Inj.6. If symptomatic they should be treated as septicaemia (section6.4. If the sepsis screen is negative and the infant remains asymptomatic at 48-72 hrs. Ampicillin 10012 hrly8 hrly and 5 24 hrly24 hrly Gentamicin Antibiotic Inj. A sepsis screen should be done in such infants. 6.2 Maternal risk factors for sepsis The various risk factors for early bacterial • Maternal fever (temperature • Membranes ruptured more • Foul smelling amniotic sepsis are: >37. antibiotics may be discontinued.4) In asymptomatic babies. lethargy or unconscious • Persistent irritability • High pitched cry • Apnoeic episodes • Convulsion • Bulging fontanelle To conrm the diagnosis of meningitis a lumbar puncture should be done immediately unless the young infant is convulsing actively or is hemodynamically unstable. frequency and duration to be used is as shown in table 9. The dose. such an as ceftriaxone (50 mg/kg every 12 hours (use with caution in infants with jaundice) or cefotaxime (50 mg/kg every 8-12 hours) for 3 weeks.1 Meningitis Suspect meningitis in an infant of septicemia if any one of the following signs are present: • Drowsiness. Treat meningitis Give antibiotics • Give ampicillin aminoglycoside and with gentamicin or third generation a combination of cephalosporin. 64 . presence of two or more risk factors warrants the institution of antibiotic therapy.4.9ºC) than 24 fuid before delivery or hours before delivery during labour The babies born to mothers with these risk factors may be symptomatic or aspymptomatic. Cefotaxime and 5 (Weeks) IV IV 24 hrly24 hrlyIV IV 3 weeks 3 weeks 3 weeks 3 weeks Manage convulsions and provide supportive care for the sick young infant with meningitis as discussed earlier. necrotizing enterocolitis (NEC) or a bleeding diathesis. (Table 8). • Encourage exclusive breastfeeding. Approach to a young infant with blood in stool Blood in stool in a young infant may be because of dysentery but is often due to surgical cause. If the stools have it is to be be a sign of While management of diarrhea has been discussed earlier in IMNCI as per annexueI. young infants with blood in stool may signify a serious illness. Assess Signs • Active baby week of signs of • • • 1st No age sepsis • Signs of possible • • Abdominal Attacks mass of crying with Loose stools with blood • • sepsis pallor Severe persistent diarrhoea If the young infant has diarrhoea for 14 days or more. give a breast milk substitute that is low in lactose.3 Diarrhea Diarrhea is uncommon in breastfed babies and is usually seen The normally frequent or loose stools of a breastfed baby are changed from usual pattern and are many and watery.• - Sepsis screen: A positive “sepsis screen” takes into account two or more positive tests as given below: TLC <5000 or > 20.2 Micro ESR (ESR> 15mm 1st hour) C-Reactive Protein–positive 6. If given. manage as case of severe persistent diarrhoea. Help breastfeeding to re-establish lactation. Assess for: • Signs of dehydration • Duration of diarrhoea • Blood in the stool in babies who are not breastfed. • Give supplement vitamins and minerals ampicillin & gentamicin mothers who are not only animal milk must be for at least 2 weeks. not diarrhoea. Treat severe persistent diarrhoea • • • Admit the young infant.000/cumm (age > 72hrs) Neutropenia (Absolute Neutrophil Count < 1800/cmm) Immature neutrophil(band cells) to total neutrophil (I/T) ratio > 0.4. then labeled as diarrhoea. . Investigate and treat for sepsis: Start Inj. Manage dehydration if present. Diarrhoea may systemic sepsis or UTI. 65 . 66 . Clostridium tetani. Antibiotics Crystalline penicillin is given in dose of 100. Once spasms are controlled. 6. Ensure appropriate supportive care including temperature maintenance. Provide a quiet and comfortable environment touch for the baby as stimulation by light. the progression of skin staining is from head to toe and the level of bilirubin can be clinically assessed by extent of skin staining (Fig 23). Initially it is given IV intermittently and later as the spasms are controlled it can be given orally. diazepam is decreased by 10% of its dose every third day.e. breathing.4. Diagnosis Neonatal tetanus is diagnosed by the presence of: • Onset at 3-14 days • Diffculty in breast feeding • Trismus • Spasms which are provoked by external stimuli eg. An alternative antibiotic is oral erythromycin (by nasogastric tube) in a dose of 40 mg/kg/day 12 hourly. A single dose of 500 units IM is given at admission.1-0.6. Control of Spasms This is the most important part of management as most deaths occur due to uncontrolled spasms resulting in hypoxic damage. If newborn is jaundiced . Diazepam is the drug of choice initiated at a dose of 0. sound and induce spasms. If spasms are not controlled then the dose of diazepam can be increased up to 0. touch Treatment Tetanus immunoglobulin (TIG) TIG is given to neutralize the circulating toxin. Jaundice can be physiological or pathological.4 Tetanus Neonatorum Tetanus Neonatorum occurs in a baby whose mother is not completely immunized during the pregnancy along with a history of unclean cord cutting practice at birth.000 unit/kg/day 12 hourly IV to eliminate the source of toxin i. 2 mg/kg/dose given every 3-6 hours.4 -0. circulation. care of airway. Antibiotic therapy is given for 7-10 days. Immunization: The neonate at discharge should be advised the standard immunization schedule.6 mg/kg/dose. uids and nutrition.5 Management of Jaundice More than 50% of normal newborns and 80% of preterm infants have some jaundice. Chlorpromazine can also be added at a dose of 1-2mg/kg/day in 4 divided doses orally by NG tube. Blood groups of baby and mother (other investigations that may be required in some babies with suggestive history and relevant examination ndings include sepsis screen. Assessment of jaundice clinically Check if .Serum bilirubin (total/direct) .Hemoglobin/hematocrit . Fig 24 and 25 provides guidelines for initiating phototherapy and exchange transfusion in babies > 35 weeks. Table 10 : Guidelines for phototherapy and Exchange transfusion in Low birth weight infants Birth Weight (Gm) Total serum bilirubin (mg/dl) Phototherapy ExchangeTransf usion 500-750 5-8 12-15 750-1000 6-10 >15 1000-1250 1250-1500 8-10 10-12 15-18 17-20 1500-2500 15-18 20-25 Note: Lower bilirubin values in the range applies to lower birth weight values in the range .Fig 23. Ultrasonography of abdomen etc.Onset of jaundice is within 24 hrs of life .) Treatment Treatment of pathological jaundice is usually phototherapy or an exchange transfusion. LFTs.Baby is more than 14 days of age If any one of the above is ‘yes’ then do the following investigations: .Clinical assessment: Jaundice beyond abdomen . thyroidfunction test. Table 10 provides guidelines for initiating phototherapy and exchange transfusion in LBW babies. 67 . If below the intervention line.6. How do you use the chart? It is similar to the process described in section6.1 Guidelines for initiating Phototherapy: Fig 24 provides guidelines on how to initiate phototherapy in newborns. • plotted bilirubin value is above the selected baby to be started on phototherapy. the in InsuchbabiesalsochecktheExchangetransfusionchart(Fig. Fig.5. Next decide whether the (ii) baby is > 38 serum bilirubin against the (i) baby weeks with > 38 factors or weeks and well. 24: Guidelines for initiating Phototherapy in Neonatal Hyperbilirubinemia for neonates (> 35 weeks)(AAP.25)becausesomeofthesebabiesmayneedex change transfusion.5. 35-37 weeks and is risk well. Monitoring baby on photherapy: Follow guidelines provided in Fig 24 on initiating and monitoring the baby on phototherapy. . requires intervention baby’s age If the line. Besides estimate bilirubin 12-24 hrly and plot values on the chart to decide on when to stop phototherapy.5. observe and monitor bilirubin 12-24 hrly. 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. 6.2 Guidelines for Exchange transfusion: Fig 25 provides guidelines on how to decide when a baby needs exchange transfusion. or (iii) 35-37 weeks with risk factors and select the appropriate intervention line. Exchange transfusion is not described in this manual.1.2004) How do you use the chart? • • First plot the baby’s total hours. 68 . The record should mention the parameters to be monitored. with date & time. If the baby’s stools are pale or the urine is dark. . The table given below provides a checklist for monitoring. 25: Guidelines for Exchange transfusion in Neonatal Hyperbilirubinemia for neonates (> 35 weeks)(AAP.6 Monitoring of sick young infant All sick young infants should be regularly monitored to detect improvement or worsening. frequency of monitoring.Fig.2004) Prolonged Jaundice Jaundice lasting longer than 14 days in term or 21 days in preterm infants is abnormal. refer the baby to a specialized centre for further evaluation and management Group Discussion on jaundice management 6. 69 . F.Danger Signs 9Communication For Home care: • Exclusive Breast Feeding • Maintain Temperature • Cord & Eye Care • Danger Signs • Maternal Health For care during referral 10 • Follow Up 2 weeklyfor initial 2-3 visits. Heart Rate. Colour.F.C. feeding. every month thereafter • Check weight.7 Discharge from the hospital Careful monitoring correctplanning of of the infant’s discharge from overall response the hospital to are treatment just as and important as making the diagnosis and initiating the treatment.5ºCRemoval of excess clothing.F.Table 11 : Checklist for monitoring sick young infant (Mnemonic for monitoring: T. change environment.M.M. The discharge process for all sick infants should include: • • • • Counseling the infant at home Ensuring the Communication infant or who Correct timing of discharge correcttreatment from the and feeding mother on infant’s with the will be immunization status and record card health personnel who referred responsible for follow-up care hospital of are the the up-to-date (discharge card or a referral note. CRT. Sepsis screening 2AirwayObstructed Open the airway (Position and suction) 3BreathingApnoea/Gasping PPV with Bag and Mask Respiratory Distress Oxygen 4CirculationShock • 5Fluids No Shock Give 20 ml/Kg Normal saline/RL in 30 min Maintenance Fluid Suspected sepsis. this will lead to more appropriate referrals to hospital and better relationship between hospital and community health workers) • Instructions the need on to when to return for return immediately follow-up care and signs indicating .A.B. Respiration.C. problems • Immunization 6. Jaundice Antibiotics. phototherapy 6Medication & Other Management 7FeedingAs per wt & age guidelines 8MonitorTemperature.) SNOCHECKLISTASSESSMENT ACTION Rewarm by 1TemperatureMild hypothermia KMC Rewarming byradiant warmer Hypothermia (Moderate/Severe) Rapid Fever (temperature > 37. 70 . Decide what intervention this baby will require serum bilirubin? 3. How will you adjust the IV ?uids for this baby (write the volume. List the emergency signs in this baby on triaging b. cold extremities. Write the most likely diagnosis c. A 5 day term neonate weighing 3 kg was admitted with respiratory distress.5ºC. On examination the infant is lethargic. composition and infusion . weak pulses. • Diarrhoea with • Yellow palms & to return immediately if the Young Infant develops Breastfeeding or drinking poorly fever or Diffcult blood in soles feels cold breathing stool to 3. heart rate 170/min and bulging fontanelle. a. List the investigations you would perform d. the the hospital should Young Infant’s Mother should be advised any of the following signs: • • Becomes sicker • Develops a • Fast breathing. The baby has yellow staining of extending upto legs and is active and feeding well. A 7day old infant is brought to emergency room with decreased activity and poor feeding for 1 day. What investigations would you do other than b.8 Providing follow-up care 1.6. A term baby weighing 3 kg presents at 72 hrs age with history of jaundice. The serum bilirubin is 17 mg/dl. CFT 5 secs. mother of Young Infant’s Remind immunization visit the the touch next EXERCISE . a. The baby started improving and is started on 5 ml EBM 3 hourly by NG tube on day 7 of life. Infants who are discharged from return for follow-up care for checking condition in relation to the present problem 2. a. Write the steps of treatment for this baby in the order in which they should be undertaken 2.4 1. temperature 35. rate) 71 . therefore. Low birth weight. Preterm babies have distinct physical features that help in their recognition. a LBW neonate may be both preterm as well as small for-dates. but the baby is undernourished. If it is less than 37 completed weeks. some LBW babies may remain more prone to malnutrition. A preterm baby has not yet completed 37 weeks of gestation. 2) Chart intravenous fuid requirements for a sick neonate as per the baby’s birth weight.SECTION. recurrent infections. Here. The second situation that leads to low birth weight is intrauterine growth retardation or IUGR. The external ear or the pinna is soft and devoid of cartilage. 7 MANAGEMENT OF LOW BIRTH WEIGHT BABIES A neonate who weights less than 2500 gm is a low birth weight baby. First. LBW 3) a Type of LBW A newborn baby can be LBW because of two reasons. the baby in question is preterm.0 Learning Objectives: The participant after completing this section should be able to:1) Enumerate problems of Preterm & LBW. Two thirds of our LBW neonates fall in this category. it is obvious that if the delivery takes place prematurely. the baby is likely to have less weight. gestation may be full term or preterm. it does not . 7. and neurodevelopment handicaps. you notice that the deep skin creases on them are present only on the anterior one third. Hence. Nearly 75 percent neonatal deaths and 50 percent infant deaths occur among the low birth weight neonates. Enumerate modes of enteral feeding for LBW neonate as per the baby’s birthweight. How to recognize preterm and SFD infants? It is desirable and of practical relevance to make clinical distinction between the two types of LBW babies. Since fetal size and weight are directly linked to gestation. If you examine their soles. Such a baby is also called a small-for-date or SFD neonate. In India. the baby may be preterm. Preterm baby is diagnosed on the basis of period of gestation. low birth weight. Even after recovering from neonatal complications. At times. over 30 percent infants born are LBW. is a key risk factor of adverse outcome in early life. This condition is similar to malnutrition. undersized and therefore. recoil back promptly on being folded. not covering the labia minora. 72 . the scrotum does not have rugae and testes are not descended into the scrotum. the labia are widely separated. resulting in the prominent appearance of the clitoris. In males. The back of the preterm babies has abundant growth of ne hair called lanugo. The breast areola is poorly pigmented and the breast nodule is usually absent or < 5mm in diameter. In female infants. This in-utero transfer of a low weight fetus is far more desirable. convenient and safe than the transport of a low weight baby after birth. • Hypoglycemia • • Sepsis Malformations 7. Metabolic Acidosis and Problems of Small for Date babies. Meconium Aspiration syndrome Hypothermia. If not possible baby should be nursed . an anticipated Premature labor LBW as baby well should be as intrauterine growth retardation is indications for referral of the pregnant mother to a well-equipped facility.7. Deciding the place where a LBW baby should be managed The mother and the family under the supervision of a health worker or family physician can manage an otherwise healthy LBW newborn with a birthweight of 1800 gm or above at home. Intra-Ventricular Hemorrhage. at least one of them should be well-versed with a the art of neonatal resuscitation.2. • • Asphyxia. the conducted delivery of in hospital. Metabolic Problems like Hypoglycemia. The indications for hospitalization of a neonate include the following. (a) Birth weight less than 1800 gm (b) Neonate who is unable to feed from the breast or by katori-sopon (c) A sick neonate 7. • Fetal Distress. Infection Retinopathy of Prematurity. Delivery should be conducted by trained health professionals. The standard procedure of resuscitation should be followed efciently.2 Management Delivery of low birth weight babies Ideally. Hyperblirubinemia.1 Problems of LBW neonates Problems of pre-term • • • • • • • • • Asphyxia Hypothermia Inability To Breast Feed Respiratory Distress Syndrome Apneic Spells.1 Keeping LBW babies warm At home Baby should be provided skin to skin contact care (KMC). The baby should be clothed well. If the room is not warm enough. Two or three layers of clothes are generally required. a blanket should be used to cover the baby. Besides. hands with mittens and head with a cap. as the mother herself is a good source of warmth for the baby. Feet should be covered with sock.next to the mother. woolen sweater should also be put on. the room where a LBW baby is nursed should be kept rather warm. 73 . Further. Ensure use of expressed breast milk (see annexure-3 for technique of expressing breast milk). and then gradually to breast feeds. In early stages of hypothermia. the trunk is warm but the soles and palms are cold to touch. Breast milk is the ideal feed for the low birth weight babies. and gradually build up. Regular monitoring of axillary temperature should be carried out in all hospitalized babies If a child is maintaining normal body temperature. Although the baby may not obtain much milk. In a couple of days. later. give cupspoon feeds feeds Breast Later (1-3 wks) Cup-spoon feeds Breast feeds Breast feeds After some time (4-6 wks) Breast feeds Breast feeds Breast feeds -IV uids -Triage -Gavage feeds if not sick 1200-1800 30-34 Gavage feeds Note: 1. In order to promote lactation and enable the baby to learn sucking. the baby shifted to katori-spoon feeds. all of their nutritional needs from direct breastfeeding. This condition. Breast milk is the best milk for LBW baby.In the hospital Apart from the above methods.Breast feeds . gestation. With improvement in their overall condition. Start with small volume. In due course. cold stress is not normal and baby requires additional warmth immediately. Neonates weighing less than 1200 g. the trunk feels warm to touch while the soles and the palms are pink and warm. it should be possible to shift them to katori-spoon feeds.2. it will help promote lactaion .If unsatisfactory. presence or absence of sickness and individual feeding effort of the baby determine the decision as to how a LBW neonate should be provided uids and nutrition (Table 12). overhead radiant warmer or incubator may be used to keep the baby warm. and then to direct breast-feeds. or those having sickness should receive intravenous uid initially. Table 12: Guidelines for the modes of providing uids and feeding Age Categories of neonates Birth weight (gm) Gestation (weeks) Initial <1200 <30 After 1-3 days Gavage feeds Cup-spoon feeds >1800 >34 . Baby may be fed by gavage or cup-spoon feeds.2 Nutrition and uids Mode for providing uids and feeds Birthweight. Ultimate goal is to meet both these needs from direct and exclusive breastfeeding. Infants weighing 1200-1800 g and not having signicant illness should be put on gavage feeds initially. the infants would start meeting part and. Enteral feeds should be introduced gradually by gavage as the baby’s acute problem begins to settle. When the baby is on gavage or cup-spoon feeds. it is important that he is put on the breast before every feed. 2. 7. all babies on gavage or katori-spoon feds should be put on the breasts before each feed for 5 to 10 minutes. Those unable to feed directly on the breast can be given Expressed Breast Milk (EBM) by gavage or katori-spoon. and enable the baby to learn how to suck. 74 . While pulling out a feeding tube. Its position is veried by aspirating the gastric contents. the feeds may be provided by cup-spoon. LBW babies may take longer on the breast as compared to their normal weight counterparts. it must be kept pinched and pulled out gently. However. At the time of feeding. the head is slightly raised and a wet (not lubricated) catheter is gently passed through the nose (nasogastric) or mouth (orogastric) down through esophagus to the stomach. total daily requirements can be estimated from the table 13 on the uid requirements. . growing LBW baby daily intake of feeds should be gradually built upto 180-200 ml/kg. The feeding of every baby should be individualized. For the orogastric catheter the distance between angle of mouth to tragus and then to the ansiform cartilage is used for insertion. Introduce in new mode for only some of the feeds to begin with. and marked. and from there to the ansifrom cartilage. The above recommendations should only serve as broad guidelines. and by injecting air and auscultating over the epigastric region. Age (days) 1 Table 13: Feeding volumes and rate of increments in LBW Feed volume (ml/kg/day) 60 2 90 3 120 4 150 5 180 6 180 Techniques of methods of feeding (a) Gavage feeds For gavage feeding. some of them may not be able to suck satisfactorily during the rst few days of life. Most LBW babies weighing more than 1800 g are able to feed directly from the breast. The baby should be placed in the right lateral position for 15 to 20 minutes to avoid regurgitation. the catheter is measured from the external nares to the tragus of the ear. When shifting a baby from one mode of feeding to another. In a stable. size Fr 5 feeding catheter is required for nasogastric or orogastric placement. the outer and end of the tube is attached to a 10/20 ml syringe (without plunger) and milk is allowed to trickle by gravity. During this period. Your Facilitator will now conduct a DRILL ON MODE OF FEEDING Enteral feeds Amount and scheduling of enteral feeds For infants on gavage or cup-spoon feeds.3. There is no need to burp a gavage-fed baby. This length of the tube should be inserted through the nose. LBW babies should be fed every 2-3 hours starting at 2 hours of age. Two hourly feeds are also applicable to LBW receiving direct breast feeding. 4. During nasogastric or orogastric insertion. For nasogastric insertion. The nasogastric or orogastric tube may be inserted before every feed or left in situ for upto 7 days. be very careful. 75 . then perform pre-feed aspirate. All • preterms supplement < in 2000g should receive doses shown below: • (5-10 drops) oral vitamin Multivitamin /day (which usually provides vitamin A vitamin D 400 IU/day) Calcium 80-100 of and mineral preparation 0. do not insist on this method. (b) Cup-spoon feeds Feeding cup with has a been spoon (or found to a be similar device such safe in LBW as ‘paladai’) babies. This and mode of feeding is a bridge between gavage feeding and direct breast feeding. Excessive weight loss. Use cup a small (1-2 size) Both and ml be washed and cleaned. A preterm LBW baby loses upto 1 to 2 percent weight every day amounting to 10 percent cumulative weight loss during the rst week of life. of spoon. the baby should be evaluated for any illness. Stasis may also result from paralytic ileus due to several conditions. Hospitalized LBW babies should be weighed every day on the same weighing machine. If the abdominal girth increases by more than 2 cm from the baseline. or inadequate weight gain indicates inadequate feeding. late metabolic acidosis etc). If the baby does not actively accept and swallow the feed. SFD-LBW babies who are otherwise healthy should not have any appreciable weight loss at all and they should start gaining weight early. While estimating the intake. Baby may also feed directly by cup. cup-spoon feeding and expression of breastmilk 7. It is important therefore to take precautions. They have small stomach capacity and the gut may not be ready to tolerate feeds.3-0. a mouth place it at the lips and let the milk fow of the baby in the corner into the bay’s mouth slowly avoiding the spill. account for the spilled milk weighing the napkin will provide exact amount of milk spilled. The baby will actively swallow the milk. gavage-fed babies are candidates for regurgitation and aspiration. Fill the spoon with milk. 4 weeks (to ascertain a weight gain of at least 200-300g) and then every month.Gavage feeding may be risky in very small babies. If the aspirate is more than 25 percent of the last feed.2. Thus.6 ml 1000 and IU/day . Birth weight is regained by the14th day.3 Vitamin supplements All LBW babies should receive intramuscular vitamin K at birth. It is based on the experience that neonates with a gestation of 30-32 weeks or more are in a position to swallow the feeds satisfactorily even though they may not be good at medium sized sucking or coordinated sucking and swallowing. Take the required amount of in the Place baby in cup. The feeds may have to be suspended till the abdominal distension improves. sepsis. Before every feeed. try gentle stimulation. a little short of the brim. cold stress. Judging adequacy of nutrition The key measure of optimal feeding is the weight pattern of the baby. If he is still sluggish. Repeat the process till the required amount has been fed. It is better to switch back to gavage feeds till the baby is ready. It is desirable to weigh all LBW babies at 2 weeks (to check regaining of the birth weight). the abdominal girth (just above the umbilical stump) should be measured. excessive insensible water loss or systemic illness (like anemia. the expressed utensils must breast milk an upright posture with a napkin around the neck to mop up the spillage. Your Facilitator will show you a VIDEO on gavage feeding. mg/kg/day Phosphorous • 40-50 mg/kg/day 76 . 3 Vaccinations in LBW babies If the LBW baby is not sick. should receive these vaccines only on recovery.5kg • Mothermust be informed about her nutrition and health with .4 Discharge and Follow up LBW babies can be discharged when: • They are feeding from • Gaining weight for 3 • No signs of illness • Are able to maintain mother • Motheris confdent of breast or consecutive breast and days normalbody temperature when roomed-in taking care of the cup baby 7. 7. These visits should be at weekly intervals till the infant reaches 2. monitoring illness and providing immunization. 7. They should be informed about • Providing exclusive breast milk to the baby • How to keep baby warm at home • Identifying ‘Danger signs” for seeking medical help • Scheduled visits for assessing growth.All these supplements to be given till atleast 6 months of age •Iron started at a dose of 1 of age and providedtill mg/kg/day 12 at months of should be 4 weeks age.5 Counselling at Discharge Mother and family must be provided counselling for care of LBW at home. the vaccinations schedule is the same for as the normal babies A sick LBW baby however. 77 . c. b.8ºC with blood sugar of 60 mg/dl.6 kg is brought to the health facility on day 3 of life with poor sucking. A term baby weighing 1. the baby is sucking ineffectively on the breast. The blood sugar was 30 mg/dl.EXERCISE . On examination the baby is lethargic. CFT 3 sec with normal pulses. temperature of 36ºC. On the following day after your treatment. 78 How would you plan the baby’s feeding? . a. with poor sucking on breast. What is (are) the likely diagnosis? List the plan of treatment that is immediately required and over the next 24 hours. the baby has a temperature of 36.5 1. However. Make sure that there is a genuine indication for referral. Write a note Write a precise note for facility providing details of the referral and treatment given to the baby.0 Learning Objectives After completion of this module.meningomyelocele etc. you should be able to: • Identify babies who need referral • Provide counseling and family support • To prepare and organize referral • To provide pre-referral stabilization and advice enroute 8. breathing.2 Components of neonatal transport 1. It is important to prepare the baby for transfer. Assess Make careful assessment of the baby. NEONATAL TRANSPORT 8 If the baby needs to be transferred to a special care neonatal unit. and provide care during transfer. Give rst dose of antibiotics Injection ampicillin and gentamycin. Stabilize the neonate Stabilize with respect to temperature. circulation and blood sugar. 2. 3. communicate with the receiving facility. the providers baby’s condition. • Refractory seizures Abdominal distension with bilious vomiting 8. 8. at the reasons referral for .g. airway. diaphragmatic hernia.1 Indications of transfer to neonatal care unit • • • • • • Babies with birth weight <1500g Babies needing mechanical ventilation Shock not responding to fuid challenge and vasopressors Jaundice needing exchange transfusion Major congenital malformations e. Tracheo-esophageal fstula. ensure a safe and timely transfer.SECTION. 79 . polythene Use of covering thermocol can be box. 8. you may use one of these methods. Hospitalization and the need for transport of a newborn can precipitate a crisis for the entire family. 1. she should be encouraged to reach the facility at the earliest. Encourage mother to accompany Mother should accompany the baby for breast feeding and for providing supportive care to the baby on the way and in the hospital. Baby is wearing a cap and a napkin Baby is placed facing the mother in skin to skin contact between breasts · Baby’s back is covered by tying the blouse or with a fold of gown/ ’chunari’ [The skin to skin contact can also be provided by another woman/man /father]. Nurse the baby next to the mother or another adult during transport. · · one of the following approaches to keep the baby warm during transportation: Skin to skin care: This is probably the most effective.3 Communication and family support One of the most important and often very difcult aspects of transport is the need for emotional support of parents and family. In case she cannot accompany the baby immediately. Allow parents to see and touch their child prior to transport. 5. this method may be employed. Improvised containers: padded pouch. used basket. If no other means of providing warmth is available. The accompanying members of the team should be explained care of the bottle. but with utmost caution. Cover the baby: Cover the baby fully with clothes including the head and the limbs. safe and convenient method. Arrange a provider to accompany A doctor/nurse/health worker should accompany the baby. Thorough explanation ought to be given of the clinical problems and anticipated transport care. if feasible. 2. Accepting emotional outbursts calmly and reassuring the parent that their child is being cared for can reduce parental anxiety. Explain where to go and indicate whom to contact. education The commoninfuencing factors are Socioeconomic / Traditions lack support systems. 8. Ensure communication with the referral facility and request for feedback 4.4. Consider maternal transfer whenever possible 8. 2.4 Ensure warm transport Use 1. to provide care to the baby en route. 3. The use of rubber hot water bottle is fraught with considerable danger due to accidental burns to the baby if the bottle is not wrappedproperly or remains in contact with baby’s body. If available. Interventions to and of status/ Poor reduce the stress and support the grief response must be incorporated into the transport process. It is therefore best avoided. and to facilitate transferral to the referral facility. for ensuring temperature stability during transport.5 Provide other care during transportation The accompanying person should be explained to ensure the following: . 3. 80 . will loose heat. care 2. 3. If breathing not established.Keep the neck of the baby in slight extension Do not cover the baby’s mouth and .If the baby passes urine or stool. 4. If the baby is able to feed but the mother is unable to accompany and breastfeed the baby. Ensure warm feet Whatever method employed. EXERCISE . Warm feet means that the baby is not in cold stress. Insert a gastric tube if necessary. He should not remain wet. restore breathing. initiate bag and mask ventilation. make sure that of the keeping baby’s feet the are baby warm is warm to touch. Ensure an open airway . Provide feeds: Breast feed if baby is active. otherwise he 2.Suction mouth and nose if required. . If provide tactile stimulation to the soles nose the to baby stops breathing. Which are centre?’ What are the the babies who components of need referral organization of to a Neonatal Now you will do the Case Studies and discuss with your facilitator tertiary transport? .6 1. dry him promptly. the baby must be fed using an alternative feeding method. Check breathing: Watch baby’s breathing.1. 81 . At 3 hrs. The mother complaints that she has very little breast milk. A 1600 gms 33 weeks gestation. how much and how frequently. the temperature was normal.Case Study . On day 3 the baby weighed 1550 gms. baby was active but did not suck well at the breast. How would you proceed? Case Study -2 1. The baby was brought to you at 1 hour of age and the axillary temperature was 35 degree C. .1 1. There was no birth asphyxia. List the components of the type of care you have decided for this baby 3. How would you provide fuids & nutrition to this baby ? 3. There was no respiratory distress. cup spoon were tried and the baby accepted them well but sucking at the breast was poor. How will you feed the baby. A baby is delivered at full term at your hospital. What type of care will you provide this baby?. You visit the baby at 24 hrs of age. - What is your What immediate baby? assessment? measures will you take to manage this 2. 2. infant is born vaginally at home. The baby cries while he is being handed over to you.nor did he accept feed with spoon. 82 . followed by refusal of feed and lethargy the next day. The blood sugar is mg/dl. The baby returns for follow up on day 28. Case Study 3 1. 2. 7.4. How the 20 you is most likely 12 Case Study . What advice should be given to the mother to ensure lactation.4 A Term baby who was feeding well at the breast developed discharge from the umbilicus on the 5th day of life. What is the steps for treating this infant. this When would you discharge baby? 6. What advice would you give to the mother. At the hospital- . The weight of the baby is 1650 gm.9ºC is brought with complaints of refusal to feed and poor cry. 5. After 60 mg/dl and the baby is to manage this infant? diagnosis? List hrs. had a feeble cry and on way to the hospital had a convulsion. He vomited twice. temperature of 36. baby’s blood sugar will proceed the active. A 2 day old infant with a weight of 2 kg. The baby is being discharged on Day 10 with a weight of 1600 gms. How would you manage. Weight was 2400 gm Temperature was 37ºC Drowsy RR-56/mim. 1. Abdominal distension and poor bowel sound with a normal fontanelle. What is How will your you likely diagnosis? manage this baby? 83 . no retractions. no grunt CRT-2 secs. 2. If the stools have changed from usual pattern and are many and watery. it is diarrhoea. Severe • Manage Two of the following signs: dehydration severe • Lethargic or unconscious • Sunken eyes dehydration • Skin pinch very slow (Plan C) • Start • Manage dehydration Two of the following (Plan B) signs: • Start antibiotics if • Restless. as diarrhoea is generally a manifestation of systemic infection. Assess for: • • • Signs of Duration Blood in dehydration of diarrhoea 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.ANNEXURE-1 Diarrhea The normally frequent or loose stools of a breastfed baby are not diarrhoea. Diarrhea is uncommon in breastfed babies and is seen in formula feed babies with poor hygiene. Start Inj Ampicillin and Gentamicin as for cases of sepsis. irritable signs of sepsis or • Sunken eyes low • Skin pinch slow weight No dehydrationNot enough• Plan A (Home care) signs to classify as severe or• Advise mother when to return some immediately dehydration • Follow up in 5 days if not improving Some dehydration • Treatment of severe dehydration: A young infant with severe dehydration needs IV rehydration as described in Plan C. 84 . if not available. Also give ORS (about 5 ml/kg/hour) soon as can drink: usually after 3-4 hours. give ORS ml/kg Ringer’s by lactate solution (or. divided as follows: Age * • First give 30 ml/kg in Infants (under 12 months) 1 hour* Repeat once if radial pulse is still very weak or not detectable. normal saline). Weight <4 4 kg 6 kg kg - <6 - <10 as the • child Volume of ORS solution p hour 15 ml 25 ml 40 ml . Then give 70 ml/kg in 5 hours Reassess status is the not infant every 15-30 minutes. improving. give the IV If drip hydration more rapidly. If drip is set the up. child Give can 100 drink.How to treat severe dehydration in an emergency setting (Plan C) • Start IV fuid mouth while the immediately. give antibiotics as for cases of sepsis. Classify dehydration. 85 . encourage the mother to breastfeed during rst 4 hours of dehydration. B. If possible. Treatment of some dehydration: Manage dehydration as Plan B. 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. Then choose plan (A. ml/kg) by give NG ORS tube • after 6 hours. If baby has low weight or signs of sepsis. or C) to continue treatment.• 20 - <14 kg 14 – 19 kg If ml/kg/hour Reassess an the 10 infant appropriate 60 ml 85 ml IV for treatment not 6 hours(120 possible. In addition to ORS. .Explain the 3 Rules of Home Treatment : 1.Continue breastfeeding but stop other feeding. • If the child wants more ORS than shown. .give • • • amount of ORS to give during frst 4 hours.Select the appropriate plan to continue treatment. but more slowly. Give extra ?uid 2. After 4 hours : . When to return to in complete Plan A. rehydration. . wait 10 minutes.Show her how much ORS to give to ?nish 4-hour treatment Give her enough ORS packets give 2 packets as recommended . be by Show the mother how to give ORS solution : .Diarrhoea Treatment Plan B: Treat Some Dehydration with ORS GIVE RECOMMENDED AMOUNT OF ORS IN CLINIC OVER 4-HOUR PERIOD • Determine The approximate amount of ORS required (in ml) calculated by multiplying the child’s weight ( in 75. Then continue.Show her how to prepare ORS solution at home. can also Kg ) more. .If the child vomits. . If the mother must leave before completing treatment : . .Reassess the child and classify the child for dehydration. Continue feeding Plan A 3. Also } Treatment of no dehydration: Tell the mother to continue breastfeeding and teach the mother danger signs to return immediately.Give frequent small sips from a cup.Begin feeding the child in clinic. 86 . More areola visible above than below the the the .ANNEXURE-2 Examine the breasts and observe breast-feeding • • • Assess breast feeding in Ask mother if previous hour? If infant has not fed mother to put her breastfeed for 4 minutes. Baby?s mouth is wide open 2.Observe Check attachment of baby on mothers breast Signs of Good Attachment 1. Baby?s chin touches mother?s breast 4. all the newborns infant has in the infant to breastfed in previous hour. Lower lip is turned outwards 3. ask the breast. Fig 26: Good (left) and poor (right) attachment of infant to the mothers breast 87 . 2. less milk leads to resulting in poor weight gain. Entire body of the baby faces the mother. then look for ulcers or white patches the mouth (thrush). 4. Baby?s abdomen touches mother?s abdomen Fig 27:Babys body close. frustrated baby who refuses If attachment is not good: Check for correct positioning Signs of proper position of the baby while breast-feeding are: Signs of Good Position 1. The head. neck and the body of the baby are kept in the same plane. This is • not feeding. in . 3. Baby?s body is well supported. facing breast neck twisted Fig 28:Babys body away from mother. Check for babys sucking Effective sucking is when the infant shows slow deep sucks. supply hence baby irritableafter Breast produces to suck.It is very important to ensure good attachment because poor attachment results in • Pain or damage to • nipple leading to sore Breast milk not thus causing removed effectively breast engorgement Poor milk satisfedand • nipple. sometimes pausing • If not sucking well. 88 . milk starts to drip out. then express the other side. she can press on them. • Press the areola in the same way from the sides. • To relieve breast problem weight or sick and plan and to store return to it for e. but after pressing a few times. At frst no milk may come. She supports the breast with her other ngers. opposite the thumb. She must press on the lactiferous sinuses beneath the areola. This should not hurt – if it hurts the technique is wrong. They are like peanuts. press and release. • Press her thumb and frst fnger slightly inwards towards the chest wall. • Avoid squeezing the nipple itself. and hold the clean container near her breast. The movements of the fngers should be more like rolling. and then repeat both sides.g. who the milk in advance babies. • Express one breast for at least 3-5 minutes until the fow slows. • Working mothers. Sometimes in a lactating breast it is possible to feel the sinuses. low birth for sometime. can the baby not breast feed work can exclusively who express breastfed Technique of expression Teach her to: • Wash her hands with soap and water thoroughly before expression. If she can feel them. Press and release.ANNEXURE-3 Breast Milk Expression It is useful for all mothers to know how to express and store their milk. • Put the thumb on her breast above the nipple and areola. Pressing or pulling the nipple can not express milk. to make sure that milk is expressed from all segments of the breast. and her frst fnger on the breast below the nipple and areola. She can use either hand for either breast. Expression of breast milk is required in the following situations: • To maintain milk production and for feeding is premature. • Press her breast behind the nipple and areola between her fnger and thumb. • Avoid rubbing or sliding her fngers along the skin. • Sit or stand comfortably. . engorgement. 89 . It is important try to express in a shorter time. the container of expressed breast milk (EBM) with a clean or a lid. can be kept at room temperature for 8 hours. • Gently shake the container to recombine the . 20-30 not to milk 8 Storing expressed breast milk • • Wash Cover cloth • EBM in at • EBM of not bowl of warm the container thoroughly with soap and water. place the container in a water.Fig 29: Technique to express breast milk by hand • Explain that to express breast milk adequately may take minutes. Havingthe baby close or handling the baby before milk expression may help the mother to have a good let-down reex. To stimulate and maintain production one should express milk frequently – at least times in 24 hours. or the refrigerator for 24 hours or in the deep freeze -20°C for 3 months. stays in good condition longer than animal milk because the protective substances it contains. It is advisable to boil the EBM. If it needs to be warmed. separated fat feeding. 90 globules with cup with or the rest spoon or of the paladai. • Feed with bottle. milk before never feed . cold stress and normal temperature. TEMPRATURE RECORDING & THERMAL CONTROL OBJECTIVE Upon completion of this session each participant i. Kangaroo care 91 . Should be able to record axillary temperature in a newborn ii) Should be able to clinically asses hypothermia. A wrist watch vi) Mother or other caregiver to demonstrate kangaroo care RATIONALE Temperature recording is a the baby’s temperature and simple bedside ascertain the tool to assess degree of hypothermia ACTIVITIES i. iii) Should be well versed with ways to achieve thermal control during domiciliary care.ANNEXURE-4 CLINICAL SKILLS 1. REQUIREMENTS i. Low reading/Normal thermometer ii) A mankin/newborn iii) Cotton Swabs iv) Cotton sheet v. institutional care & transport. Drying ii) Wrapping & covering the baby iii) Recording temperature iv) Tactile assessment of temperature (Cold stress assessment) v. if both are the thermo fexion at the of of is cold hands hands your your cold – hypothermic baby. iii) Should be able to provide routine eyes & cord care and be able to advise mother regarding maternal & baby hygiene. v. if periphery but chest is warm – cold stress. Soap ii) Running water iii) Hand washing chart iv) Disposable delivery kit v. Cover over the right shoulder & tuck on left side. Kangaroo Care • Ask mother or blouse • Unbutton top 2-3 into the shirt. contact string at b/w the baby belt & level care taker prevent the baby with a woolen duo the shawl or breast feeding. Fold from the foot end & tuck beneath the chin & nally cover over the left shoulder and tuck on the right side. on the back. INFECTION PREVENTION OBJECTIVE Upon completion of this session each participant i.PROCEDURE i. Should be able to demonstrate steps of hand washing ii) Should be able to clean and disinfect newborn care equipment and environment. ii) Dry baby from head to toe.place baby’s head on the infolded corner so as to cover the head till the hairline on forehead. 2. REQUIREMENTS i. axillae & groin and discard wet linen. • Remove thermometer & read temperature iv) Tactile assessment • Wash hands • Rub them to dry • Rub together & warm them • Touch the baby’s soles & palms the dorsum • Now touch the baby’s chest using the dorsum • If both are warm-normothermic. Place the bulb of meter in the apex of the axilla • Hold arm in adduction at shoulder & elbow for fve minutes. Cord tie vi) Cord stump vii) Spirit viii)Sterile Cotton ix) Sterile blade . • Ensure skin to skin • Tie a belt or baby from slipping down • Cover the mother sheet • Encourage frequent caretaker to wear a loose shirt or button & slip baby with only napkin on. front . Wrap the baby using a sheet spread the sheet fold one corner on itself. iii) Record temperature • Place the baby supine or on the side • Ensure dry arm pit • Abductarm at shoulder. 92 . x. Hand washing • Wet hands • Apply soap • • • • • • ii) Rub hands. Manikin xi) Disinfectant solution xii) Newborn care equipments • Bag & mask • Laryngoscope • Thermometer • Oxygen hood • • • • Skin probe Cots/mattresses Sheet Suction machine RATIONALE Prevention of infection simple measure like clean. Hand Washing ii) Equipment disinfection iii) Eye & cord care PROCEDURE i. frst palms & Then back of hands Followed by rubbing Finally rub fnger tips in The wrists Keep elbowsdependent & Resuscitation bag & mask Face mask (Disinfect daily and sterilize • Clean with detergent • Immerse in 2% • Rinse with clean water sun dried) • Resuscitation bag ( • Dismantle parts • Clean with Detergent • Immerse in 2 fngers of the thumbs palms & wash in weekly) daily and after gluteraldehyde and dry with Disinfect % daily lastly the same order each use sterile linen and glutaraldehyde (washed sterilize and weekly) . as therapyfor ACTIVITIES i. Prevention neonatal is sepsis is in newborns hand-washingand is easily achievable by keeping baby’s environment much more rewarding not always successful. • • Rinse with Reassemble clean water and the parts dry with sterilize linen 93 . Feeding tubes should be dry cord not from each use 3% phenol or 5% whenever surface bottle should contain 3% bottle should be cleaned Care of Cord & eyes Cord • Keep cord • Clean • Do Eyes • Clean eyes Soked cotton swabs for baby with detergent Lysol covering phenol or 5% with detergent is broken Lysol and changed bottle daily. spoon and paladai before use. REQUIREMENTS i. ii) Should be able to provide gavage feeds to the baby iii) Should be able to provide katori spoon feeding to the baby iv) Should be able to advise mother regarding therapy for retracted nipples.iii) iv) v. Lactating mother ii) Katori/cup 94 dry 15 . Flush with water and % gluteraldehyde should be for single use should be boiled for preferably disposable. at separate least for sterile saline BREAST FEEDING/ASSISTED FEEDING: OBJECTIVE Upon completion of this session each participant i. vi) Laryngoscope • blade isopropyl with 70% alcohol after use. have separate alcohol after bottle containing Oxygen hood • Clean every day vii) Suction • • daily • • • ix) Wipe after for use dry each use each cotton Change tube connected to Soak for disinfection in 2 Ideally suction for catheter utensils Cup. Should be able to allay all fears & anxiety of a lactating mother regarding adequacy & superiority of breast milk. base dry apply anything medial to lateral side eye. Should be able to advise mother on manual expression of breast milk. Thermometer • Ideal to • Wipe with • Store in or Cots and mattresses • Clean everyday with • Replace mattresses apparatus Suction Suction viii) Feeding • min • 3. v. lean forward a bowl using both hands • Position the thumb and the forefnger at areola on sides & press the tissue both breast the margin of into the ribcage • Maintaining thumb & the the backward forefnger of pressure each hand start bringing towards the the nipple • same till not further milk be fr catheter Repeat the expressed several times can out. • Stimulate the spoon with 1-2 ml 8 angle of mouth till depending on mouth to tragus to xiphisternum the desired length has been a syringe air close outer end & a stethoscope to after removing the a and 10 ml syringe insert nozzle into the barrel open end next feeding session & lap hold the baby semi upright angle of milk at the the mouth and angle of rest the the mouth. feeding in the with . ACTIVITIES i. Gently stroke behind the ear or on the sole. Manual expression of Breast Milk • Ask mother to sit and support the breast over comfortably. ii) Gavage feeding • Take 6 fr or gestation and weight • Measure length from • Insert the tube from introduced • Check position using auscultate the gush of • Tape the tube & syringe • To instill feed-Take without the plunger of the feeding tube.iii) Spoon/paladay iv) 6 fr & 8 fr feeding tubes v. • Continue this manner till the desired amount has been fed. Manual Expression of breast milk ii) Gavage feeding iii) Katori spoon feeding iv) Treatment for retracted nipples PROCEDURE i. • Check residue at to feed iii) Cup spoon feeding • Take baby in head well supported. 10 ml 7 5 ml syringes vi) Adhesive tape vii) Manikin viii)Blade RATIONALE Advantages of breast milk are may fold and this mode of feeding id the ideal for all neonates. the proceed • Pour milk slowly into open mouth & watch for swallowing. head supported a little 95 .• Burp the • Place in higher than the baby right rest lateral position with of the body. If the baby is hypothermic. • Insert plunger into the barrel • Place the barrel’s open end the nipple in the barrel & pull far as possible. Should be able to assess perfusion by using CRT method ii) Should be able to catheterize the umbilical vein iii) Should be able to demonstrate peripheral venous access on an improvised model. Normal saline vi) 2ml/5ml syringe vii) 5fr. Feeding tube or umb. nipple between thumb and cut care the that nozzle end the syringe from on back the the the cut nozzle end areola including plunger as follow putting the baby forefnger to ASSESSING CRT & VENOUS ACCESS: OBJECTIVE Upon completion of this session each participant i. transversely using a new blade. Spirit xi) Iodine xii) Gloves xiii) Soap & Water xiv) Sticking tape xv) Splint RATIONALE i) CRT-CRT is simple sign to assess perfusion (BP of the Baby) of a baby. venous canula. viii) Straw. A CRT of >3 seconds denotes poor peripheral perfusion. Splint . Stop watch/wrist watch ii) Umbilical cord 1 ft iii) Blade iv) Forceps v. • IV access: To provide parental medications a quick IV drugs during fuids & the . Take barrel’s cut margin is not ragged. This can also be prolonged in hypothermia due to peripheral vaso constriction. • Umbilical. CRT should be reassessed after temperature improvement. • Repeatthis several times & breast to encourage suckling. Tongue depressor ix) Polythene sheet x. 4. Postnatal • Take a 10 ml syringe.iv) Treatment of Retracted nipples Antenatal • Teach mother to roll out several times a day. Venous access – It is access for infusing volume expanders & resuscitation. REQUIREMENTS i. 96 . Normal CRT is upto 3 sec • of ii) CRT>3 secs indicates poor perfusion. model. ii) iii) CRT assessment Umbilical Venous cannulation Peripheral IV access on an on a improvised cord stump. Vein caliber. IV Access • Select the vein (dorsum of hand/foot) • Wash hands and dry • Wear gloves • Prepare skin. dry hands forehead or release and return of color. in presence Umbilical Venous Cannulation • Wash hands & dry. (In the ‘O’ lock position) • fow Insert the saline flled of blood can be catheter appreciated sterlile blade. sternum look at using index fnger /thumb the blanched area for PROCEDURE i.betadine.ACTIVITIES i. Identify 2 is a thin the arteries cord in a cord Cord transversely clean with a arteries & 1 vein – walled patulous large opening which are thick walled normal position the Umb. thread the needle further up • Secure the scalp vein needle by adhesive • Secure splint • Inject fuid/medications between applications vein prominent of puncture give way) into the teeth tape . in contrast and much smaller in is a t 11-12 the live vein baby (Black by gently into in a pulling at the plunger) • In inserted a free • Inject • Pinch • Press iii) actual situation is usually the 1-2 length of the cm below the catheter skin till to be there is ow of blood. fush the catheter with saline & keep ready • Take a small piece (about 10 cm long) of fresh umbilical kidney tray • • • Vein to Hold or mount Cut the umb. of hypothermia interpretation may be however fallacious. the umb. spirit. prevent bleeding. Note the time taken for return of color. CRT assessment • Wash and • Press the for 5 sec. • Wear gloves • Connect syringe to the catheter. Note the time taken for return of the color. let dry • Hold the limb proximally to make the • Pierce skin distal to the intended ‘site • Insert needle into the vein (feeling of • Ensure free fow. the the the drug or catheter cord to volume & remove. • Check distal limb for adequacy of circulation 97 . Know the parts of a warmer ii) Be able to demonstrate the working of the warmer.High • If between 36-36. RADIANT WARMER OBJECTIVE Upon completion of this section the participant should i.5-37. Bassinet ii) Quartz rod iii) Skin probe iv) Air probe v. 98 . iii) Place baby iv) Connect probe v. Read temperature on display vi) Adjust heater output • If below 36ºC. Connect to mains ii) For prewarming keep heater output to maximum. vii) Measure temperature 1/ 2 hourly X 2 hours & then 2 hourly. iii) Know the dangers associated with its usage and should be able to manage minor equipments maintenance.ANNEXURE-5 EQUIPMENT DEMONSTRATION 1.5ºC-Remove baby/Switch off warmer. PARTS i.5ºC-Low • If >37.5ºC-Medium • If between 36. Control panel vi) Heater output WORKING i. Calibration ii) Annual maintenance Contract 2. PHOTOTHERAPY UNIT OBJECTIVE Upon completion this section the participant should i. Check temperature ½ hourly/2 hourly ii) Ensure warm feet iii) Ensure probe is connected iv) Do not leave baby unattended.CLEANING & DISINFECTION i. Increased insenable water loss ii) Fluid intake must be tailored to meet demands iii) Hyperthernia iv) Hypothermia MAINTENACE i. Ensure side walls are fastened up vi) Ensure adequate clothing in case of electricity failure TROUBLE SHOOTING i. ii) Be able of understand the functioning and demonstrate the working of a phototherapy unit iii) Be able to place a baby under phototherapy unit PARTS Tubes - Number Irradiance Duration Wavelength 6 White 20 4-8uw/cm2/nm 3 months 420-460nm Distance cms Color Watt - ------ 45 99 . ii) plug Check fuse Check iii) Check cords SIDE EFFECTS & DANGERS i. Know the parts of a phototherapy unit. Glutaraldehyde 2 % ii) Soap/detergent } Once daily DOS & DONTS i. v. TROUBLE SHOOTING i. Reassess frequently.prevent hypo/hyperthermia iii) Check weight daily iv) Frequent breast feeding/increasing allowance for uid v. ii) Switch on the unit & check that all tubelights are working iii) Place baby naked only with the napkin on iv) Cover the eyes v. Change position frequently vi) Increase uid intake • Breast feed frequently • Spoon/Gavage/IV – by 20 ml/kg/day vii) Provide continuous phototherapy CLEANING Glutaraldehyde 2% • Soap/Detergent DOS & DONTS i. Connect to mains. Hyperthermia/Hypothermia ii) Increased insensible water loss iii) Tailor uid intake to meet demands MAINTENANCE i.every three minutes ii) Check ux(if possible ) iv) Annual Maintenance contract 100 . Change tubes .if ends black or .WORKING i. Baby covered ii) All tubes not working iii) Flickering light iv) Tube ends have black circles SIDE EFFECTS AND DANGERS i. Cover eyes ii) Check temperature. ii) plug Check fuse Check iii) Check Cord iv) Change tube if ickering or ends are blackened INEFFECTIVE PHOTOTHERAPY i. Check fuse ii) Check cord iii) Check earthing iv) Check for leakages in the bottle/tubing SIDE EFFECTS & DANGERS i. CLEANING & DISINFECTION i. Connect to main ii) Switch on the unit and occlude distal end to check the pressure. Wash suction bottle with soap & bottle ii) Change bottle solution every day Dos & DONTs i. Ensure it does not exceed 100cm of water iii) Take disposable suction catheter iv) Connect to suction tubing v) Perform suction gently vi) Switch off the suction machine.3. Local trauma ii) Bradycardia 101 . Know the parts of a suction machine ii) Know how to use a suction machine and iii) Know its sterilization the participant should PARTS i. SUCTION MACHINE OBJECTIVE Upon completion of this section i. Suction Catheter ii) Suction tubing iii) Suction bottles TYPE i) Dee Lee’s suction ii) Foot operated iii) Electric (if available) trap WORKING i. Suction gently ii) Do not do vigorous & deep suction iii) Use only disposable suction iv) Check adequacy of suction pressure catheters TROUBLESHOOTING i. v) Patientoutlet vi) Valve assembly vii) Ensure adequate seal viii) Perform PPV-Check for chest rise.iii) Apnea iv) Infection MAINTENANCE i. BAG & MASK OBJECTIVE Upon completion of this section the i. Apnea or gasping respiration ii) HR<100/min iii) Central cyanosis despite free ow oxygen CONTRA INDICATION i. Congenital diaphragmatic hernia meconium stained liquor 102 ii) Thick participant should . WORKING i. Body of the bag ii) Oxygen inlet iii) Air inlet iv) Safety valve/pressure release valve. Check for adequacy of suction pressure ii) Change tubing if leaky or broken iii) Annual maintenance Contract 4. Assemble bag ii) Check bag iii) Connect to oxygen source iv) Attach reservoir v. Know the parts of a bag & types of masks ii) Be able to demonstrate the use of a bag iii) Know how to clean a bag & mask PARTS i. Fix appropriate size mask vi) Apply mask on manikin INDICATION i. Change bag ii) Check for oxygen source iii) Remedicals actions for no chest rise MAINTENANCE i. Clean and disinfect as per protocol ii) Replace if damaged or leaky WEIGHING MACHINE 5. Know how to calibrate the weighing machine ii) Be able to demonstrate the use of the weighing machine iii) Be able to classify newborns by weights as NBW/LBW/VLBW & ELBW PARTS i) Pan baby tray or ii) Weight scale dial iii) Machine proper WORKING i. Wipe clean the weighing pan ii) Check for and adjust zero error iii) Calibrate using a known weight iv) Place baby with sheet Note weight (a) vi) Remove baby vii) Weigh the sheet above (b) v. OBJECTIVE Upon completion of this section the participant should be i.CLEANING & DISINFECTION i. Check bag prior to use iii) Choose appropriate size mask iv) Use enough pressure to v) Do not Perform overzealous vi) Check for adequacy of ventilation • Chest rise. 103 . Increase in • Appearance of spontaneous vii) Check and maintain adequate seal obtain easy PPV chest rise HR. Improvement in respiratory effort color TROUBLE SHOOTING i. Wash with soap and water daily ii) Soak in glutaraldehyde 2% for 6 hrs once a week iii) Clean mask with sprint between patient use DOs & DONTs i. Always look for and adjust zero error ii) Always calibrate using a known weight iii) Do not weigh baby naked iv) Remove excessive clothing v. Clean with soap and water ii) Wipe with spirit swab b/w patient use DOs & DONTs i. Calibration ii) Annual maintenance contract .viii)Subtract b from a (a-b) ix) Record weight CLEANING AND DISINFECTION i. TROUBLESHOOTING i) Place on fat frm surface a ii) Caliberate before each use iii) Record zero error if it can not be corrected and account for it MAINTENANCE i. Do not stack up line or other objects on the weighing pan when not in use vi) Record weight only when needle is stationary & not oscillating. 104 . abdomen or soles n v Has the infant breastfed in the previous hour? to put i her infant to the breast.Mouth wide open Yes ___ No ___- Lower lip turned outward Yes ___ No ___More areola above than below the mouth Yes___ No___ no e r t d . sometimes pausing)? O e attachment at all not well attached good attachment· Is the not suckling at all not suckling effectively suckling effectively If not sucking well.0º F l a t Normal (36. U N G I N F A infant suckling effectively (that is.5º C/ feels hot) • See C – 35. • Have you given any feeding the infant? other foods or If EXAMINE THE INFANT Yes.4º C) Mild hypothermia (36. Is Look for skin pustules. Are a big boil? Measure axillary temperature (if not fever or low body temperature): Fast breathing? it there red 10 possible. Observe the breastfeed for 4 minutes. _______breaths Count the ulcers or r (thrush). slow deep sucks. Look and listen for grunting.9º C.5-37. Iss what diffculty drinks to per o r e theinfant? or minute pain n while i feeding? p • p • • • • • Repeat if elevated________ Look for severe chest indrawing. then look for:· Y o N T .0-36. ask the mother • face. Look at the umbilicus. how many times in 24 hours.RECORDING FORM Assessment of the newborn in Postnatal Wards Name: ______________ Date and time of Birth ______________ Sex: M/F Birth Weight:______________ Mode of Delivery: Vaginal/Forceps/ Cesarian section Resuscitation at birth Yes/No ASK: Does the mother or infant have any problem? __________________________ ASK THE MOTHER • Has the infant passed stools? • Has the infant • passed there urine? • Have you started breast If Yes.4º C/ cold feet) Moderate hypothermia and abdomen) Severe hypothermia (< Fever (> 37.feel or or • e draining pus? more pustules or for if young infant (32. breast able look to for:- attach? To Chin touching Yes ___ No ___. Are the yellow? • Look for malformations ASSESS BREASTFEEDING:· If infant has not fed in the previous hour.· Is check the infant attachment. cold feet o 32º l C) r s H A S T H E is lethargic • Look for jaundice. and how ? • breaths in one minute. OPV Any other problems: 0 . HEP-B 1 105 .D1D2 RECIEVED • Vitamin K • BCG . __________ Date of Birth ________ Time of Birth ____ Birth Weight ___________ g Presenting Complaints: Antenatal History Maternal Leaking Illness: Anemia / PIH / Diabetes PV: Present / Absent. Duration If Leaking > 24 hr .RECORDING FORM Assessment of Sick Young Infant in Health facility Name ______________ Age ______ (days) Sex______ Reg.Ask For: Fever / Foul smelling liquor / Others (specify) _____(hrs) TT Immunization: Yes / No Delivery History Place of Delivery: Institution / Home Type of Delivery: Vaginal/Foreceps/Cesarean Presentation: Vertex/breech / other Person conducting delivery: TBA Did the cry at birth? Did the baby details) need resuscitation? baby /ANM /Nurse /Doctor Yes / Yes / / Others No No (if yes. Infant Immunization BCG OPV0 DPT1 OPV1 HEPB1 Examination Weight:_________g severely underweight/moderately underweight/not low weight for age Gestation: / Term Preterm Heart Rate____________ CRT Respiratory rate:_____________ 106 Temperature _________  3 sec / > 3 sec Nasal aring/ grunting/ apnea/ cyanosis provide . No. the any breast how infant diffculty feeding many times received ____________________________ in the a any feeding the infant? day?______ other foods or If Yes. Assess for dehydration • Sunken eyes • Skin pinch / jitteriness immediate / slowly / very slowly how ? Assess For feeding Ask Mother • Is • Is • If • Has there she yes. infant? drinks? what and . more 10 or big boils • Umbilical Discharge Redness: / Present / Absent • Ear Discharge: Present / Absent • Pallor: Present / Absent • Jaundice: Present / / Chest / Abdomen Absent / Soles • Abdominal distension: Present • Activity: lethargy / • Abnormal movement: seizure • Bleeding from site any If / present: Face Absent irritable If Diarrhoea present.• Bulging anterior Fontanelle • Pustules: than less than 10. More areola above than below the mouth Yes ___ No ___ no attachment at all not well attached good attachment . Observe the breastfeed for 4 minutes.Mouth wide open ___ Yes ___ No . look for: 107 . ask the mother to put her infant to the breast.Chin touching breast check attachment. • Is the infant able to attach? To Yes ___ No ___ Yes ___ No .If there is difculty in feeding or feeding less than 8 times/day or receiving other foods/uids or low or very low weight then assess breaqst feeding If infant has not fed in the previous hour.Lower lip turned outward ___ . 6. 2. sometimes . 5. 3. ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Monitoring 108 deep sucks. Any Other Examination: Provisional Diagnosis _______________________________________________________________ Plan of Management: 1. slow pausing)? not suckling at all not suckling effectively suckling effectively If not sucking well. then look for: • ulcers or white patches in the mouth (thrush).• Is the infant suckling effectively (that is. 4. MODULE-3 Facility Based Care of Sick Child PARTICIPANTS MANUAL 109 . in Annexure 7. Learning Objectives • • Management of up to 5 Management of hospital. After the triage and providing the emergency care if required. These include case management of children presenting with Drug commonly tables for diffcultbreathing of of severe anemia severe acute malnutrition in used drugs are a included hospital. severe acute malnutrition in sick children children in (2 months a small Problems of sick children including Severe Acute Malnutrition (SAM) Sections 9-13 problems years of the following: • Cough or • Diarrhoea • Fever • Management • Management provide guidance for the management of in children from 2 months up to 5 age. common problems of years of age). The triage process and how to provide emergency treatment has already been discussed. Some of them are extremely sick and need emergency life saving treatment. the child should be assessed (history and examination) in detail for identifying the problems and for appropriate management.INTRODUCTION A referral unit receives sick children with diverse clinical presentations. . 110 . 9 CASE MANAGEMENT OF CHILDREN PRESENTING WITH COUGH OR DIFFICULT BREATHING 9. who often presents with recurrent pneumonia. • Understand approach to a child presenting with wheeze. Respiratory Causes 1.g. Renal Failure While children with distress due to respiratory causes will have cough as an important symptom. Metabolic acidosis. Pneumothorax 6. one important clinicalconfounder to rule-out is a child with acyanotic congenital heart disease. B. 3. as listed in Table 14.0 Learning objectives After completion of this section the participant should be able to: • Manage all cases of pneumonia. Viral croup 7. Raised intra-cranial tension. at a frst referral facility should be furtherrefned as rapid breathing can be due varietyof causes. Bronchiolitis 4. Congestive heart failure 2.1 Diagnosing pneumonia The IMNCI algorithm classifes children with cough and rapid as pneumonia and furthergrades it as severe or very depending upon chest in-drawing and other features of distress.g. The respiratory distress . breathing severe respiratory this to a Table 14: Differential diagnoses of a child presenting with acute onset difcult breathing A. children in respiratory distress due to other causesusually do not have signifcant cough. Foreign body Empyema in the Non-respiratory Causes 1. Meningitis Diabetic Ketoacidosis. with stridor. Asthma 3. Pneumonia 2. Yet. However. airways e. Effusion and 5. 9. • Understand approach to a child presenting • Manage acute asthma. e.SECTION. 111 . e) Very severe pneumonia. The RNTCP guidelines for managing given in the Annexure 7.and • Is not responding to appropriate antibiotic therapy. Pneumonia is breathing usually identifed on and signs of respiratory the basis of distress. cough. Radiology of diagnosis the in chest is not all cases of indicated pneumonia. c. examination and the clinical setting to arrive at the diagnosis of pneumonia. As young children can also have rapid breathing and to differentiate those with wheeze with respiratory cases rapid asthma or with wheeze due infections.2 Treatment of childhood community-acquired pneumonia The management of disease as pneumonia is guided by the severity listed in Table 15: Table 15: Classication of severity of pneumonia of the are . If child has SAM or Post-measles state. only if there is no response to bronchodilators (persistence of fast breathing). If the diagnosis is not clear. Where complications are suspected. You may seek the help of an expert/ specialist. or . where needed. You fever. b. A very careful evaluation of cardiovascular system for a murmur is required and you should seek help from a more experienced person. In such a situation treat as pneumonia with antibiotics. be given a trial of rapid acting inhaled bronchodilator (up to 3 cycles). sputum or gastric aspirate for Tuberculin test. fast should use history. Children with wheeze and fast breathing and/or chest indrawing. particularly those with a past history of similar attacks should.Salbutamol by a metered dose inhaler with spacer device. 9. The patient fails to respond to the antibiotic therapy. therefore.in such a situation can also be due to congestive heart failure. TB using chest AFB and paediatric tuberculosis routinely to establish Indications for chest x-ray a. when in doubt. The patient should be investigated for paediatric radiograph. Also consider the possibility of tuberculosis in a child with cough and difcult breathing if: • Child has fever and cough for more than 2 weeks. d. Give the rapid-acting bronchodilator by one of the following methods: Nebulized salbutamol. it breathing due to respiratory lower to is important pneumonia from infections. 112 . Sign or symptom Classication Treatment . Children therapy for 4-6 weeks. or pneumothorax. or (c) child has large skin boils or abscess or infected scabies.• • Central cyanosis Severerespiratory distress • Not able to drink due to respiratory distress. reassess for (80 mg/kg or Injection Ceftriaxone daily) for 10 IM days. or (b) there is pneumatocoele. above improves. stabilize and oxygenate the child before sending for and Give antibiotics Give Injectable Gentamicin (7. every 6 If the continuetreatment responds well. IV Alternatively.5 • radiograph. I/V . Very severe pneumonia • Chest indrawing Severe pneumonia • Fast Pneumonia 2 months upto months:  breaths/min months upto :  breaths/min 12 50 Defnite crackles 12 • breathing 5 40 • Admit to hospital • Manage the airway • Give oxygen • Give recommended • Admit to hospital • Give recommended antibiotic • Treat high fever if present • Give appropriate antibiotic for 5 days • Soothethe throat and relieve cough with a safe remedy • Treat high fever if years 9. continue total course of 3 (Empyema) need or every 6 hourly) to choice of antibiotics. If staphylococcal pneumonia is suspected. improve by 48 hours to any complications and switch to once one Then continuethe for 3 times a day for - If the child does not of these treatments. Cloxacillin weeks at longer orally 4 times a least.Staphylococcal pneumonia is suspected if: (a) there is a rapid progression of the disease. mg/kg IM same drug orally in the same dose a total course of 10 days. Radiography in very severe pneumonia is required at admission to assess the extent of disease and to rule out presence of puemothorax or effusion In case of severe distress. or (d) post-measles pneumonia which is not responding within 48 hours to the initial therapy. . discharge after 5 days home with oral Amoxicillin (15 mg/kg per day) plus IM Gentamicin once daily for to dose a three hours) child times further 5 at a days. Ampicillin mg/kg IM/IV (50 once mg/kg IM/IV a day). or effusion on chest X-ray. add Inj any with When the day for child a complicated pneumonia Cloxacilin of the (50mg/kg/dose.3 Treatment of very severe pneumonia • • Admit the child in hospital Obtain a radiograph of the chest if facilities are available for the same. give Injectable every 8 hours) until the Chloramphenicol (25 child has improved. 113 . . and/or . Monitor for signs of improvement. signs of distress.• Give Oxygen Where pulse oximetry is available. Encourage breastfeeding and oral fuids once the distress settles and the child is able to feed. q8h).If the child has fever ( 38. obtain a repeat chest X-ray. 9. Consider transfer to a higher facility in case of poor response or deterioration despite second-line therapy. 3 if 9. If the child does not improve within or for Ampicillin at least amoxicillin is at 48 (50 3 (15 least 5 hours. . • Give supportive care Ensure that the child receives daily maintenance fuids appropriate to child’s age.Less fever. When the child improves. .1 Treat severe pneumonia • • Admit the child to hospital. However. Continue with oxygen until the hypoxia (such as severe lower chest wall in-drawing or breathing rate of  70/min) are no longer present. A chest radiograph rarely gives information which will change the management of severe pneumonia and is. Give antibiotics Give Benzylpenicillin (50 000 units/kg) mg/kg) IM or I/V every 6 hourly) days after hospitalization. give a rapid-acting bronchodilator (as described in the next section).5ºC) which appears to be causing give oral Paracetamol (15mg/kg/dose).4. which the child cannot clear. by gentle suction. Maintain SaO2  92%. switch to oral mg/kg/dose. a radiograph is indicated if the diagnosis is not clear or child has SAM. A patient who is improving on treatment should have: .An improvement in the respiratory rate. Remove any thick secretions in the nose/throat. or the child’s condition has worsened. If wheeze is present. look for complications or other diagnoses. or . • Monitor the child The child should be checked by nurses at least every hours and by a doctor at least twice a day. If possible.Improved ability to eat and drink. The total course of treatment days.Less indrawing of the lower chest wall. therefore. post-measles state and suspicion of empyema and / or pneumothorax. use oxygen saturation of the blood (SaO2) to guide oxygen therapy. • Watch for complications If the child has not improved after two days. routinely not needed.4 Severe pneumonia A child diagnosed to have pneumonia is considered to have severe disease when the child also has chest in-drawing. 4. switch to Chloramphenicol (25 mg/kg/dose every 8 hours IM or I/V) until the child has improved.• • deteriorates. look for complications and treat accordingly. Then continue orally for a total course of 10 days. every 6 Monitor hours for . least day. 9. Give Oxygen in children with suspected hypoxia (clinical signs or pulse oximetry). Provide supportive care as for very severe pneumonia. If there are no apparent complications.2 Monitoring The 114 child should be checked by nurses at and by a doctor at least once a signs of improvement as discussed above. Chest drainage All empyemas should be treated by drainage of the pleural cavity by chest tube thoracotomy with under water seal. Section 9. Usually. assess for reasons for non-response like phlebitis.5. Failure to improve If fever and despite other signs of illness continue adequate chest drainage and beyond 5-7 days.1 Treating empyema a. impetigo. etc. metastatic pus lesion elsewhere in the body or less commonly tuberculosis. Considerreferring such cases for specialist (paediatric) opinion. need be drained. eg decreased breath sounds persists despite antibiotics more than 48 form of dull on boils. (c) Clinical percussion and Fever An of staph infection in examination suggestive. A surgical help may be taken for the inter-costal chest tube drain and its subsequent management. hourly) and as c. continuewith Cloxacillin orally. x-ray is in the to be done chest along with to confrmthe presence of diagnostic pleuraltap. When 4 times a day. both sides shall placing b. the child Continue mg/kg the or antibiotic fever comes once 6 day) therapy shall be down later little improves. usually due to of children with wheezing pneumonia consider pneumonia as is present with an wheeze. to aureus is a Give Cloxacillin common (dose: 50 causative mg/kg IM organism or I/V of every Gentamicin (dose: 7. If the disease is bilateral and signifcant. Give antibiotics Staphylococcus empyema. After frst years age. respiratory infections wheezing such as is mostly caused bronchiolitis.5 IM I/V a drugs.3. intravenous Unlike pneumonia anti-staphylococcal needed for 7-10 days.9. It alternative is diagnosis. 9. Sometimes important to particularly in the .6 Child presenting with wheeze In the frst acute viral 2 years of life. 9. (b) H/o pain chest. treatment for minimum of therapy as a Supportive therapy Every child should receive oxygen and other supportive discussed above under “very severe pneumonia”.5 Pleural effusion and empyema A child with severe or very severe pneumonia should be suspected to have pleural effusion or empyema if any one of the following is present: (a) Evidence abscesses. by 5-7 days. Frank pus or thin) is in cases the fuid specimen Grams staining and aspirated for of empyema. (d) hours. 3 weeks. fuid (thick Always send culture. by 2 asthma. antimicrobial therapy. The in a child is detailed in differential Table diagnosis of wheezing 16.frst 2 years of life. 115 . 116 . to coughs and Wheeze always relatedto coughs and colds No family or personal history of asthma/eczema/hay fever Prolonged expiration Good response to History of sudden onset of choking or wheezing • Wheeze may be unilateral Foreign body • Air and Signs air note No Fever • • • • Pneumonia trapping mediastinal of lung entry and with hyper-resonance shift collapse: reduced impaired percussion response to Cough with fast bronchodilators breathing 9. 9.7 Asthma Asthma is associated a with chronic variable infammatory condition airfow obstruction that of is the airways often reversible.1 Treatment of acute asthma Mainstay of drug therapy and steroids. their doses are largely governed by the severity of the attack (Annexure 9).Diagnosis Table 16: Differential diagnosis of the child presenting with wheeze In favour Asthma • • History of some unrelated colds First episode of wheeze in a child aged <2 years • Wheeze episode at time Bronchiolitis • • • of seasonalbronchiolitis Hyperinfation of the chest Prolonged expiration Reduced air entry (if very severe. The types of drug used. Any episodes of wheezing is likely with is bronchodilators treatment more than with 3 to have asthma particularly in the presence of personal or family history of atopy. It is characterized by cough. and diffculty in breathing. airway obstruction) Poor / no response to bronchodilators • Wheeze • associated with lower respiratory• cough or cold • • • recurrent wheeze. episodes which respond to child bronchodilators and anti-infammatory drugs.7. recurrent of wheezing. . three Injection three times. monitoring fnding is very life-threatening situation. in this hour. advise the mother on home care with inhaled or oral salbutamol. Continue inhaled the response Salbutamol as is partial or poor: before for another hour. and there are occasional or no rhonchi on auscultation. This Give dose. three distress) min interval. in First dose given promptly. spacing out each at 2-3 min interval. 20-30 Nebulized mainstay of beta every 20 min very severe chest. OR Injection Adrenaline subcutaneously every 20 min three times. Reassess after 1-2 hrs patient starts and systemic steroids other drugs added after are chest should be the are the if only the response is poor or ill sustained. spacing out each at 2-3 min becomes equivalent to a single nebulized course as before every 20 min. important in this every min initially and responding. • Reassess the child after 1 hour: .If the respiratory distress has resolved completely.Patients with deterioration are treated as moderate to severe attack. If the response is partial. . Keep this child under observation for the next 4 hrs to see that the response is sustained. puff course as before every 20 OR subcutaneously when there is min. b. If the child continues to stay well and does not have fast breathing. This is Adrenaline preferred wheeze as a silent of if steroids (oral not started Prednisolone 1mg/kg) so far. start oral steroids (Prednisone 1-2 mg/kg/ day in 2-3 divided doses). Repeat 4-5 this hour. with spacer: interval. • Mild attack ? (Alert child with no signs of severe respiratory Rapid-acting bronchodilators: Nebulised Salbutamol 3 doses at 20 OR Salbutamol by metered dose inhaler(MDI) 4-5 puffs. • Moderate to severe attack (Presence of severe respiratory distress or cyanosis) Admit the patient Give free fow oxygen to keep saturations  92% Rapid-acting bronchodilators: Nebulised Salbutamol 3 doses at 20 min interval. in and rate. OR Salbutamol by MDI with spacer: Give 4-5 puffs. this is considered as a good response. puff Repeat 4-5 times. of the sensorium. Keep this child under observation 4 hours to there is no further deterioration. potentially every agonists treatment times. • If - on reassessment. This becomes equivalent to a single nebulized dose. • Continuous respiratory oxygenation. Such patients see that for the next can then be sent home on oral steroids and oral/inhaled salbutamol.but the child is stable and able to take orally.a. continue Salbutamol inhalations 1 or 2 or 4 hourly depending upon the time for which the response to initial treatment is sustained. If the child starts improving or is stable. 117 . 20 min Continue systemic steroids. Ipratropium bromide should be continued at 8 hourly intervals.• This If can available. also be mixed with add inhaled Ipratropium bromide. Give 3 doses at interval. Salbutamol nebulized solution. when there is persistent fever and other signs of pneumonia such as bronchial evidence breathing. however. by a doctor and watch for . is Aminophylline infusion is medications.7.7. 9. shows improvement (i. This solution is then given as intravenous • • infusion over 30 min or so.05-0. as soon as food can be taken. and • is on 4-6 hrly inhalations. add mg/kg up to a infusion in dose a and arrange current level transfer of or response shows good response hours. to 4-6 at followed not good. salbutamol to medication orally. at least twice a day.Once good response is seen. Encourage maintenance fuids appropriate adequate feeding for for the child. by decrease Follow the Ipratropium inhalation frequency of in Salbutamol hourly.7. Antimicrobial treatment is indicated. medications can usually stopped in frequently hr. 9.e. decreased breathing rate and less respiratory distress). Record the respiratory signs of impending and rate respiratory failure.4 Monitor the child A hospitalized child or every 6 should be hrs as assessed the child by a nurse every 3 hrs. able take 9.1ml/ kg body weight of 50% Magnesium Sulphate with a 1ml syringe and add to about 30-50 ml of normal saline. 9. monitoring intensively. if no and be response decreased. intervals every 30 min to 1 Reassess Injection maximum and if the Aminophylline of mg/kg Continue to a treatment is • 5 of - Reassess response loading is dose still (5-6 maintenance 300 mg) followed by every 6 hrs. • In case of poor or no response after initial treatment with Salbutamol and Ipratropium: Take 0.5 Plan discharge when • • the patient is does not need oxygen therapy.7. Monitor oxygen therapy.3 Supportive care Ensure that his the / child her receives daily age. Mere presence of crackles is not an of pneumonia and does not warrant antibiotics. stop Ipratropium inhalation and then gradually increase the interval between Salbutamol inhalations every 6 hrs or so and plan discharge.2 Antibiotics Antibiotics should not be given routinely for acute asthma. Whenever sustained patient for 4-6 “last out” in-frst principle to withdraw 24 hours next Then gradually 24 inhalation hours. higher facility continuing Plan the in case of any deterioration seen in next 4-6 hours. A long-term treatment plan should be made based on the frequency and severity of symptoms.6 Give follow-up care Asthma is a chronic and recurrent condition. Any child with persistent symptoms or frequent episodes (>1 / month) or symptoms of cough and breathlessness following exercise should be referred because this child will require evaluation / long-term preventive therapy [inhaled corticosteroids] 118 .7.9. This course is repeated every 20 0. be stopped without tapering.5 • mg/dose (5 mg/ml inhalation nebulizer mg/ml solution).3 ml/kg ml) of • nebulizer min x min 0. by 3 or Adrenaline 2. This repeated every • Inj (max of 0.01 0.01 ml/kg ml) of 1:1000 solution subcutaneous min x • every 20 x 3 inhaled or oral salbutamol 6 hrly puff) 1 m g / k g o r 3 1:1000 solution 3• Continue 3 or Inj Adrenaline (maximum of subcutaneous Good response: Home treatment • mg/dose (5 solution). Prednisolone H y d r o c 4-6 hrly inhalation • o Discharge r if t improvement seen Home treatment: • Continue inhaled or oral Salbutamol 6 hrly • Short o n e 1 for can s course steroids 3-5 i days. physical examination MILD ATTACK MODERATE TO SEVERE ATTACK Initial Treatment • Salbutamol inhalation Initial Treatment • Salbutamol 2. by every minutes x 3 Salbutamol MDI-spacer or inhalation 4 puffs by (100mcg/puff) at 2-3 20 interval.3 every 20 by min or Salbutamol inhalation MDI-spacer 4 puffs course is (100mcg/ at 2-3 20 minutes x min interval.5 Incomplete or poor response: • Add steroids • Observe for 4 hrs • Continue Salbutamol every 20 min x Oxygen • Start steroids. 0 m .Management algorithm for treating acute asthma in a hospital Initial assessment and grade severity of attack History. R E F E R 119 infusion in 1224 hours. and • .g/ kg I/V st at Re ass ess ev ery 60 mi p e a t R e • Add Ipratropium bromide inhalation (may mix or alternate with i n i t i a l Good response at any salbutamol) • Follow “Last • stage: Oxygen the principle Oral Prednisolone in – First of out” (1-2mg/Kg) Omit aminophylline Reassess every 60 min Poor response: a t m e n t • • Omit 1-2 • • a Continue bronchodilator inhalation in next 12-24 hrly and Ipratropium hrs hrly. Continue every 60 min b Poor response: • Give one of Mag. if used t r e n Poor response: • • ore. inhalation to 4-6 hourly Sulph /aminophylline Plan discharge Reassess dose Sulph. e aminophylline choosing what was f not used in the previous step Or s • ipratropium 8 steroids Reduce the salbutomal Give one dose of Mag. 7 How medications to give (a) asthma Nebulized Salbutamol • The drivingsource for the nebulizer oxygen at least 6–8 l/min. When oxygen simultaneously through nasal cannula. then be given.e.7. measured accurately with a 1 ml syringe is given subcutaneously (for injection technique. A slow deep breath is preferred but may not be feasible if the child is not earlier trained. (c) Subcutaneous epinephrine (adrenaline) Subcutaneous injection of Epinephrine (Adrenaline – 0.9. • Place the bronchodilator solution nebulizer chamber to make a minimal fll volume of the ml). The child’s neck should be supported in slight extension. In a younger child one may attach a face mask to the spacer. the drug delivery may be severely compromised. The dose .5 mg mg/ml nebulizer solution).5 ml of the 5 be given 1-4-hrly initially. it can must deliver air using an air or pump. the fnal fll (e) Oral bronchodilators Once the oral child has Salbutamol improved suffciently to (in syrup or tablets) be can discharged home. • Allow normalbreathing for 3-5 breaths. • Place the child’s mouth over the opening in the spacer.01 ml/kg of 1:1000solution (up to a maximum of 0. Home made spacers using plastic bottles can also be used. The (i. still kept the same (3-4 ml). (d) Ipratropium bromide Inhaled Ipratropium benefts seen when used alone. Give Salbutamol inhalation up to Salbutamol are mixed together. see Annexure 8). (b) Salbutamol by metered-dose inhaler with a spacer device Spacerdevices with a volume of 250-750 ml are commercially available. child’s condition improves. • Remove the cap and shake the metered-dose inhaler(MDI). Nebulize until the liquid is dose of Salbutamol is 2. bronchodilator is less effective it mixed with or 24-48 hrs. • Give Salbutamol inhalation by MDI-spacer 4 puffs (100mcg/puff) at 2-3 min interval.3 ml). If the child is crying. If be given more frequently. alternate with When Ipratropium and volume is Bromide may add to the with inhaled Salbutamol but The dose is 250 mcg. • Release a puff (100 micrograms of Salbutamol) into the spacer chamber after attaching the MDI to the other end of the spacer. This can reducing to 6-8 hrly once the necessary in severe cases. 0. give and add sterile saline in the volume more than the chamber (usually 3-4 almost all used up. 1ml/ Magnesium Sulphate is measured with . If the child remains very sick. drowsy or unable to retain oral medication. give oral prednisolone. Usually 0.05-0. Steroids are used for 3-5 days and no tapering of dose is necessary. 1-2 mg/ kg. It drugs at is home to (f) Steroids If a child has a severe acute attack of wheezing and a history of recurrent wheezing.for children aged 1–5 years: 2 unnecessary to teach or provide those with intermittent wheezing. Parenteral steroids do not confer any advantage in an outpatient settingbut may be used in hospitalized children who are severely distressed. Hydrocortisone 10mg/kg I/V stat followed by 5mg/kg every 6 hrly. Give Inj. mg 6-8 inhalation hrly. continue the treatment until improvement is seen. (g) Magnesium Sulphate Injection an acting kg a 120 Magnesium Sulphate additive therapy beta 2 agonists body weight of 50% as an infusion may be useful as if the initial treatment to rapid and Ipratropium fails. • Antibiotics recommended. or (b) has a pulse rate >180 / min. mg/kg (up ml of to a maintenance fuids dose 0. The major causes of severe stridor are viral croup (caused by measles or other viruses). to develops 9. when severe.9 so. • are Oxygen 2 not . If the obstruction is severe. sub glottis or trachea. Type Mild croup Moderate to Severe croup • • Diagnosis hoarse A voice • A • barking or to return) hacking cough Stridor that heard only is when the child is agitated. • Epinephrine (adrenaline) – Nebulized Epinephrine (1:1000 solution) 2ml in ml normal of saline. • Stridor when the child is calm • Rapid drawing of breathing and • Treatment Home care (fuid. when Admit to hospital • Steroid – Single dose of Inj Dexamethasone in- the lower chest wall. Most the upper airway which. or (c) a headache. This section can be deals with croup caused by various respiratory viruses. can cause striated (h) Aminophylline Inj I/V aminophylline– initial dose of 5-6 maximum of 300 mg) dilutedin 50 over 30 min. retropharyngeal abscess. if (a) the child starts vomit. (0. 9.6 mg/kg) I/M or oral Prednisolone (1-2 mg/kg). This and this solution is is added to about 30-50 ml then given as intravenous of normal infusion 30 min or Rapid infusion hypotension and muscle relaxation. diphtheria. which is due to narrowing of the air passage in the oropharynx.1ml over syringe saline. followed by a maintenance to 6 hrly maintenance of mg/kg/hr added fuid. Omit the initial dose if the child has already received any form of Aminophylline in the previous 24 hours. Intravenous Aminophylline can be dangerous in an overdose or when given too rapidly. and trauma to the larynx (see annexure 6).1 Viral croup Croup causesobstruction in life threatening. feeding. Stop giving it immediately.8. or (e) has a convulsion. stridor may also occur during expiration. severe episodes occur in infants.8 Conditions presenting with stridor Stridor is a harsh noise during inspiration. foreign body. • Oxygen therapy • Intubation or Tracheostomy in children with incipient obstruction. • Antibiotics are not recommended. Epinephrine (adrenaline) – NebulizedEpinephrine (1:1000 solution) 2ml in 2 of ml normal saline.(1-2 • mg/kg). . when feasible. such as lower chest wall and restlessness.Consider intubation and tracheostomy • If there are severe indrawing signs of of the incipient airway obstruction. This is preferred over tracheostomy. 121 . consider intubating child with an size. if expertise is the the appropriate endo-tracheal tube one size smaller than available. c. On respiratory rate of ronchi are audible in the past one year. a.4ºC and indrawing. reports to the health facility. Satish. transfer to a hospital where intubation or tracheostomy can be done. What is your diagnosis? What is the likely etiological agent? Outline the management plan along with the drug doses in this child. On further examination. a 2-year-old child weighing 8 kg. and weighs15 kg. a large boil on the thigh is detected and crackles are heard on auscultation. fast breathing. What is your diagnosis? b. temp of 37.He has cough and respiratory distress for 2 days. the child emergency urgently Intubation or tracheostomy should only be done by experienced staff. His respiratory rate is 70/min. Manoj is 4 years old health facility with cough and alert. He comes to the examination he is 46/minwith no chest on both sides of chest. temperature is 39ºC and is unable to feed and has chest indrawing. . 2. EXERCISE 7 1. b. Write the initial treatment plan. On auscultation His mother says he had 3 similar attacks a.• If this is not possible. 122 . some of these the health facility for further assessment management in the facility are similar to those in the IMNCI module. The most common cause of dysentery is Shigella bacteria. The principles of which you have already learned hospitalization: with severe dehydration. If an episode of diarrhoea lasts less than 14 days. it is acute diarrhoea. Amoebic dysentery is not common in young children. Acute watery diarrhoea causes dehydration and contributes to malnutrition. Most diarrhoeas which cause dehydration are loose or watery. 10 CASE MANAGEMENT OF CHILDREN PRESENTING WITH DIARRHOEA 10. . It is often seen in those who are not on breastfeeding and more so if they are bottle-fed. • Facilitate settingup of an ORT corner in the facility. Diarrhoea with blood in the stool. Children 2.0 Learning objectives After completion of this section the participant should be able to: • Manage cases of diarrhoea with severe dehydration • Manage cases of dysentery. The death of an infant with acute diarrhoea is usually due to dehydration. Up to 20% of episodes of diarrhoea become persistent. with severe acute malnutrition. is assessment and management of in the IMNCI module. Indications for 1. However. Exclusive breast feeding up to 6 months protects children against diarrhoea. • Assess and manage cases of persistent diarrhoea. Children mucus. If the diarrhoea lasts 14 days or more.SECTION. with or without called dysentery. it is persistent diarrhoea. You have already learned the acute and persistent diarrhoea children with diarrhoea can level. Persistent diarrhoea often causes nutritional problems and contributes to deaths in children. Diarrhoea is common in children especially in those between 6 months and 2 years of age. Most be managed at out patient children will be referred to and management. 123 .3. Children with associated co-morbid conditions. 10. and You have antibiotic effective recommended drug) of doxycycline is (1/2 tab) between learnt this with close the child process. is the preferred normalsaline can be I/V solution.The assessment and dehydration is described in Table 17. thirsty· advise mother on • Skin pinch goes back home care slowly • Follow up in 5 days if not improving Not enough signs to • Give fuids. the 2 years. If used. • Drinks eagerly. Note: Ringer’s it is lactatesolution not available. 5% dextrose not effective and should not be used.1 Severe dehydration (without severe acute malnutrition) Children with monitoring. irritability· dehydration (Plan B) • Sunken eyes· • After rehydration. This provides some base and potassium be adequately solution is supplied by I/V severe acute malnutrition is fuid. where cholera is give frst The 50 an line dose mg endemic. In patients should start to receive ORS solution at the rate they can drink. zinc classify as some supplements and food or severe dehydration and advise to continue ORS at home (Plan A)· • Advise mother when some and no dehydration. see Annexure 6. single dose. Table 17: Assessment and classication of dehydration Signs or symptoms Treatment Classication Severe dehydration Some dehydration No dehydration For classifcation of management of Two or more of the following signs: • Give fuids for • Lethargy / severe dehydration unconsciousness (Plan C) • Sunken eyes • Unableto drink or drinks poorly • Skin pinch goes back very slowly 2 Two or more of(> the following signs:· • Give fuids for some • Restlessness. detailed addition all of which 5ml/kg/hr when may not . In areas against cholera (Doxycycline is to children above 100 mg tab between 4-5 yrs 2-4 yrs. Management of later in severe dehydration section on with SAM. severe dehydration require which is followed by rapid I/V rehydration oral rehydration once already starts to improve suffciently. 124 . If possible.2 Dysentery Dysentery is diarrhoea visible blood. drink. and give fuids according to . • Assess hrs and a child hrs. B dehydration or C. ORS 20 ml/kg/hr an infant after dehydration again. lethargic. Treat dysentery Indications for admission Children Children and tenderness with who or severe malnutrition and are toxic. 10. B.jejuni and infrequently and rectal pain. It is presenting usually with loose frequent stools containing associated with fever.histolytica.Start I/V by solution fuid immediately. - Also give ORS (about 5 ml/kg/hr) as soon as can drink: usually after 3-4 hrs (infants) or 1-2 hrs for If 6 I/V hrs treatment not (120 ml/kg) by possible. to Shigella but can by E. convulsions. For dysentery have abdominal • In for admitted 5 days children may be children give an oral antibiotic effective for Shigella (e. Then (Refer to cholera Annexure 6) if child 2 6 can the sure child that for the at least mother child ORS solution by 6 hrs maintain mouth. Ciprofoxacin. IM/IV Ceftriaxone used. observe after rehydration to be hydration by giving the 3 Classify weak or 70 * after very follows: Then give ml/kg in 5 hours 1 hour* still ORS (5ml/kg/hr) ml/kg Ringer’s lactate not the detectable.coli. normal child set can up. Treat dehydration Assess the child Treatment for Plan signs of A. as they can increase the severity of the illness. If mouth while the drip (or if not AGE the is available. children with watery Provide supportive care Supportive care dehydration includes the and continued prevention feeding. E. oral antibiotic for (A. divided as First give 30 ml/kg in Infants (under 12 months) Repeatonce if radial pulse is • Reassess status is the not child every 15-30 minutes. • • to Give years or older. give NG tube. give the I/V If drip hydration more rapidly. improving. or to reduce the frequency of stools. • Prescribe diarrhoea. Most be caused by Salmonella. give Give 100 saline). or correction of Never give drugs for symptomatic relief of abdominal pain and rectal pain. abdominal cramps episodes in children are due C.g. a zinc as done for supplement distension (100 mg/kg) once non-admitted/discharged daily Cefxime). choose the appropriate plan or C) continue treatment. child (children). 125 . if and low or output. Give antimicrobial therapy if: Associated systemic infection: Ampicillin and aminoglycosides Combination of is usually parenteral appropriate. • occur in or is Avoid diazepam. 2. mg/kg.2ºF) which Paracetamol. Screen for intestinal infections: Stool routine and culture if facility is available. • severe malnutrition: Use of an for associated systemic infection even if uncertain whether there is systemic infection. treatment. coconut water or dark green leafy vegetables. Assess dehydration. Sepsis. prepare a bananas.Nutritional management Ensuring a marked good diet adverse is very effect on important nutritional as dysentery status. Haemolytic-uraemic syndrome: Where laboratory suspect haemolytic-uraemic syndrome (HUS) tests are not in patients with easy bruising. convulsion may is prolonged rectal altered anticonvulsant of this giving refer give single episode However.3 for 5 . • • • Manage dehydration as Plan B or C. possible. UTI. • • High fever: If 102. 3. Alternatively. combination Presence mg/kg) of once Shigella Ciprofoxacin) for Give if Metronidazole10 (eg. Assess 1. 10.Otitis media and Oral thrush. suspect HIV if there are other clinicalsigns or risk factors. cases. repeated. Amoebiasis: days only gross blood in daily or an oral 5 Ampicillin and stools: Give IM/IV oral antibiotic Associated aminoglycoside Ceftriaxone effective (100 times a day as for days. 4. • Convulsions: A these children. no urine and these consciousness. or Fails to routine OPD management for persistent diarrhoea. or Has associated severe malnutrition or severe illness. Rectal prolapse: surgical glove fever ( causing or give  warm solution of saturated magnesium sulphate and apply compresses with this solution to reduce the prolapse by decreasing the oedema. pallor. 2. has a Manage complications • Potassium solution depletion: This (when indicated) can or be prevented potassium-rich by giving ORS foods such as the child appears has to high be  39ºC distress. In areas where HIV is highly prevalent.3 Persistent diarrhoea Admit • • • child with persistent diarrhoea if: Dehydrated (severe persistent diarrhoea). Screen for non-intestinal infections: Pneumonia. Treat severe persistent diarrhoea 1. Gently push or a back wet the rectal prolapse using a cloth. or .Two different antibiotics. • Giardiasis: Give oral metronidazole 5 day.Microscopic examination of reliable laboratory reveals fresh faeces carriedout trophozoites of E. in a histolytica red blood cells. 126 mg/kg.3 Giardia times a lamblia with . have been given without clinical improvement. which are usually effective for Shigella locally. for 5 days if trophozoites of are seen in the faeces. Help mothers who are not breastfeeding exclusively to do so. After recovery. to been feeding initially. serious infection has establish lactation. including milk. . 5. In addition to zinc. which provides at least 110 calories/kg/day. If there are signs of dietaryfailure or if the child is not improving after 7 days of treatment. do not use a feeding bottle. stop the frst diet and give the next diet for 7 days. Children may then return home. provide vitamin A (single large dose) if he has not received as pre-referral treatment. Ensure at least three weight before you conclude that weight gain is occurring. until any 24–48 Such children may require nasogastric hrs. • in to hospital give a require specialdiets daily intake of at and least Breastfeeding should be continued. If such preparations are not available. • 6 months or older Feeding should be restarted Reduced lactose diet achieve a total intake Many sick treated for at children will eat poorly. Give zinc supplements for 14 days (Tablet Zinc Sulphate 20 mg) Zinc : > : 6 Up to months 6 = months 20 mg = 10 mg 4. Feeding Children treated the goal is 110 kcal/kg. Give Give supplementary multivitamins and minerals supplement vitamins 2 weeks. twice the supplements only after RDA the for at least diarrhoea has ceased. iron and vitamin A.3. children with persistent diarrhoea also require supplementation with other multivitamins and minerals such as folate. Recommended diets for persistent diarrhoea Given in Annexure 6 are three diets recommended for children and infants aged >6 months with severe persistent diarrhoea. day of least 110 calories/kg/day (annexure-6). . Once the child improves.Introduce and iron minerals. Give additional banana and well-cooked vegetables to children who are responding well. The most important successive days criterion is of increasing weight gain. resume an appropriate diet for their age. help the mother to re- as soon should be as the given 6 child can times a eat. copper and magnesium. but follow them up regularly to ensure continued weight gain and compliance with feeding advice.If child is not breastfeeding give a breast milk substitute that is low in lactose such as yoghurt or lactose free commercial formula. Use a spoon or cup. Up to 6 months Encourage exclusive breastfeeding. 000 IU 127 .• Vitamin A 12 months IU (Single dose) months = : = 6 100.000 >12 200. This their children who clinic for several When there are can be no used not wasted.One RDA for a child aged 1 year is: • • • • • • 6.the the space oral to stay area is located and corner will help the staff to manage the patients easily. toilet and washing and well-ventilated. the following solution and supplies. Folate 50 Zinc 10 Vitamin Iron 10 Copper Magnesium micrograms mg A 400 mg 1 mg 80 mg micrograms Monitoring Check the following • Body weight daily • Temperature • • Food intake Number of diarrhoea stools 10. ORS packets (a supply of at least 300 packets per month). ORT Then there conveniently equipped are ORT dehydrated patients. These supplies are for a clinic that receives 25-30 diarrhoea cases in a week. 6 bottles that will hold the correctamount of water for mixing the ORS packet. a back where while holding mother can conveniently furniture. where staff staff can frequently observe pass the by but not child’s progress and encourage the mother. The • ORT corner should be: Located in an area in a passageway. holding supplies. The • • facilities. The • • • Near a Near a Pleasant water source.this corner. including some containers like those that . • Small rest the cup ORT corner should have the following supplies. When adequately a health facility available for area is needed because need ORS solution will have hours. The • • • ORT corner Table for Shelves Bench or can sit should have mixing ORS to hold chairs with comfortably table where the of ORS solution. the the mother child. diarrhoea patients using the for treating other problems.4 ORT Corner An ORT corner rehydration mothers and at the is an area in therapy (ORT). spoons. • • • 128 6 6 2 cups.mother will have at home. droppers (may be easier to use than spoonsfor small infants). . cooked cereal. The should contain information about ORT. some dehydration. and some mashed vegetables. Other on immunizations. Doctors should in person. Mothers are interested in posters about the prevention of diarrhoea and dehydration. Since mothers sit in the ORT corner for a long time. Mother’s a child Card) that with diarrhoea. He been referred with classifcation weight for age and anaemia. children times). using a Mother’s available. . severe persistent diet includes a.• Cards or pamphlets (such remindmothers how to A card is given to each mother to Soap (for handwashing). they will have a good opportunity to learn about health prevention from the posters. breastfeeding. of to the clinic. What diet should Sonu be taking? He has had He has diarrhoea. Sonu is 8 months old diarrhoea for 20 days. low animal milk. and has of His weighs6. handwashing. Wastebasket.0 kg. adequate for informing also counsel mothers Card if there is one EXERCISE 8 1. Should Sonu be admitted? b. treatment and posters water. In which situation will you start antimicrobial therapy in Sonu? c. may offered be food or The ORT corner is a good place to display informative posters. and when to take the child health messages should include information Posters alone are not mothers. Food available (so that eat at regular meal • • • as a care for take home. the use latrines. use of clean weaning foods. 129 . dengue haemorrhagic fever. relapsing fever). 18).SECTION. Fever with rash (Table 20). 11 CASE MANAGEMENT OF CHILDREN PRESENTING WITH FEVER 11. meningococcal meningitis). .g. or other disease entities which have been elucidated in the IMNCI module. • Manage cases of severe malaria. Other fevers are seasonal (e. malaria. As many of these are respiratory tract infections which are viral in origin and there can be mild variant of malaria. Following are the indications for children with fever who would require admission in the health facility: • If any emergency signs • Toxic child.g.0 Learning objectives After completion of this section the participant should be able to: • Identify causesof fever. 11. typhoid fever. • Manage cases of bacterial meningitis. • Manage cases of severe dengue. It is important to remember that majority of the children with fever do not require hospitalization. meningococcal meningitis) or can occur in epidemics (measles.1 Child presenting with fever There • • • are three major categories of children presenting with fever: Fever due to infection without localized signs (no rash)(Table Fever due to infection with localized signs (no rash)(Table 19). • Sometimes prolonged fever not responding to conventional treatment. Some causes of fever are only found in certain regions (e. 130 . petechiae Shock or hypothermia in Seriously and obviously ill with no apparent cause Abdominal tenderness Shock Confusion Costo-vertebral angle or supra pubic tenderness· Crying on passing urine Passing urine more frequently than usual Incontinence in previously Table 19: Differential diagnosis of fever with localized signs Diagnosis of FeverIn Favour Meningitis Otitis media Mastoiditis Osteomyelitis Septic arthritis Pneumonia Viral upper respiratory tract infection • Fever with headache. tender.Table 18: Differential diagnosis of fever without localizing signs Diagnosis of FeverIn Favour Malaria (only in children exposed to malaria transmission) • • Septicaemia • • • • Typhoid • • • • • • Urinary tract infection • • • • Sudden onset of fever with rigors followed by sweating Febrile paroxysms occur every alternate day Blood flm positive Rapid diagnostic test positive Severeanaemia Seriously and obviously ill with no apparent cause Purpura. swollen • Cough with fast breathing • Lower chest wall indrawing • Fever • Coarsecrackles • Nasal faring • Symptoms of cough/cold • No systemic upset 131 . vomiting • Convulsions • Stiff neck • Bulging fontanelle • Meningococcal rash • Red immobile eardrum on otoscopy • Pus draining from ear • Tender swelling above or behind ear • Local tenderness • Refusal to move the affected limb • Refusal to bear • Joint hot. runny nose. What is severe malaria? Presence of any of the following features in a child with microscopy or RDT positive for malaria indicates severe malaria: • Altered consciousness • Severeanaemia (haematocrit < 15% or haemoglobin < 5g/dl) • Hypoglycaemia • Respiratory distress • Jaundice Severe malaria. red eyes • Recent exposure to a measles Viral infections • Mild systemic upset • Transient non-specifc Meningococcal infection • Petechial or purpuric • Bruising • Shock • Stiff neck (if meningitis) Dengue haemorrhagic • Abdominal tenderness fever • Skin petechiae • Bleeding from nose or gums. severe anaemia and acidosis. standardized full course of treatment prevent emergence of resistant cases. The illness starts with high grade fever. drugs is very important not anti-malarial lives in such cases but also to contain the spread of this species. Children can deteriorate rapidly over 1–2 days. falciparum is a life-threatening condition. Use only to save . The and Rapid Diagnostic cases in high risk The Policy also recommends to is P. headache. or manifesting convulsions. Use recommends all to save doing microscopy of lives in clinically suspected malaria microscopy in low risk areas. or GI bleed • Shock rash 11. Plasmodium vivax most cases. to falciparum 2% of infection may cases. going into coma (cerebral malaria) or shock. restlessness and often vomiting.5% P. Mortality lead may to result in such cases if timely treatment is not given. It is observed complications in about of 30% of appropriate that 0. drugs is National Malaria Policy Test areas very 2008 (RDT) in and using India.2 Severe malaria Malaria and a major health problem falciparum are responsible in for appropriate anti-malarial important malaria cases.Table 20: Differential diagnosis of fever with rash Diagnosis of FeverIn Favour Measles • Typical rash (maculopapular) • Cough. which is most commonly due to P. 132 . • I/M Quinine: Give 10 mg of quinine salt per kg I/M and repeat after 4 hrs. 8 hrly. quinine 10 mg/kg bw three times a day with clindamycin (20 mg/kg/day in 2 divided doses for 7 days) should be given to complete seven days of treatment. Give . Treat severe anaemia. Treat convulsions.Emergency measures: to be taken within the rst hour • • • • • • • Check and correcthypoglycaemia. •The parenteral treatment should be given for minimum of 48 hrs and once the child tolerates oral therapy. if present.8 ml ¾ 1. Manage shock.2 ml 1 * Loading dose is double the maintenance dose given above **Quinine salt • I/V Quinine: Give a loading dose of 20 mg/kg of quinine dihydrochloride in 10 ml/kg of I/V fuid. it is safer to give I/M quinine. give every 8 hrs until the malaria is no longer severe. Also give treatment for bacterial meningitis if it cannot be excluded.6 ml ½ 0. minimize aspiration pneumonia (insert a nasogastric the gastric contents). 5% dextrose saline over 4 hrs followed by maintenance dose of 10mg/kg. If this is not possible. Then. Antimalarial treatment Severe malaria is an emergency and treatment should be given as per severity and associated complications. It is essential that I/V quinine is given only if there is close nursing supervision of the infusion and control of the infusion rate.4ml ¼ - 0. if present. Provide supportive care if child is the tube risk and of remove unconscious. infusion rate should not exceed 5 mg salt/kg of body weight per hour. Antimalarial treatment. Parenteral quinine or artemisinin derivatives should be used irrespective of Chloroquine resistance status of the area. Quinine for severe malaria Age or Weight 2 4 1 2 3 – <4 months – <12 months – < years (10 – <3 (10 – – <5 (14 – (4 Table 21: Quinine dose for severe malaria Intravenous* or Intramuscular Oral Quinine sulfate Quinine tablet (2 ml ampoules) 10 150mg/ml** 200mg ** (6 2 – years <14 years 19 0. If the child is unconscious.0 ml ¾ 1. The parenteral solution should be diluted before use because it is better absorbed and less painful. primaquine (0.single gametocidal dose of transmission in the community.75 mg/kg) to prevent OR 133 . 2 mg/kg on admission then 1. Provide supportive care of an unconscious child • Care of an unconscious child: of airway.4 mg/kg after 12 hours and 24 hrs. irritability. respiratory least the frst • Check blood sugar • Monitor the • Fluid intake and checked at least rate and 48 hrs: every 3 rate of output. breathing. Eyelid oedema is a In children with no their daily fuid requirements but the recommended limits. • Take the following precautions Check for dehydration and During rehydration. vomiting. • IV or IM Artesunate: Give 2. blood pressure least every 3 hrs and Monitor temperature. every 6 hrs. Anterior fontanelle if open may be bulging. Children with meningitis have neck stiffness with photophobia. headache. diagnosis is confrmed with a lumbar puncture and examination of the CSF (Table 22). Early The diagnosis is essential for effective treatment. Be I/V fuids. (See Annexure 8 for drug policy). by nurses at twice a day. 11. . and the section ETAT. for at hrly I/V child until the infusions.• IM Artemether: Give 3. dehydration. • Complete treatment following parenteral artemisin derivatives by giving a full course of artemisin based combination therapy (ACT). Suspect meningitis if child has fever. is conscious.4 mg/kg on admission. position circulation the as child you and have take care learnt in in the delivery of fuids: treat appropriately. ensure that they receive take care not to exceed particularly careful in monitoring Monitor the child The child should be by a doctor pulse rate. • Arteether is not recommended in children. inability to feed and seizures. fne fullness of neck veins when useful sign in infants. Additional crackles at lung bases and/or upright. followed by 2. start the treatment immediately even if lumbar puncture is not possible or lumbar puncture cannot be done because the child has signs of raised intracranial pressure. However. then once a day for a minimum of 3 days or until the child can take oral treatment. The most an enlarged liver.6 mg/kg daily for a minimum of three days until the child can take oral treatment.3 Meningitis This section covers management of meningitis in children and infants over 2 months old. examine overload. frequently for signs of fuid reliable sign of overhydrationis signs are gallop rhythm. 134 . all mononuclear< 40 mg/dl 50-80 mg/dl> 2/3 of blood glucose .Table 22: CSF ndings in various types of meningitis Norma l AppearanceCells Proteins Glucose Crystalclear<6. upto Decreased 100 or polymorphonuclear mg/dl none Clear or Increased. or available 1. • Focal paralysis in any of the limbs or trunk.000 hrs.5 The alternative other is oral intravenous ml of glycerol 1 gm/kg 20% 4-6 hrly. every 6 hrs If Ceftriaxone use other alternative Chloramphenicol : / 25 Cefotaxime is drugs as given below: mg/kg every IM/IV not 6 hrs. later mononuclear Clear or 0 to few 20-125mg/dlNormal slightly hundred.25-0. plus units/kg) All cases should be looked for the following signs of raised intracranial pressure • Unequal pupils.e. : every 6 hrs : 25 : Chloramphenicol Benzylpenicillin 6 hrs IM/IV. • Irregular breathing. OR mg/kg IM/IV every 6 60 mg/kg (100. the days. • Review diagnosis is 10 therapy when CSF is confrmed. over 30–60 min every 12 100 mg/kg IM/IV. • Rigid posture or posturing. untreatedCloudy to 1000s. plus Ampicillin 50 mg/kg IM/IV 2. hrs. Ceftriaxone: 50 mg/kg IM/ IV. Treatment Give antibiotics • Give antibiotic treatment immediately after admission. 1. Raised intracranial mannitol mannitol). partially treated Viral Tubercular * May be clear or during the purulent*100s frst few hours of illness. OR Cefotaxime: 50 mg/kg IM/IV.5 can be managed by gm/kg/dose.25-2.Bacterial. pressure (0. results are available. all Increased. i. mostly Increased Decreased or slightly polymorphonuclea normal clouded r. opalescent mononuclear 45-500mg/dlDecreased Straw coloured or 250-500 slightly cloudy mononuclear Bacterial. once daily. total duration of If the treatment every . 135 . risk pain if a behind the eyes. vomiting and/or a rash may occur but are not always present. especially record the head circumference of infants. Measure and for neurological problems. such as cellulitis at injection sites. Treat with an antimalarial if malaria is diagnosed. an III other common infections.•Ifthereispoorresponsetotreatment: Consider the presence such as subdural effusions of common complications. It can be diffcult childhood Causative has a to distinguish dengue from virus I. 11. and give simple suggestions to the mother for passive exercises. Diagnosis Confrmation of diagnosis of dengue fever is based on demonstration of IgM antibody specifcfor dengue virus. or osteomyelitis. organism. abdominal pain. (persistent fever plus focal neurological signs or reduced level of consciousness) or a cerebral abscess. refer the child to a hospital with specialized facilities for further management. Total leucocyte count is either normal or decreased. On discharge. Supportive care: As discussed earlier (see section on severe malaria).4 Dengue fever Suspect child dengue fever in an has fever lasting more than area 2 of dengue days. hypoglycemia has already been dealt. at least twice such as convulsions. If there is neurological damage. Management the child’s state every 3 hrs and a of complication of consciousness. Sensorineural deafness is common after meningitis. to acute nutritional support and nutritional Monitor the child Nurses should monitor and pupil size every 6 hrs). during the frst 24 doctor should monitorthe child respiratory rate hrs (thereafter. . Give due attention rehabilitation. borne virus and Aedes aegypti day time mosquito is the principal vector in India and countries of South-east Asian region. Fluid and Nutritional Management • There is no in children fuid • good with evidence bacterial to support meningitis. . take a blood smear to check for malaria since cerebral malaria should be considered as a differential diagnosis or co-existing condition. . joint and muscle pains. Headache. mostly seen in rainy season or in months following rainy season. arthropode and IV). daily. If these are suspected. hearing assess all children loss. Platelet count is less than normal. refer the child for physiotherapy.Look for other sites of infection which may be the cause of fever. if possible. arthritis. Arrange a hearing assessment on all children one month after discharge from hospital. dengue 4 serotypes (Den is II. Give fuid restriction them their daily requirement.In malarious areas. All 136 cases of Dengue health authorities. as fever should be it is a reported notifable to the disease. local/district/state . of severe disease (mucosal or alteredmentalstatus. cold. lethargy or restlessness. • ORS solution to Give paracetamol for high uncomfortable. where possible. the only haemorrhagic manifestation is a positive tourniquet test and/or easy bruising.g.Treat dengue fever Most children can have reasonable be managed access to the • Counsel follow-up mother to bring the to return immediately if the but at home provided hospital: child any back of the parents for the daily following occur: severe abdominal pain.5 Severe dengue What is severe dengue? Severedengue includes dengue shock syndrome (DSS). bleeding e. Check for signs of severe disease. • • • Encourage replace oral fuid losses from intake with fever and clean water or vomiting. Grade : Spontaneous bleeding in addition to the manifestations of Grade I patients. usually II in the form of skin or other haemorrhages. Suspect severe dengue Suspect a the • • • severe dengue in an area child has fever lasting more than of 2 dengue days plus risk any if of (Hematocrit = 3X following features: Evidence of plasma leakage High or progressively rising haematocrit gm/dl) Pleural effusions or ascites Circulatory compromise or shock Spontaneous bleeding Hb . Grade III : Circulatory failure manifested by a rapid. until the temperature is normal. weak pulse and narrowing of pulse pressure or hypotension. with the presence of cold. clammy skin and restlessness. haemorrhagic fever (DHF) and dengue Grading of dengue haemorrhagic fever DHF of is classifed into IV are considered thrombocytopenia with and II DHF from four grades of severity. Grade I : Fever accompanied by non-specifc constitutional symptoms. clammy extremities. daily daily signs shock. not give or if the child ibuprofen as fever these drugs may Follow up Check the Admit any severe skin the child haematocrit child with bleeding. is Do aspirin aggravate bleeding. persistent vomiting. convulsions or jaundice) or with a rapid or marked rise in haematocrit. Grade IV : Profound shock with undetectable blood pressure or pulse. where grades III and to be DSS. 11. The presence concurrent haemoconcentration differentiates grades I DF. black stools or coffee-ground vomit. 137 . If there is improvement with colloid therapy or blood transfusion. reduce fuid volume form 10 ml to 6 ml and further to 3 ml/ kg/hr accordingly. .• • Altered consciousness .Lethargy or restlessness - level Coma Convulsions Severegastrointestinal involvement Persistent vomiting Increasing abdominal pain with tenderness in the right upper quadrant Jaundice Treat severe dengue Most cases of DHF grade I can be managed on outpatient basis. • Check vital signs. vital signs. Signs in such cases include: • Tachycardia • Increased capillary refll time (>2 seconds) • Cool. fuid therapy can be changed to crystalloid (10 ml/kg/hr) and can be gradually reduced. In case of improvement. Indications for hospitalization Hospitalization for bolus intravenous fuid therapy may be necessary where signifcant dehydration has occurred and rapid volume expansion is needed because of reduced blood volume due to plasma leak. increase I/V therapy to 10 ml/kg over 1 hr. Cases with unstable vital signs and falling hematocrit (suggesting internal bleeding). urine output and hematocrit should be checked. fuid therapy should be changed to colloid (Dextran 40 or plasma) 10 ml/kg for 1 hour. •If there is no improvement with initial fuid therapy.fuid administration can be decreased to 3 ml/kg/hr for 3 hrs. • With further improvement continue I/V therapy 3 ml/kg/hr for 6-12 hrs and then discontinue. mottled or pale skin • Diminished peripheral pulses • Changes in mentalstatus • Oliguria • Sudden rise in haematocrit or continuously elevated haematocrit despite administration of fuids • Narrowing of pulse pressure (<20 mm Hg) • Hypotension (a late fnding representing uncorrected shock) Fluid management cases without shock (pulse pressure >20 mm Hg) • In cases of severe dengue fever without shock. therapy should be initiated with crystalloid fuids such as 5% dextrose in normal saline 6 ml/kg/hr for 3 hrs. If there is improvement. If vital signs are unstable and hematocrit is rising. urine output and hematocrit after 3 hrs. should be given whole blood 10 ml/kg over one hour. • In cases with no improvement with 10 ml/kg/ hr fuid therapy. • of 138 Cases not improving require vasopressor shock. Module I). with colloid therapy therapy (see or blood transfusion management may . Fluid management severe dengue without shock DHF-Grade I or II (Pulse pressure >20 mm Hg) Haemorrhagic (bleeding) tendencies. Haematocrit rise. Vital signs – stable Initiate I/V ml/kg/hr solution for Improvement Therapy 6 Crystalloid 1-2 hrs No Improvement . Thrombocytopenia. Improvement* I/V therapy by crystalloid Successively reduce the from 10 6 to ml/kg/hr. consider adding fow to 3 6. ml/kg for 1 hr. Dopamine (as described in management of shock).Reduce Crystalloid 6-12 I/V 3ml/kg/h duration hrs Increase IV ml/kg/h Crystalloid for hr Improvement Further 10 1 No improvement improvement Haematocrit Reduce I/V to 6 ml/ kg/h crystalloid with further reduction Haematocri t falls rises to 3 Discontinue IV fuids IV ml/kg/hr. Discontinue (Dextran 40) 10 hrs after Blood Colloid transfusion 24-48 10 ml/kg for 1 hr. Discontinue after 24-48 hrs * If no improvement. 139 . 6-12 20 hrs Further Improvement Discontinue therapy Check Hct to Haematocrit Rises intravenous after 24-48 hrs Haematocrit Falls IV 40) Colloid (Dextran or Plasma 10 ml/ kg over 1 hour as intravenous bolus (repeat if necessary) Blood transfusion (10 ml/kg over 1 hour) Improvement* I/V therapy by crystalloid successively reducing the fow from 10 to 6 to 3ml/kg/hr Discontinue after 24-48 hrs * If Dopamine (as described in management of shock). 140 no improvement consider adding 6.Fluid management severe dengue with shock (pulse pressure  20 mm Hg) UNSTABLE VITAL SIGNS Urine output falls Signs of Shock Immediate. rapid volume replacement: Initiate I/V therapy 10-20 ml/kg cystalloid solution over 1 Improvement No hr Improvement I/V therapy by crystalloid successively reducing 10. . 10 to Crystalloid duration from 6. reabsorption of extravasated plasma may lead to drop in hematocrit. In these circumstances continue to monitor frequently and it is likely that the haematocrit will start to fall within the next 24 hrs as the reabsorptive phase of the disease begins. give another bolus of the crystalloid over 1 hr bringing the fuid dose to 20-30 ml/kg. This should not be interpreted as a sign of internal hemorrhage.fuid administration can be gradually reduced as per chart. a rising haematocrit together with unstable vital signs (particularly narrowing of the pulse pressure) indicates the need for a further bolus of fuid. Manage haemorrhagic complications • Mucosal but is platelet bleeding may occur in any patient with dengue usually minor. i. If hematocrit is falling. and this usually improves rapidly during the second week of illness. pulse pressure widens). I/V fuids can be stopped after 36-48 hours. plasma or 5% albumin) should be administered 10 ml/kg rapidly. review vital signs hourly and monitor urine output closely. Internal bleeding for many hours until the frst black this in children with shock who usually patients may not stool is fail to from the with very become passed. For example. colloids (Dextran 40. reduce to 10 ml/kg for one hour and then gradually to 6 ml/kg/hr over the next 6-8 hrs. whole blood 10 ml/kg should be transfused. • If shock persists oxygen should be started and hematocrit should be checked.If the child does not respond (continuing signs of shock). improve severe or apparent Consider clinically . If the child responds (capillary refll and peripheral perfusion start to improve. Give 10-20 ml/kg of an isotonic crystalloid solution such as Ringer’s lactateor 5% dextrose saline over one hour. • In most cases. during later part of the disease. • If major bleeding occurs it is gastrointestinal tract. • Make furtherfuid treatment decisions based on clinicalresponse. It is due mainly to the low count. Similarly. • Electrolyte and/or acid-base disturbances may occur in severe cases and will require appropriate management. • Patients not showing improvement with above fuid therapy may require vasopressors ( see management of shock in module 1). . • If the hematocrit is rising. Changes in the haematocrit can be a useful guide to treatment but must be interpreted together with the clinical response.e. but extra fuid is not needed if the vital signs are stable even if the haematocrit is very high (50–55%). particularly in prolonged shock. Remember that many deaths result from giving too much fuid rather than too little. • With clinicalimprovement.Fluid management patients with shock (Pulse pressure  20 mm Hg) • Treat as an emergency. with fuid treatment, particularly if the haematocrit is stable or falling and the abdomen is distended and tender. • In children with profound thrombocytopenia (<20 000 platelets/mm3), ensure strict bed rest and protection from trauma to reduce the risk of bleeding. Do not give IM injections. • Monitor clinicalcondition, haematocrit and, where possible, platelet count. • Transfusion is very rarely necessary. When indicated it should be given with extreme care because of the problem of fuid overload. If a major bleed is suspected, give 5-10 ml/kg fresh whole blood slowly over 2 to 4 hrs and observe the clinicalresponse. Consider repeating if there is a good clinicalresponse and signifcant bleeding is confrmed. • Platelet concentrates (if available) should only be given if there is severe bleeding. They are of no value for the treatment of thrombocytopenia without bleeding. Provide supportive care • Give Do bleeding. • Do paracetamol for high not give aspirin or not give fever if ibuprofen the as child this is will uncomfortable. aggravate the steroids. 141 • • • Convulsions are dengue. But earlier. • If an unconscious Children with Hypoglycaemia present, give not if the child. shock (blood I/V common in children with severe they occur, manage as described child is unconscious, provide care for or respiratory glucose <54 glucose. distress mg/dl) is should receive unusual but oxygen. if Monitoring • In children with shock, monitor the vital signs hourly (particularly the pulse pressure, if possible) until the patient is stable, and check the haematocrit 3 to 4 times per day. The doctor should review the patient at least four times per day and only prescribe intravenous fuids for a maximum of 6 hrs at a time. • For children without shock, nurses should check the child’s vital signs (temperature, pulse and blood pressure) at least four times per day and the haematocrit once daily, and a doctor should review the patient at least once daily. • Check the platelet count daily, where possible, in the acute phase. • Keep a detailed record of all fuid intake and output. Criteria for discharging inpatients The • • • • following criteria should be DHF/DSS are discharged: Absence of fever for at antipyretics. Return of appetite. Visible clinicalimprovement. Good urine output. • Stable met before patients least 24 recoving hours without haematocrit. • At least 2 days after recovery from shock. • No respiratory distress from pleuraleffusion or • Platelet count of more than 50000/mm3. Refer to specialized care unit: •Patientswithrefractoryshock •Patientswithmajorbleeding the ascites. from use of 142 11.6 Fever lasting longer than 7 days (Table 23) As there are many causes of prolonged fever, it is important to know the most common causes in a given area. Investigations for the most likely cause can then be started and treatment decided. Table 23: Additional differential diagnosis* of fever lasting longer than 7 days DiagnosisIn Favour Absces • s Diagnosis In Favour Fever with no Infective obvious focus endocarditis of infection (deep abscess) • • Enlarged spleen • Tender or fuctuant Weightloss • Anaemia • mass • Heart murmur • Local tenderness Petechiae • or pain • Specifc Splinter signs depend on haemorrhages in site Subphrenic, liver, Psoas, Retroperitoneal, lung, renal, etc nail • beds Microscopic haematuria • Finger clubbing Rheumatic fever• Heart murmur which Tuberculosis may change over time • Arthritis/arthralgia • Cardiac failure • Fast pulse rate • Pericardial frictionrub • Chorea • Recentknown streptococcal infection • • Kala-azar • • • • • Endemic area Childhood • Enlarged spleen and/or Malignancies liver • Anaemia • Weightloss Causes in addition to given in • • • • • Weightloss Anorexia, night sweats Cough Enlarged liver and/or spleen Family history of TB Chest X-ray suggestive of TB Weightloss Anaemia Bleeding manifestations Lymphadenopathy • Enlarged previous boxes 11.7 Typhoid fever Suspect typhoid fever if a child presents with fever, plus any of the following: diarrhoea or constipation, vomiting, abdominal pain, particularly if the fever has persisted for more than seven or more days and malaria has been excluded or the fever has not responded to appropriate antimalarial therapy. On examination key features of typhoid fever are: • Fever with no obvious focus of infection. • No stiff neck or other specifcsigns of meningitis, or a lumbar puncture for meningitis is negative. • Signs confusion of toxemia and convulsions. e.g., lethargy, disorientation/ 143 • Rose spots on the abdominal wall in light-skinned children. Hepatosplenomegaly, tense and distended abdomen. • Typhoid fever can present atypically in young infants as an acute febrile illness with shock and hypothermia. Diagnosis Complete blood counts in most cases with typhoid fever are normal. Leucopenia or pancytopenia is seen in 10-25% cases. Widal test, which detects agglutinating antibodies to O and H antigens of Salmonalla typhi is often the only test available for diagnosis of typhoid fever in resource poor settings. Level of 1 in 160 dilution or more is taken as positive test. Widal test may be negative in cases with fever of less than 5-7 days duration. Blood cultureand sensitivity testing/ IGM Typhidot test should be done whenever possible. Management Since the emergence of multidrug resistant (MDR) typhoid fever, third generation cephalosporines are recommended for treatment of typhoid fever. Cases requiring hospitalization should be treated with ceftriaxone (80mg/kg I/V or IM once daily). In ambulatory patients cefxime (20 mg/kg/day) can be used. In areas where sensitive strains have reemerged, use of chloramphanicol (25 mg/kg/dose, 8 hrly) is recommended. Duration of antibiotic treatment should be for 5 days after the child becomes afebrile or 10-14 days whichever is later. Other drugs used to treat typhoid fever include fuoroquinolones (ciprofoxacin 15-20 mg/kg/day in 2 divided doses, ofoxacin 10-20 mg/kg/day in 2 divided doses) and azithromycin (10-20 mg/kg/day). The cases with typhoid fever should be closely monitored for complications like gastrointestinal hemorrhage, intestinal perforation, hypotension and shock. Antipyretics for fever and maintenance intravenous fuids may be required initially in cases who have poor oral intake. 144 EXERCISE - 9 1. Kareena, a 4-year-old child has been urgently referred to you with classifcation of very severe febrile disease. Not very low weight and anaemia. She is from a high malaria risk area. She is in coma and has no signs of shock. The child is not severely malnourished and has some pallor. Her temperature is 39.2ºC. a. List the emergency signs. What emergency treatment would you give? b) Enlist important c. What is your differential diagnosis? d. What investigations would you like to do? points in Further examination reveals neck. CSF examination is Plasmodium falciparum. e. history and that she normaland physical examination. has no rash and no stiff blood smear shows asexual forms of What is the most likely diagnosis? How would manage the case? 145 . an enlarging liver and rarely pulmonary oedema. Severe anemia in a child is suggested by the presence of severe palmarpallor and may be associated with a fast pulse rate. Hence. There may be signs of heart failure such as gallop rhythm.0 Learning objectives After completion of this section the participant should be able to• Understand approach to a case of anaemia • Understand treatment of nutritional anaemia • Understand indications for blood transfusion Anaemia is very common in children in developing countries. folic acid and vitamin B12. This presentation with symptoms and signs resulting from cardiorespiratory decompensation due to anaemia is uncommon. anaemia/pallor should be looked for in each patient attending the health facility. Iron defciency anaemia (IDA) commonly occurs in later part of infancy and preschool children particularly if they are not receiving adequate complementary feeding. Physical examination of children with IDA is usually unremarkable. . Children having anaemia due to folic acid and/or B12 defciency (megaloblastic anaemia) may have hyperpigmentation of knuckles and occasionally bleeding manifestations due to thrombocytopenia. diffculty in breathing. They do not have signifcant hepatosplenomegaly or lymphadenopathy. Nutritional anaemia results from defciency of iron. 12 MANAGEMENT OF CHILDREN WITH ANAEMIA 12. mild to moderate aemia is a common co-corbidity in children attending health facility for various condition. Clinical approach Nutritional anaemia is the most common cause of anaemia in children. However. or confusion or restlessness.SECTION. 146 . in children less than 5 years Table 24: Findings on anaemia in children History Examination • Duration of symptoms • Severepalmarpallor • Usual diet (before the • Skin bleeds (petechial current illness) and/or purpuric spots) • Family circumstances (to • Lymphadenopathy understand the child’s social • Hepato-Splenomegaly background) • Signs of heart failure • Prolonged fever (gallop rhythm. Iron therapy results in prompt clinical response (return of appetite. Iron continued8-12 level is achieved. Usually leucocyte counts B12 defciency will if have available. basal crepitations) • Lymphnode enlargement • Previous blood transfusions • Similarillness in the family (siblings) Laboratory diagnosis Annemia < in children less 11gm/dl. therapy should be 2-3 can mg/kg/day (dose of take tablets can be weeks after normal given haemoglobin The children on iron therapy should be evaluated for response to treatment. • Worm infestation • Bleeding from any site respiratory distress.1 Give blood transfusion as soon as possible to: • • - All children with Hb <4 gm/dl.Clinical is assessment listed in of anaemia Table 24. Check haemoglobin level after two weeks of therapy. decreased irritability). performed with all Haemoglobin using microcytic-hypochromic folate and/or electronic cell counter anaemia. Treatment IDA should be elemental treated using oral iron). These cases may have associated leucopenia and/or thrombocytopenia. Children and platelet macrocytic anemia. Complete than 5 years in defnedas blood counts and examination of blood smear should in should be examined for be cyst and occult blood. Such cases should be referred for specialised investigation as in these cases other causes resulting in alterations in blood counts (bi/pancytopenia) and macrocytosis need to be excluded. Stool examination for ova. Children should be evaluated for compliance to treatment and adequacy of dose and presence of infections not responding to treatment such as UTI the following: tuberculosis. Children with anemic children if peripheral possible. Older children iron who IFA tablets. Blood flms parasites particularly in high malaria risk areas. Children with Hb 4-6 gm/dl with any Dehydration Shock Impaired consciousness Heart failure Fast breathing Very high parasitaemia (>10%of RBC) of and . 12. raised JVP. Blood counts should be done malaria IDA will have counts are normal. 147 . if excluded or not strongly suspected. 12. lymphadenopathy. similar history in Cases of anaemia with manifestations. responding to adequate dose of iron/folate .The details of blood transfusion is given in Annexure 10. the signifcant • family (siblings). bleeding abnormal/immature cells or marked or pancytopenia on smear examination. Cases of anaemia with leucocytosis or bicytopenia Children who are not given for 2 weeks.2 Refer for investigations and further management: • • • • Cases of malaria anaemia has been Children with and Hepato-splenomegaly/Splenomegaly. 148 . This section for the management of 13. • Provide general treatment for malnutrition. . Reference values for weight-for-height or length are given in Annexure 11. • Perform initial assessment of the severely malnourished child. • Understand organization of care. • Treat associated conditions. 13 CASE MANAGEMENT OF CHILDREN WITH SEVERE ACUTE MALNUTRITION (SAM) Malnutrition remains one of the most and mortality amongchildren. • Understand discharge and follow-up guidelines of the severely malnourished child. specifcguidelines severely malnourished children.0 Learning objectives After completion of this section the participant should be able to: • Recognize criteria for hospital admission of malnourished children. z score of median of WHO child If weight-for-height or weight-for-length cannot be measured. The severely malnourished children can standardized and easily implementable provides simple. use the clinical signs for visible severe wasting (see Figure 30). 13.SECTION.1 Criteria for hospital admission • • Weightfor height/length <-3 growthstandards or Bipedal edema. common causesof morbidity high case fatality rates among be reduced by using protocols. 149 . 30: Child with Marasmus (Baggy Pants appearance). 150 . 31: Child with Kwashiorkor. Fig.Fig. 13. Examination .2 Assessment of severely malnourished child A good history and physical examination is required for deciding the treatment but always start the emergency treatment frst. The details of history and examination can be recorded History later. • • Recent intake of food and fuids Usual diet (before the current illness) • Breastfeeding • Duration and frequency of diarrhoea and vomiting • Type of diarrhoea (watery/bloody) • Loss of appetite • Family circumstances (to understand the child’s social background) • Chronic cough • Contact with tuberculosis • Recent contact with measles • Known or suspected HIV infection. groin. thighs. genitalia. • Immunizations Note: Children with photophobic and vitamin will keep A their • Anthropometryweight.0° F)· • Mouth ulcers • Skin changes of kwashiorkor: . Bitot’s spots Corneal ulceration Keratomalacia· • Localizing signs of infection.Hypo or hyperpigmentation Desquamation Ulceration (spreading over limbs.0° C or <95. slow capillary refll. skin infection or pneumonia· • Fever (temperature  37. including ear and throat infections.5° F) or hypothermia (axillary temperature <35.dry conjunctiva or cornea. Fig.mid arm circumference • Oedema • Pulse. and behind the ears) defciency are likely to be eyes closed.It is important to examine the eyes very gently to prevent corneal rupture.5° C or  99. respiratory rate • Signs of dehydration • Shock (cold hands. weak and rapid pulse) • Severepalmarpallor • Eye signs of vitamin A defciency: . 32 : Vitamin A deciency signs 151 . height/length. Severe anemia. Facilities and preparation suffcient staff of appropriate should be feeds. with no draughts). Prepare for No iron growth follow-up The focus of initial management is to prevent death while stabilizing the child . will need urgent treatment. if present.Total and differential leukocyte count. 13. Initiate feeding 8. Sensory stimulation 10. • Serum electrolytes (sodium. after which the child should be dried immediately.3 Organization of care On admission. Hypothermia 3. and constantly monitored. Accurate weighing machines are needed. Catch-up 9.Laboratory Tests • Haemoglobin or packed cell volume in children palmarpallor. Stabilization Days 1-2 Days an initial stabilization Rehabilitation 3-7 Weeks 2-6 Hypoglycaemia 2. potassium) • Screening for infections: . blood culture (If possible) Urine routine examination Urine culture Chest x-ray with severe 13. and available to to carry out ensure correct regular feeding during the day and night. and records should be kept of the feeds given and the child’s weight so that progress can be monitored. • Blood sugar. Electrolytes 5. the child with severe malnutrition should be separated from infectious children and kept in a warm area (25–30°C. There are 10 phase and 1. Infection Micronutrients 7. essential steps in two phases: a longer rehabilitation phase. Dehydration 4. Washing should be kept to a minimum. 6.4 Providing general treatment for malnutrition The triage process and assessment of children with severe malnutrition and management of shock has already been discussed. 152 . 13. or convulsing.Only give I/V fuids to children with signs of shock. Giving iron early in treatment has been associated with free radical generation and may interfere with the body’s immune mechanisms against proliferating bacteria. give the feed of starter formula (75 cals/100ml). or convulsing. I/V fuids can easily cause fuid overload and heart failure. Keep the baby warm and check temperature. with glucometer). The oedema will go away with proper feeding.1 Hypoglycaemia All severely malnourished children hypoglycaemia (blood glucose important cause of death. are <54 at risk of mg/dl) which is developing an If there is any suspicion of hypoglycaemia and blood glucose results can be obtained quickly (e. • Give 2-hourly feeds. Treat hypoglycaemia • • • • • If the child is lethargic. unconscious. followed by the frst feed as soon possible. • Do not give iron during the initial feeding phase. If is deterioration glucose was prick blood) and the axiliary in the level low. if it is available and then continue with 2 hourly feeds.Important things not to do and why? • Do not give I/V uids routinely. they are unable to tolerate the usual amount of dietary protein. Almost all severely malnourished children have infections.4. • Do not give high protein formula. Because of these problems. If not lethargic. If the frst feed is not quickly available give of 10% glucose or sugar solution (4 rounded of sugar in 200 ml or one cup of water) orally nasogastric tube. Add iron only after the child has been on catch-up formula for 2 days (usually during week 2). repeat the measurement (using fnger estimate blood sugar after 30 temperature falls <35°C or if there of consciousness anytime. Give appropriate and start feeding as soon as possible. assume that all children with severe malnutrition have hypoglycaemia. Give appropriate antibiotics. measure immediately. If IV dose given immediately.g. day and night. unconscious. • Do not give diuretics to treat oedema. If the blood glucose cannot be measured. impaired liver and intestinal function. repeat . 10% glucose 5 ml/kg followed by 50 ml of glucose or sucrose by NG tube. at least frst day. give the NG dose frst. Giving diuretics will worsen child’s electrolyte imbalance and may cause death. give IV 10% cannot be antibiotics frst quickly 50 ml teaspoon or by as for the Monitoring If the initial blood prick or heel minutes. Continue starting feeding immediately or. repeat the 10% glucose or rehydrate frst.2 Manage hypothermia What is hypothermia? If the axillary register on temperature is <35ºC (<95ºF) a normalthermometer. night. throughout the if necessary. assume or does not hypothermia. Prevent hypoglycaemia/Begin Starter Formula Feed 2 hrly.4. 13. 153 . again <54 mg/dl.the blood sugar measurement • If glucose is sugar solution. making it diffcult or impossible to detect dehydration reliably or determine its severity.5ºF) to take the rectal confrm the hypothermia. Cover with a warmed blanket and place a heater (not pointing directly at the child) or lamp nearby. Avoid exposing the child medical examinations). Feed the child 2-hourly.4. Moreover. A severely malnourished child is usually apathetic when left alone and irritable when handled. Oedema if present. rehydrate frst). Alwaysgive feeds through warm.5ºC or <95. In severely malnourished child.Wherea low-reading thermometer is available. after bathing. Many of the signs that are normally used to assess dehydration are unreliable in a child with severe malnutrition. many signs of dehydration are also seen in septic shock. Treat all hypothermic children for hypoglycaemia and for infection as well. child and the bed dry. Treat hypothermia • and • Make sure the child is clothed (including the head). .5°C. or put the child on the mother’s bare chest or abdomen (skin-to-skin) cover them with a warmed blanket and/or warm clothing. or during the mother for warmth in the starting immediately (see the night. Prevent hypothermia • • • • • • Place the bed in a keep the child covered. Let the child sleep with night.3 Dehydration Recognize dehydration Dehydration tends to be over diagnosed and its severity is overestimated in severely malnourished children. As a result dehydration tends to be overdiagnosed and its severity overestimated. Monitoring • Take the 36. • Check for child’s Take the the temperature 2-hrly until it it half-hourly if a child is covered at head covered. preferably hypoglycemiawhenever rises to heater is all times. It fattensvery slowly when pinched. with a hypothermia is more than being used. Change wet nappies. draught-free part of the ward and to keep the clothes and bedding to cold (e. • Feed the child immediately (if necessary. the loss of supporting tissue and absence of subcutaneous fat make the skin thin and loose. Give appropriate antibiotics. initial refeeding). 13. Ensure that night. Do not use hot water bottles. temperature (<35. Keep to reduce heat loss. or may not fatten at all.g. • especially at warm bonnet found. may mask diminished elasticity of the skin. If the child has watery diarrhoea or vomiting. rehydrate a dehydrated child with severe malnutrition orally or through a nasogastric tube. assume dehydration and give ORS (Also ask about blood in the stool. Remember a child with severe acute malnutrition may be dehydrated in the presence of oedema. as this will affect choice of antibiotics).Ask the mother if the child has had watery diarrhoea or vomiting. 154 . Treatment Whenever possible. for the frst 2 hrs and then hourly. . give 50–100 ml after each watery stool. Those with septic amount of fuid given must be avoided. omit received the frst IV fuids for 2-hour treatment shock and and start with amount for the next period of up to 10 hours. Urine output – Frequency of a stool or Ask: Has stools and vomited the child vomiting since last passedurine since last – Ask: Has the checked? hydration 15/min). In risk of addition hypokalemia (syrup supplements to prevent of syrup provides 20 the hypokalemia due to ORS start potassium chloride -15 meq of potassium)-refer to section 13. As a Shock in severely malnourished children Shock from dehydration and malnourished children. REMEMBER: Use IV rehydration only if the child has signs of shock and is lethargic or has lost consciousness Calculate amount of ORS to give How often to give ORS Amount to give Every 30 minutes for the frst 5 ml/kg 2 hours body Alternate hours for up to 10 5-10 ml/kg* hours The * amount offered in this range should be based on the child’s willingness to drink and the amount of ongoing losses in the stool. Children with dehydration will respond to shock and dehydration will not respond. Give ORS between feeds to replace stool guide. the Monitor the child who is taking ORS Monitor every 30 min Signs to check: • • • • Respiratory rate. Overhydration no the severely on clinical signs fuids. • - Measures to prevent dehydration from continuing are similar to those for well-nourished children.4. sepsis are They are likely to diffcult to coexistin I/V differentiate alone. watery diarrhoea losses. Pulse rate.4. The is determined by child’s response.A severe acute malnourished child to reduced muscle potassium ml is at mass. Starter formula is given in alternate hours during this period until the child is rehydrated. (increasing stop ORS checked? child had Signs of overhydration: If you fnd 5/min and signs of pulse rate over by respiratory rate by immediately and reassess after 1 hr. • If is the child switching has to already ORS. If the child is breastfed. continue breastfeeding. 155 . Ringer’s lactatewith 5% is not commercially available. 1ml of potassium. either orally or by nasogastric tube. If there is end of diagnosis at the ORS at the treat frst of 1. faster capillary refll) at the the frst hour of IV fuid infusion. • Administer IV antibiotics • Monitor pulse and respiratory rates every 5-10 min. consider of severe dehydration with shock. consider septic shock and accordingly. Since. 40 mEq/litre. intraosseous dextrose saline with 15ml/kg (pulse time. use half normal(N/2) 5% dextrose as rehydrating fuid.5ml potassium you add You should over hydration rate (> 5 per minute). pulse volume. overhydration . Fast Pulse 2 12 months months up up 160 beats or more per minute beats or more per minute Intravenous rehydration The only indication for I/V infusion in a severely malnourished child is circulatory collapse caused by severe dehydration or septic shock. • If there is no improvement or worsening after hour of the fuid bolus. per minute) and increasing increasing edemaand periorbital which may be dangerous and may lead to heart alone fuids at the rate passes urine. route should be used. Caution: • Do not use 5% dextrose • Add potassium to the IV per 100ml after the patient chloride provides 2 mmol of 1ml to 100 ml it will not increase to more than • Monitor frequently and look and cardiac decompensation. improvement (pulse slows. • Give oxygen • Give rehydrating fuid at slower infusion rates of over the frst hour with continuous monitoring rate.Give I/V uids to severely malnourished child if: - • Child • Has Slow Weak and fast is lethargic cold hands plus capillary refll pulse or unconscious and (longer than 3 seconds) Slow Capillary Rell You have already read how to check for to to 12 5 months: years: 140 capillary refll. respiratory rate. Repeat rehydrating fuid same rate over the next hour and then switch to 5-10ml/kg/hour. for features of Increasing respiratory pulse rate (> 15 puffness indicates failure. Thus if give 20 mEq/litre. capillary refll urine output). Fluid management in shock with severe dehydration In case of inability to secure intravenous access. 156 . Estimate the weight not known Oxygen sure child is warm weight if child cannot be weighed Insert an IV line and draw blood for emergency laboratory investigations Give IV Glucose Give IV fuid 15 either Half-normal saline with lactate Measure the every 5-10 10 ml/kg/h up to 1 hour of glucose or Ringer’s rate the start at and If the child deteriorates during If the child fails to improve the IV rehydration after the frst 15 (RR increases ml/kg IV by 5 /min or PR IV 15 Assume The child has septic shock or with ORS. then • Switch to oral nasogastric rehydration ml/kg over with • • Give (4 Start maintenance IV fuid ml/kg/h) antibiotic treatment • Start dopamine re-feeding possible as • soon Initiate as . 10 hours.Chart 5: Management of shock in a child with severe acute malnutrition Give this treatment only if the child has signs of shock AND is lethargic or has lost consciousness • Weigh or • Give • Make the child. • Initiatere-feeding starter formula 5% pulse and breathing min minutes Signs of improvement (PR and RR fall) • Repeatsame fuid ml/kg over 1 hour more. 157 . If a specifcinfection is identifed (such as Shigella). Thereafter.Potassium can be given as syrup potassium chloride. Hypoglycaemia and hypothermia are often signs of severe infection.6 meq/kg daily) orally.3mL/kg up to a maximum of 2 ml).4.5 Infection Presume and treat infection Assume all children with severe malnutrition admitted in a hospital have an infection and give broad spectrum antibiotics. • Prepare food without adding salt to avoid sodium overload. If oral commercial preparation is not available you can give injection magnesium sulphate (50% which has 2 meq/ml) orally as magnesium supplements mixed with feeds for 2 weeks. Select antibiotics and prescribe regimen Select antibiotics as shown in the chart below. 13. give 50% magnesium sulphate IM once (0. Status Antibiotics .4–0.4 Electrolyte imbalance • • Give supplemental potassium at 3-4 meq/kg/day for at least 2 weeks. the most common preparation available has 20 meq/15 ml. give extra magnesium (0.13. give specifcappropriate antibiotics according to condition identifed. On day 1.4. Investigate and follow HIV guidelines. oral thrush. Start ATT if tuberculosis is diagnosed or strongly suspected (Mx and Xray chest). Gentamicin 7. Amikacin 15 Meningitis • IV Cefotaxime 50 mg/kg/dose 6 or Inj. • Ceftriaxone 100 mg/kg once a day Duration of antibiotic therapy depends on the diagnosis i. Cerftriaxone 50 mg/kg/dose improvement in initial hours hrly plus Inj. Give 10 ml/kg slowly over 4-6 hours and give Inj.: Suspicion of clinical sepsis: at least 7 days Culture positive sepsis: 10-14 days Meningitis: at least 14-21 days Deep seated infections like arthritis and osteomyelitis:at 6 is hrly 12 hrly 12 for 5 days least 4 weeks Treat Associated Conditions • • • • • 158 Give antimalarials if blood smear positive for malaria parasites. Frusemide 1 mg/kg at the start of the transfusion. Severeanaemia: Give whole blood or packed cell transfusion if Hb is < 4g/dl or Hb is 4-6 g/dl and child has respiratory distress. Ceftriaxone 50 mg/kg/dose hrly a Dysentery • Inj. parotid swelling or generalized lymphadenopathys . Ampicillin 50 mg/kg/dose 6 and Inj. pneumonia. in addition to vitamin A doses instill ciprofoxacin eye . Do not repeat blood transfusion within 4 days.All admitted cases Inj. If eye problems (keratomalacia) due to vitamin A defciency.e.5 mg/kg once day for 7 days • Add Inj. Suspect HIV if he has also other problems like persistent diarrhoea. Cloxacillin 50 mg/kg/dose hrly if staphylococcal infection suspected • Revise therapy based on sensitivity For septic shock or worsening/ • IV Cefotaxime 50 mg/kg/dose 6 no or Inj. poor activity . In the rehabilitation the poorly formed loose stools are not a cause for child’s weight gain is satisfactory.000IU lakh IU. If the child has persistentdiarrhoea. screen for non-intestinal and treat appropriately. • 6-12 months : 1 • Older children: 2 lakh IU. provided the feeding during give infections feeds with and subsequently change to lactose free options if diarrhoea persists. Response to treatment for infection •Goodresponse . Continue breast and try to low lactose initially 5 gm/kg/day concern.1 and 14 of vitamin A should be daily given if (if clinicalsigns should receive (intramuscular) 1 . of age injectable 0. Other micronutrients for 2 at least weeks: : 50. Also cover the eyes or soak eye with drops 3 pad and times a bandage. • Children < 8 kg irrespective lakh IU orally.4.6 Micronutrients Give oral vitamin A in a single dose. Vitamin A orally in single dose as given below: • < 6 months of defciency are present). • Give same dose there is on Day clinicalevidence defciency.Lethargic. (Annexure 6). • Give half of the above dose if vitamin A needs to be given. it should subside the frst week. evidence of infections Danger signs present If poor response • Ensure child has received appropriate and adequate antibiotics • Check whether vitamin and mineral supplements are given correctly (see below) • Reassess for possible sites of infection • Suspect resistant infections (malaria.Absence of complications like hypoglycaemia or hypothermia •Poorresponse .Poor appetite or no weight gain Clinical/ lab.Alert and active Improved activity and weight gain > . • day for 7- Skin lesions: Bathe 10 min in 1% potassium or nystatin cream if available to cream) to the raw areas.Absence of clinical and lab. the affected areas for permanganate solution and apply gentian skin and any barrier cream sores violet (zinc • Persistent diarrhoea: Diarrhoea is common in severe malnutrition but with cautious refeeding.drops 2-3 hourly and atropine 10 days. phase. evidence of infections . tuberculosis) or HIV • Look for lack of stimulation and other social problems 13. • Multivitamin C.3 mg/kg/day use commercial 1. (if separate preparation not preparation containing copper). diarrhoea add 3 159 . • When commences there mg weight gain of iron/kg/day. and is no mg/day. then 1 A. D. B- 5mg on day 2mg/kg/day. 0. complex): • Folic acid: • Zinc : • Copper: available supplement E and 2 (should B12 & contain not just vitamin vitamin Recommended Daily Allowance. or mouth. Use an of the feed NG the tube child if does is take feeds. low osmolarity child of has proteins. 80-100Kcal/kg/day and 1-1. or continue 2-hrly feeds. 2. Feed the child Starter formula orally. give the feed frst. till child continue takes orally 75% breastfeeding but rehydration. Encourage feed a very so nursing staff should do this frst and help feeding later when child becomes stronger. signifcant diarrhoea. with It a cup takes skill and to spoon. or by NG tube if necessary: Oral feeding It is best the child weak child. • Offer 130 ml/kg/day of liquids (100 ml/kg/day if severe oedema).4. to to feed fnish the the child feed. Ensure night feeds. of all feeds. Record intake and output on a 24-Hour food intake chart. If there is vomiting. • Feed the child if alert and drinking even during • Give frequent and small nutrient rich feeds of low lactose. Remove the NG tube when the child takes: • • 75% Two of the consecutive day’s amount feeds fully by orally. Recommended schedule with gradual increase in feed volume is as follows Days Freq Vol/kg/feed Vol/kg/d ay . diarrhoea than before. and most feeds are feeds poor apetite. They may die if given too the body’s children needs without provides overwhelming 75 the calories /100 ml. If there is little or no vomiting. occasional diarrhoea. change feeds. or high amounts of fat. Criteria for increasing volume/decreasing frequency of 1. is 2-7 days tolerate usual and • Starter Formula Starterformula started until the amounts of is as to soon be as child is stabilized. 3. to NG use tube a if child not for 2-3 consecutive with demand between starter task mother may on Nasogastric feeding It may very 75% be necessary weak. After a day on 3-hrly feeds: If there vomiting. change to 4-hrly. is to less 3-hrly is no consumed. Starter formula is specially made to meet child’s of treatmentwhich systems in the initial stage ml and gm of protein/100 0. Severely malnourished sodium this proteins and used during initial management.and most feeds are consumed.13.9 cannot stage.5 g/kg/day Use • • nasogastric feeding If child breastfed.7 Initiate feeding Essential features of initial feeding are: • Start feeding as early as possible. Encourage breastfeeding formula feeds.It possible and continued for at much protein or sodium. 6 160 1-2 2 hourly 11 ml 130 ml 3-5 onwards 3 hourly 4 16 ml 22 130 ml 130 hourly ml ml . 6 60 90 125 5.6 40 60 80 3.0 35 50 65 3.6 30 45 55 2.2 25 35 50 2.0 90 130 175 8.2 90 135 180 8.4 60 90 120 5.0 100 145 200 9.0 75 115 155 7.8 40 60 85 4.4 35 55 75 3.4 50 70 95 4.2 70 100 135 6.0 20 30 45 2.0 55 80 110 5.0 65 100 130 6.8 85 130 170 8.6 105 155 210 9.4 25 40 55 2.6 50 75 100 4.2 45 70 90 4.8 65 95 130 6.2 80 120 160 7.0 110 110 160 160 215 220 161 .6 85 125 165 7.8 10.8 30 45 60 3.8 55 80 105 5.2 55 85 115 5.6 95 140 190 8.4 105 155 205 9.6 75 110 145 6.8 75 110 150 7.4 90 140 185 8.4 80 120 160 7.Table 25: Volumes of starter formula per feed (approx 130 ml/kg/day) 4Childs weight 2-hourly 3-hourly hourly (Kg) (ml/feed) (ml/feed) (ml/fee 2.2 100 150 200 9.2 35 55 70 3.4 70 105 140 6.0 45 65 90 4.8 95 145 195 9. cooled boiled water to the Mix the measuring Transfer to to 100 ml mark. Prepared diet may be kept at hrs or 24 hrs wherever 1 litre diet could be of each constituent 100 there is prepared by measuring for and preparation 100 ml 6 room temperature for a facility refrigeration.5 6 (Approximate measure of one level (3/4) (2) teaspoon) Vegetable oil (g) 2 2. The above charts give the composition for diet.2 1. water requirement • Add stir monitoring left over charts) Demonstration on lling of 24-hour food intake chart is .0 whole dried milk How to prepare the feeds • • Wash hands before measuring Mix sugar and oil. cooled time.9 1. rice jug. milk Slowly add or and the cooking pot min. Add boiled. Boil gently for 4 cooled. Cooking can be you use puffed rice powder or commercial pre-cooked rice as cereal four. mix milk and sugar in a jug. do need sugar. four.1 1.2 1. in a water to 100 ml. Some a jug will evaporate.2 with 3.5 3 (Approximate measure of one level (1/2) (1/2+) (3/4) teaspoon) Water: make up to (ml) 100 100 100 Energy(kcal) 75 Protein (g) Lactose (g) *Can replace fresh milk 30 ml 75 0. Whisk vigorously so that oil does not separate out. oil cooking. by multiplying for osmolarity) diarrhoea.5 gm 75 1. If using milk powder. boiled paste. ingredients add the stirringall fresh the milk.Table 26: Initial diets recommended in severe malnutrition: Starter formula Diets contents (per 100ml) Starter formulaStarter formula Starter (Cereal formula based)Ex: (Cereal 1 Fresh cow’s milk or equivalent 30 30 25 (ml)* (1/3) (1/3) (1/4) (Approximate measure of one cup) Sugar (g) 9 6 3 (Approximatemeasure of one level teaspoon) (1 + 1/2) (1) (1/2) Cereal four:Powdered puffed rice (g) 2. then add oil and • make a Milk milk cereal diets powder. diet Monitoring Appendix offered consistency avoided if the 10. up mixture vigorously. so transfer the mixture to and add enough water to make ml. then water up to 100 ml. The initial cereal based low lactose (low recommended for those with persistent Monitor and record (see • Amounts of feed • Stool frequency and • Vomiting • Daily body weight whisk stirring continuously. 162 . . 163 . Give a milk-based formula. Catch up formula Catch up formula is used to rebuildwasted tissues. successive feed feeds. more calories and protein. If the child is feeds. feeds of starter formula) Begin giving catch up formula slowly and gradually Make a gradual transition from starter to catch-up formula. Continue by 10 increasing the amount until some feed remains uneaten. Table 27: Catch-up formulas Diets Contents(per Lactose (g) 100ml) Fresh milk or equivalent (ml) (approximate measure of one katori) Sugar (g) (Approximatemeasure of teaspoon) Cereal four: one Puffed level rice (g) (Approximatemeasure of one level teaspoon) Vegetable oil (g) (Approximatemeasure of teaspoon) Water to make (ml) Energy (kcal) Protein (g) one C a t c h u p level f o r m u . so give catch up formula as indicated. • Replace the starter formula with an equal amount catch-up formula for 2 days. After a gradual transition. breast milk continue does not to have breastfeed suffcient between energy and protein to support rapid catch-up growth. such as catch-upformula which contains 100 kcal/100 ml • 2.13.4. However. unlimited amounts • 150–220 kcal/kg/day • 4–6 g of protein/kg/day.9 g of protein per 100 Then ml on as the long 3rd as Increase each is fnishing day: child It contains of and ml.8 Catch-up Recognize growth readiness for transition Signs that a child has reached this phase are: • Return of appetite (easily fnishes • Most / all of the edema has 4-hourly gone. breastfed. give: • Frequent feeds. The point when some of the feed remains unconsumed is likely to occur when intakes reach about 200 ml/kg/day. 9 3.laCatch-up formula based)Ex: 95 75 (3/4+) (1/2) 5 2.5 100 (cereal 1 (1) (1/2-) 7- 100 (2) 2 2. 164 101 2.9 2 (1/2) (1/2) 100 The catch-up cereal based low lactose (lower osmolarity) diets are recommended for those with persistent diarrhoea.8 3 . 5 0 .0 .5 .0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Day 165 .Blank Weight Chart Name __________________________ Weighton admission____________ Age Weighton discharge____________ ____________________________ .5 .0 . (eg. comforting. environment.4.9 Sensory stimulation During rehabilitation provide: • Tender loving care. body successive determine: weight days If feeding.DEMONSTRATION ON FILLING WEIGHT CHART & CALCULATING DAILY WEIGHT GAIN 13. for 15-30 min a soon as child is much as possible day. . Failure to respond to treatment Table 28: Criteria for failure to respond to treatment Criteria after admission Primary failure • Failure to regain appetite Day 4• loose oedema • Time Failure to start Day present 4 to Oedema still Day 10 • gm/kg of Failure to gain body weight per at day least Failure to gain 5 gm/kg of per day during rehabilitation for the weight gain Day 5 10 Secondary failure • at is least <5 3 g/kg/day. • A cheerful stimulating • Structured play therapy • Physical activity as • Maternal involvement as play). well. e. hygienic storage. what was offered minus what was left over) correctly recorded? Is the quantity of feed recalculated as the child gains weight? Is the child vomiting or ruminating? • Feeding technique: is the child fed frequent feeds. measurement of ingredients. • Repeaturine microscopy for white blood cells. tuberculosis and giardiasis. otitis media. The following are easily overlooked: urinary tract infections. Inadequate feeding Check • • That night feeds are given. a Whether children this major this as occurred review of occurred if they in case in were all cases being treated (if management is required). That target energyand protein intakes are achieved. unlimited amounts? • Quality of care: are staff motivated/gentle/loving/patient? • All aspects of feed preparation: scales. • specifccases (reassess these new admissions). mixing. • Whether complementary foods given to the child are energydense. • Examine the stool. • If possible. taste. adequate stirring.• Whether so. • Vitamins and mineral supplements are given appropriately Look for untreated infection If feeding is adequate and there is no malabsorption. In such a case: • Re-examine carefully. take a chest X-ray. 166 . Is the actual intake (i. suspect a hidden infection. 13.4. with with the child affection. children reach the target weight Before discharge. seeking. particularly for: Inadequate feeding Untreated infection HIV infection Psychological problems Child is considered to weight for height -1 z <5g/kg/d. > treatment If moderate weight gain i.e.10 Discharge and prepare for follow-up Table 29: Criteria for discharge from hospital care Criteria Child•Weightfor • food • height reached Eating adequate that mother -1SD of median of WHO amount of nutritious can prepare at home Consistent gain • All treated • All or are weight vitamin and infections and being treated mineral defciencies other conditions like anemia. The With high energy feeding most for discharge after 2-4 weeks. standards been treated malaria. spend time playing behaviour such self-stimulation as stereotyped movements through regurgitation). tuberculosis Weigh the child discharge Full immunization programme started Able to take care of the child Able to prepare appropriate foods and feed the child Has been trained to give structured play therapy and sensory stimulation Knows how to give home treatment for common problems and recognizes danger signs warranting daily and plot it on a graph. intake targets are being met • 10 g/kg/d. can love and attention. Motheror caretaker • • • • • usual weight gain severely malnourished is about 10-15 gm/kg/day. and (rocking).continue 5-10 or g/kg/day.e. Encourage attention child.e. Treat by who ruminates.e. reaches WHO child a growth standards. Monitoring progress during treatment • If good weight gain i. The target weight for is equivalent to -1SD of the median WHO reference values for weight-for-height. ensure that the mother or caretaker understands the importance of continued . giving special the child the mother to with the same the frmness. For assist.Psychological problems Check for abnormal rumination (i. have have been diarrhoea. make a full have recovered when he score of median of assessment. check whether if infection has been overlooked • • If poor weight gain i. Every attempt child recovery and to avoid relapse and regularly at 1. 2. till should times Follow- and 167 . 4 weeks. Appropriate mixed diets are same as those healthy child given at least 5 a day providing 100-120 be made to manage the death after discharge. Continue breast feeding. then monthly for subsequently every 6-months for 2 years.correct feeding for her recommended for up a child and is able to prepare nutritious complementary foods. 6 months Kcal/kg/day. a early discharge may be planned. plan either through specialclinic in for the the OPD Kcal/kg/day and oedema· gm/kg/day for 3 age follow-up until or nutrition recovery rehabilitation centre or local health worker who will take responsibility for continuing supervision. child should be referred back. Table 30: Criteria for early discharge Criteria Child•Has a good apetite. and if protein 4 gm/kg/day) to take. weight on discharge. eating atleast 120-130 receiving adequate micronutrients· • Has lost • Consistent weight gain (at least 5 consecutive days)· • Completed antibiotic treatment· • Completed immunization appropriate for Motheror • Trained on caretaker appropriate feeding· • Has fnancial resources to feed If child is discharged early. In there is failure to weight loss general between any two . treatments to be continued. Write a detailed discharge note mentioning inpatient treatment given. parents will insist for early discharge or the hospital does not have resources to look after all the malnourished children till full recovery.13. feeding recommendations (150 and the child should be weighed gain weight over a Kcal/kg/day action health worker is expected weekly and 2-week period or measurements.5 Discharge before full recovery In some cases. 168 . b) Does c. 10 months old female child weighing 4. her extremities are 5 seconds.10 1. Rekha is cm.0 kg has been referred urgently & inability to drink or problem. pallor. She lethargy breathing time is diarrhoea. Reena. she need hospitalization? 1 year old. a. and length is hospital has no capillary She has she has 66 for refll no some .EXERCISE.0 kg is brought with loose stools and vomiting for 2 days. Pulses are fast her axillary temperature is List the emergency signs. Her length is 68 cm. cold and 36ºC her the She & weak. How would you manage her dehydration? 2. She is irritable. weighs5. The child has no breathing problem or signs of shock. eyes are sunken and skin pinch goes back slowly. and to feed. a. List the emergency signs. 169 . He some pallor. List the emergency and priority signs. Annexure 11). visible severe wasting a. Write the emergency treatment for this child? Rahul is 11 severe malnutrition and diarrhoea or fever. He has no and has has been referred cough. What investigations would you like to do? is 66 cm. b) On assessment blood sugar is Rahul has no obvious signs of infection 30 mg/dl. Write the treatment plan? c) The length of length from the the child Table ( d.8 old He kg infant. Determine the and weight-for- for and . 3. When will you start feeding this child? e. weighs4. months Anaemia.b. 170 . The nurse reports that when offered. Write your plan of action? . he consumed about 90-100ml. He is with a formula nurse can frst 48 not breastfed feeding bottle milk in the give 2 hourly hours.f) g. He has taken the nasogastric tube out. The feeding plan for After 6 days you observe that child is more active and demanding feeds. is dal he Write being water. took the given dilutedcow’s milk When offered starter only 2-3 spoonful. and and ward feeds. 171 . respiratory odema signs is of kg.5 73 cm and has no visible wasting and no has some pallor. He able to feed.Case Study Anshu 1 year cough and old boy has diffcultbreathing been for brought to 3 days. Write the emergency management plan. he days back a. c. Mother gives history child has measles 8 passing blood in for 2 days. List the emergency signs from the above case description? b. However. length feet. He weighs 7. irritable but 52 per stools the is hospital restless cyanosis. no dehydration and has warm extremities. . What history would you take? What would you like to examine in the child? On examination you 2 superfcial d. He has no minute with severe lower chest indrawing. What is the probable diagnosis in this case? found that child mouth ulcers and rate with and is and has no eye complications but has chest auscultation reveals bilateral crepitations. 172 . What investigations would you like to perform? f.e. Write the treatment for the child? g. How would you monitor the child in the hospital? h. What complications might occur? 173 . What is his weight for height Z Soni is a 1 year old Her weight is 5. 67 cm. weight is 6. 2 year old Kg 75 cm. to length is Kg Kg height is and length is score? 4. (The participants should refer the Training Module depicting scores 1. Kg His .8 82 cm.Drill 1 Calculate weight-for-height for the following Annexure 11 of reference charts) (or weightforlength) Z cases. Vikas is a His weight for height Z score? 3 year old His weight is 9.9 her weight for height Z 4 year old boy. weight is 14 and His Kg height is Her 13 boy. What is Reena is and a length is score? 2. a weight is 7.3 weight for height Z score? 6. and a the weight is score? Kg Rahul is girl. What is her weight for height Z 6 month old boy. What 5. 95 cm. Arvind is boy. What is his 3.1 and length is 72 cm. Kishan is and girl. What is his a 3 year old 95 cm. is his month old cm. 174 weight for height Z score? 7. Divya is girl. Her weight is 6.7 and her weight for height Z What is Kg score? a length is 8 68 . getting • Inability to swallow • High fever Croup • Barking cough • Hoarsevoice • Associated with upper respiratory tract infection Diphtheria • Bull neck appearance of neck due to enlarged lymph nodes • Red throat • Grey pharyngeal membrane • No DTP vaccination Congenital heart disease• Diffculty in feeding • Central cyanosis • Heart murmur • worse Enlarged liver Pneumothorax • Sudden onset • on percussion • Shift Hyper-resonance in .ANNEXURE: 6 Diagnostic considerations of children presenting with Emergency signs (differential diagnosis) Table 31: Differential diagnosis of the child presenting with an airway or severe breathing problem Diagnosis or underlying causeIn favour Pneumonia • Cough with fast breathing and fever • Lower chest wall indrawing • Crepitations on Asthma • History of recurrent wheezing • Prolonged expiration • Wheezing or reduced air entry • Response to Foreign body • History of sudden aspiration choking • Sudden onset of stridor or respiratory Retropharyngeal abscess• Slow development over days. Shift in mediastinum 175 . Child presenting with shock Table 32 : Differential diagnosis of the child presenting with shock Diagnosis or underlying cause In favour • History of trauma· Bleeding shock Bleeding site Dengue shock syndrome • Known dengue Cardiac shock • • Septic shock • • Shock associated with severe dehydration • • • • 176 outbreak or History of History of disease Enlarged neck History of illness Very ill child Known outbreak History of diarrhoea Known cholera season high heart veins febrile of profuse Table: 33 Differential diagnosis of a child or a young infant with lethargy, unconsciousness of convulsions Differential diagnosis of the child presenting with lethargy, unconsciousness or convulsions Differential diagnosis of the young infant (less than 2 months) presenting with lethargy, unconsciousness or convulsions Diagnosis or underlying causeIn favourDiagnosis or underlying causeIn favour Meningitis Meningitis • Very irritable • Stiff neck or bulging fontanelle • • Apnoeic episodes • Convulsions • Petechial rash High-pitched (meningococcal cry • Tense/bulging fontanelle Cerebral malaria(Often positive for seasonal)• • • • • Febrile Blood malaria parasites Jaundice Anaemia Convulsions Hypoglycaemia • convulsions smear Birth asphyxia Hypoxic ischaemic encephalopathy Birth trauma Prior episodes of short • Onset frst days of life • Sepsi s • convulsions when febrile • in 3 History of diffcult Fever or hypothermia • Shock • Seriously ill with no apparent cause Associated • • with fever Age 6 months to 5 years CSF normal Hypoglycaemia by Head injury (Always seek blood sugar • and treat levels. Signs or history of head trauma the cause Neonatal to prevent a tetanus recurrence).Confrm • • • Onset (age 3–14 days) Irritability Diffculty in breast feeding • Trismus • Muscle spasms • Convulsions Poisoning • History of poison ingestion or drug overdose Shock (unlikely to cause convulsions) Poor perfusionRapid, weak pulse Haemolytic disease of the newborn, kernicterus • • Onset in frst 3 days of life Jaundice Acute glomerulonephritis with • encephalopathy • Diabetic ketoacidosis Raised blood pressure Peripheral or facial oedema • Blood in urine • High blood sugar • History of polydipsia and polyuria • Acidotic (deep, laboured) 177 Table: 34 Differential diagnosis of the child presenting with stridor Diagnosis In favour Viral croup • Barking cough • Respiratory distress • Hoarsevoice • If due to measles, signs of measles Retropharyngeal abscess • Soft tissue swelling • Diffculty in swallowing • Fever Foreign body Diphtheria • • • Congenital • • • • • 178 anomaly Sudden history of choking Respiratory distress Bull neck appearance due to enlarged cervical nodes and oedema Red throat Grey pharyngeal membrane Blood-stained nasal discharge No history of DTP vaccination Stridor present since birth Table:35 Differential diagnosis of the child presenting with chronic cough DiagnosisIn favour Tuberculosis• • • • • • • • Asthma Weightloss or failure to thrive Anorexia, night sweats Enlarged liver and spleen Chronic or intermittent fever History of exposure to infectious tuberculosis Signs of fuid in chest (dull to percussion/reduced breath sounds) Positive tuberculin test Suggestive X-ray chest • History of recurrent wheeze, cough • Hyperinfation of the chest • Prolonged expiration • Reduced air entry (in very severe airway obstruction) • Good response to bronchodilators Foreign body Pertussis HIV • • • • • • • • • • • • • • • • • Bronchiectasis • • • • Lung abscess • • • Sudden onset of choking or Unilateral chest signs (e.g. wheezing or Recurrent lobar consolidation Poor response to medical treatment Paroxysms of cough followed by whoop, vomiting, cyanosis or apnoea Subconjunctival haemorrhages No history of DPT immunization Afebrile Known or suspected maternal or sibling HIV infection History of blood transfusion Failure to thrive or weight loss Oral thrush Chronic parotitis Skin infection with herpes zoster (past or present) Generalized lymphadenopathy Chronic fever Persistent diarrhoea Finger clubbing • History of tuberculosis or Poor weight gain Purulent sputum, bad breath Finger clubbing Localized signs on X-ray • Reduced breath sounds over Poor weight gain / chronically ill Cystic or cavitating lesion on chest stridor hyperinfation) aspirated foreignbody abscess child X-ray 179 Diarrhoea Treatment Plan B: Treat Some Dehydration with ORS GIVE RECOMMENDED AMOUNT OF ORS IN CLINIC OVER 4-HOUR PERIOD • Determine amount of ORS to give Age*Up to 4 months4 months up to 12 months Weightin ml < 6 kg 200400 * Use The also by the child’s age only approximate amount be calculated by 75. 6 < 10 kg 400-700 when do of ORS multiplying during frst 4 hours. 12 months up to 2 years up 2 years to5 years 10 12 – < 19 12 kg kg 900-1400 700-900 not know the weight. required (in ml) can the child’s weight (in Kg) • If the child wants more ORS than shown,give more. •ShowthemotherhowtogiveORSsolution: - Give frequent small sips from a cup. If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue breastfeeding but stop other feeding. •After4hours: Reassess the child and classify the child for dehydration. - Select the appropriate plan to continue treatment. - Begin feeding the child in clinic. •Ifthemothermustleavebeforecompletingtreatment: Show her how to prepare ORS solution at home. Show her how much ORS to give to fnish 4-hour treatment Give her enough ORS packets to complete rehydration. Also give 2 packets as recommended in Plan A. Explain the 4 Rules of Home Treatment: 1. 2. 3. 4. 180 Give extra fuid Give zinc supplements Continue feeding When to } Plan A Teach the mother how to mix and give ors. It is especially important to give ORS at home when: • The child has been treated with Plan B or Plan C this visit • The child cannot return to a clinic if diarrhoea worsens. milk. yoghurt drink. Then until the diarrhoea stops. supplements supplement for . to give : give give the the zinc zinc continue. Give the mother 2 packets of ors to use at home. Show the mother how much fuid to give in addition to the usual fuid intake: Up to 2 years 50 to 100 ml after each loose stool 2 years or more 100 to 200 ml after each loose stool Tell the mother to: • Give frequent small sips • If the child vomits. lemon drink.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) Tell the mother: If the child is exclusively breastfed : Breastfeed frequently and for longer at each feed. vegetable soup. • from wait a 10 cup. green coconut water or plain clean water. If the child is not exclusively breastfed: Give one or more of the following home fuids. rice or pulses based drink. minutes. ORS solution. more slowly. • Continue giving extra fuid 2. during but GIVE ZINC SUPPLEMENTS Tell the mother how much zinc 2 months Up to 6 months 10 mg per day for 14 days 6 months and more 20 mg per day for 14 days Show the mother how to Remind the mother to the full 10-14 days. If passing frequent watery stools: • For less than 6 months age give ORS and clean water in addition to breast milk • If 6 months or older give one or more of the home fuids in addition to breast milk. • • • CONTINUE FEEDING WHEN TO RETURN: Advise mothers to return immediately if: Not able Becomes sicker • Develops a fever Blood in stools • Drinking poorly to drink or breastfeed 181 . 4.3. Management of dysentery • Young infants (<2 months): .First and second generation cephalosporins (e. intussusceptions) .g. nitrofurantoin.g. gentamicin. cefamandole). Age Or in Past 6 < 1 Hospital Weeks Hospital Second Antimicrobial For Shigella Yes BetterIn 2 Complete 5 Treatment Days Days NO Refer To Hospital Or Treat For Amoebiasis Antimicrobials that are treatment of Shigellosis Ciprofoxacxin day for Ceftriaxone (100 once daily 15mg/Kg/2 3 days mg/kg) for 5 effective for Antimicrobials that are treatment of Shigellosis times per MetronidazoleStreptomycin Tetracyclines Chloramphenicol IM/IV days - ineffective - Sulfonamides Amoxycillin Nitrofurans (e. days. Severely Give once daily for antibiotics for (100 mg/kg) NO Change young infant IM/IV ceftriaxone days. (100 mg/kg) • Child: Give oral IM/IV Ceftriaxone used. furazolidone) . if appropriate. 182 for .Aminoglycosides (e.and refer to a surgeon.g.Admit and rule out surgical causes (for example. kanamycin) . In admitted children daily for 5 days may be CHILD WITH LOOSE STOOL WITH BLOOD Malnourished? Yes Refer To NO Give Antimicrobial For Better In 2 Days NO Initially Year Measles the 5 3 once To Yes Complete 3 Days Treatment Yes Refer To Shigella Dehydrated. cephalexin. dalia] Ingredients diet. . milk sooji Approximate quantity gruel.DIETS FOR PERSISTENT DIARRHOEA The Initial Diet A: [Reduced lactose rice with curd. milk Measure rice gruel. sugar.5 g make 100 Preparation • • Mix milk. replaced by chicken. Measure Approximate quantity . egg or protein hydrolysate. rice together • Add boiled water & mix well Add oil The feed can now be given to the child The second Diet B: [Lactose-free diet with reduced starch] About 50-70% of children improve on the initial Diet Remaining children. if free of systemic infection changed to Diet B which is milk (lactose) free provides Milk carbohydrates as protein is Ingredients a mixtureof cereals and A.Milk 1/3 cup Sugar Oil Puffed rice powder* Water * Can be substituted ½ tsp level 4 level 40ml ½ level 2g tsp tsp To by cooked rice or sooji 2g 12. are and glucose. Egg white Glucose 3 level tsp 3/4 level Oil 1 level tsp Puffed rice powder* 2 Water * Can be substituted with level ¾ cup cooked 15 3g g tsp 4g tsp To rice 7g make 100 Preparation Whip the egg white well. Add puffed rice powder. 183 . Add boiled water and mix rapidly to avoid clumping. glucose. oil and mix well. The Third Diet C: [Monosaccharide based diet] Overall 80-85% recover with patients sustained with severe persistent weight gain on the diarrhoea initial Diet will A Diet B. Energy density is the second Ingredients tolerate are protein or given the source as increased by adding oil to the diet. A small percentage may not a moderate intake of the cereal in Diet B. These children third diet (Diet C) which contains only glucose and a egg or chicken. Measure Approximate quantity . chicken remove puree with the bones and glucose and make chicken puree. oil and mix well. Or Whip the egg white well.Chicken or white Glucose Egg 2 ½ level tsp ¾level tsp Oil 1 level tsp Water ½- ¾ tsp5 level 12 g25 g 3g 4g cup To make 100 Preparation Boil chicken. Add boiled water to make a smooth paste. Add boiled water and mix rapidly to avoid clumping. Mix oil. Add glucose. 184 . as snacks in thick dal servings or with added ghee/oil or khichdi . at 8 times in 24 hrs. • Do not give any other or fuids even water.Sevian/dalia/ with added oil/ghee.Counsel the Mother Feeding: Recommendations during Sickness and Health Up to 6 months of 12 months up to 2 2 years & older 6 months up to age years • Give family 12 months • Breastfeed as • • Breastfeed as foods at Breastfeed as often as often as the 3 meals often as the child child wants • each day • Also. the child wants least food wants. Add mixed cooked vegetables also in the daily. such Give at as : least 11/2 .Banana/biscuit/ katori serving* at cheeko/ mango/ papaya mixed in thick dal not with added ghee/oil or khichdi a time of Mashed roti/bread with added oil/ghee.Mashed servings or - Mashed roti/rice/bread boiled/fried mixed in sweetened milk or potatoes - - cheeko/mango/ papaya milk or Sevian/dalia/ halwa/kheer prepared in Offer banana/biscuit/ . Add halwa/kheer prepared in cooked vegetables also in the milk or .Offer banana/biscuit/ * 3 times per day if breastfed. day night. times if 5 per day cheeko/mango/ papaya * 5 times per day not breastfed. & • Give least katori a time of: - at Offer food twice 1 from the give serving* at Mashed family • roti/bread pot nutritious food between meals. Remember • by the side of child & help him to fnish the Remember : • Wash your own • Continue Remember • breastfeeding if • Keep the the child child in is sick your lap & feed with your own hands • Wash your own & & hand Sit serving child’s with soap water every time before feeding Remember : & • Ensure that the child fnishes the serving • Teach your child wash his hands with soap and water every time before . 185 . ANNEXURE-7 Drug dosages / regimens DRUG DOSE ROUTE Aminophylline For asthma Loading dose: 5-6 mg/kg (max.9 mg/kg/hour Amoxicillin Ora l 15 mg/kg three times per day For Pneumonia 25 mg/kg two times a day Ampicillin Cefotaxime Ceftriaxone 25 50 mg/kg four times a day mg/kg every 6 hours 50 mg/kg every 6 hours 80 mg/kg/day as a single dose given over 30 min For meningitis 50 mg/kg ever 12 hours (max single dose 4 g) OR 100 mg/kg once daily Ora l IM/I V IM/I V IM/IV IM/IV IM/IV 186 . 300 mg) slowly over 20-60 minutes Maintenance dose: 5 mg/kg up to every 6 IV IV hours OR By continuous infusion 0. 5 mg/kg once per 15 mg/kg 4 times a 10-15 mg/kg.01 ml/kg (up maximum of 1:1000 solution Rectal: IV (or to 0.3mg/kg Epinephrine(adrenaline) For wheeze SC 0.Calculate EXACT dose based on body weight. TMPand 20 mg SMX) sulfaOral Dexamethasone For severe viral Chloramphenicol croup 0.5 convulsions mg/kg 0. Only use these doses if this is not possible.3 ml/kg of Furosemide (frusemide) Gentamicin Nalidixic Paracetamol acid 1:1000 nebulized solution For cardiac failure 1-2 mg/kg every 12 hours 7. For meningitis IV 25 mg/kg every 6 hours (maximum IM 1g Oral per dose) For other conditions 25 mg/kg every 8 hours (maximum 1 g per dose) Chlorphenamine 0.25 mg/kg once (can be repeated IM/IV or up to 4 times in 24 hours SC Ciprofoxacin 10-15 mg/kg per dose Oral given twice per day 25-50 mg/kg every 6 IV Cloxacillin hours mg Oral Cotrimoxazole(trimethoprim-4 trimethoprim/kg sulfamethoxazole.6mg/kg single dose Diazepam For 0.2-0.3 a ml) ml/kg of of 1:10000 solution) For severe viral Croup A trial of 0.up 4 times a to day Oral or IV day IM/IV day Oral Oral 187 . 188 .5 mg/dsoe ANTI-TUBERCULOSIS ANTIBIOTICS Calculate exact dose Essential anti-TB drug (abbreviation) based on body Mode action of weight Daily dose mg/kg (range) Intermittent dose: 3 times/week mg/kg (range) 30 (25–35) Ethambutol (E) Bacteriostatic 20 (15–25) Rifampicin (R) Bactericidal 10 (8–12) 10 (8–12) Isoniazid (H) Bactericidal (8–12) Bactericidal (4–6) (20–30) 10 Pyrazinamide (Z) 5 25 35 (30–40) 15 (12–18) Streptomycin (S) Bactericidal 15 (30–40) Not Thioacetazone (T) Bacteriostatic 3 Note: Avoid thioacetazonein a child who is known to be applicable HIV-infected or when the likelihood of HIV infection is high. because severe (sometimes fatal) skin reactions can occur.5-5 mg/kg Potassium 2-4 meq/kg/dose/kg/day Prednisolone 1 mg/kg twice a day Salbutamol 1 2mg mg per Acute per dose Oral Oral dose 1-4 <1 year Oral years episode 6-8 hourly Inhaler with spacer: 2 doses contains 200 μg Nebulizer: 2.Benzylpenicillin(penicillin Phenobarbital G) General dosage 50000 units/kg For meningitis 100000 units hours IM/IV every 6 /kg hours every 6 Oral/IM/I V Loading dose 15 mg/kg Maintenance dose 2. TB includes lymph node TB and unilateral pleuraleffusion. bone and joint TB. *** Prefx indicates month and subscript indicates thrice weekly. Diagnosis to be based on a combination of: • • • • • 2. not seriously ill** * Seriously ill sputum smear negative Pul. TB other than primary complex. TB pericarditis. bilateral or extensive pleurisy. for more weight gain. extending the total duration months. Category of treatmentType of patients Category I positive Pul. Treatment of Pediatric TB DOTS is the recommended strategy for and all Pediatric TB patients under RNTCP. spinal TB with neurological complications months. • In patients with TBM drugs used during intensive Continuation phase in TBM or should be given for 6-7 of treatment to 8-9 • Steroids should be used pericarditis and reduced on category 1 treatment.with or without weight loss and history with a suspected or diagnosed disease within the last 2 years. seriously ill Extra Pul. active TB TB: Children presenting with fever and / than 2 weeks. Diagnosis Suspect or or case cases cough no of of Pul. ** Not-seriously ill Extra Pul. • Category II relapse treatment should be • New sputum smear TB Seriously ill* sputum smear negative Pul TB • Sputum smear positive • of TB registered Continuati Intensive on Phase Phase 2 H3 4H3R3 R3 Z3 E3*** 2 S3 5H3R3 H3 E3 R3 Z3 4H3R3 E3 2 H3 R3 Z34H3R3 Sputum smear positive treatment failure Category • Sputum smear III negative and • Extra pul. TB includes all forms of Pul. TB. TB includes TBM. • Before . genitourinary tract TB.Management of Pediatric Tuberculosis under the Revised National Tuberculosis Control Program (RNTCP) 1. TB peritonitis and intestinal TB. Clinical Sputum Chest X-ray Mantoux and History presentation examination wherever (PA view) test (Positive if of possible induration >10 mm after 48-72 hours) contact. the 4 phase should be HRZS or HRZE. initially in cases of TBM and TB gradually over 6-8 weeks. spinal TB with or without neurological complications. disseminated TB/military TB. 189 .starting category 11 by a pediatrician or be used for all age groups. from the same household. treatment. should be Ethambutol examined is to Chemoprophylaxis Asymptomatic children under 6 years of age. will be given 6 months of isoniazid (5 mg/kg daily) chemoprophylaxis. a TB patient expert. exposed to an adult with infectious (smear positive) tuberculosis. falciparum cases found positive by microscopy or Rapid Diagnostic kits. in therapeutic days. in addition to chloroquine. Such cases if later found positive may be treated accordingly 6.clinical malaria. This practice is to be followed at all levels including VHWs like FTDs/ASHA etc. ACT is the frst line of antimalarials drug for treatment of P.25 mg per kg bw of pyrimethamine on the frst day. Pf dose of Thispractice FTDs/ASHA In high risk 0. and treated with chloroquine in full therapeutic dose of 25 mg/kg body weight over three days. The dose is 4mg/kg bw of artesunate daily for 3 days + 25mg/ kg bw of sulphadoxine/sulphalene + 1. Jharkhand. cluster of Blocks and identifed basis of epidemiological situation. The frst line of treatment is chloroquine (Artesunate+Sulpha Pyrimethamine) combination is the treatment of Pf cases in qualifed resistant areas. Compliance and full intake is . Cases positive for Pf by RDK should be treated with full therapeutic dose of chloroquine or ACT combination as per prescribed drug in that area. all seven NE states and 50 high Pf endemic districts in the state of Andhra Pradesh.25mg/kg bw daily for 14 days as per prescribed guidelines only to prevent relapse except in contraindicated patients which include G6PD patients. identifed cluster of Blocks surrounding resistant foci.75 mg/kg cases 25 is as area bw should be treated with chloroquine mg/kg body weight divided over three to be followed at all levels well in chloroquine sensitive areas. 5. ACT should be given only to confrmed P. Primaquineshould be given in dose of 0.NATIONAL DRUG POLICY ON MALARIA (2008) 1. All clinicalsuspected cases should preferably investigated for malaria by Microscopy or Rapid Diagnostic Kit (RDK). and the ACT recommended for areas like chloroquine districts on the 3. Chhattisgarh. Microscopically positive Pv cases should be treated with chloroquine in full therapeutic dose of 25 mg/kg body weight divided over three days. Madhya Pradesh and Orissa.falciparum in chloroquine resistant areas. infants and pregnant women. single should be given on frst day. including VHWs like dose of Primaquine 4. However negative cases showing sign and symptom of malaria without any other obvious causes should be considered as . Wherever microscopy results are not available within 24 hours or the patient is at high risk of Pf both RDT and slide should be taken. be 2. 8. mono sulpha more than to the cases. mg/kg it will and will not women. should drug .to be ensured.e 0. 190 be used in pregnant be be administered as combined with The area/PHC showing a treatment failure (both Early and Late Treatment Failures ) drug in the minimum sample of 30 switched over to the alternate antimalarial Artesunate-Sulpha-Pyrimethamine (ACT) combination.75 be given with ACT combination as gametocyte clearance in P. to Artesunate tablets should not therapy. body weight. 10% chloroquine be e.falcipaum interruption of transmission. 9. may be benefcial for facilitate effective 7.g. ACT tablets are Single dose of Primaquine i. It should invariably pyrimethamine tablets in prescribed dosages. However for longer stay in high Pf endemic districts by the Military practice of chemoprophylaxis should be night patrol duty decisions of be followed.Primaquine and 15.falciparum of Directorate of NVBDCP. Mefoquine recommended for is drug the pregnant women and children less of choice for chemoprophylaxis involving longer stay. oral quinine 13. is contra indicated in pregnant woman infants. All be the medical. prescribed. However. than 8 etc and & Para-military followed wherever appropriate their Medical forces. In with drug to second line of treatment may also in a cluster of Blocks aroundthe resistant foci consideration the epidemiological trend of P.falciparum parasite and not gametocyte alone and other species. to chloroquine doxycline can and be SP-ACT. 16. This treatment may continue till such time oral Quinine/ Artemesinine derivatives become available. Hence. e. Migratory labour/project population: risk category they need to Since these groups belong to high be screened on weekly basis and treated accordingly. daily doxycycline is the drug of choice (if not it is not years.10. Such individual patients to concerned District Offcer/ROHFW Pf monitoring teams for sensitivity status. should also with no within 72 reported Malaria of drug cases resistant tetracycline or be suspected if in spite of full history of vomiting. paramedical and adequately trained village level health volunteers should . Chemoprophylaxis should be high P. 14. 18. Resistance treatment not respond should be Malaria /State monitoring 12. necessary precautions should be taken and all individuals should undergo screening before prescription of the drug. In severe and complicated P.falciparum malaria cases intra-venous Quinine/ parenteral Artemisinine derivatives are to be given irrespective of chloroquine resistance status. 17.falciparum endemic administered only areas.g. It is contraindicated in cases with history of convulsions.falciparum cases only in standard doses as prescribed by WHO against the prescription of medical practitioners supported by laboratory report showing asexual stage of P. Administrative the troops on Authority should short term chemoprophylaxis (less than 6 weeks). neuropsychiatric problems and cardiac diseases. Change of be implemented after taking into and approval 11. Mefoquine should only be given to chloroquine/multi resistant uncomplicated P. Use of in selective groups in personal protection measures including insecticide treated bed nets should be encouraged for pregnant women and other vulnerable population including travellers for longer stay. patient does hours parasitologically. For contraindicated). diarrhea. 191 . above Primaquine PRIMAQUINE IS CONTRAINDICATED IN INFANTS AND PREGNANT WOMEN Dosage as per age groups (a) P.5 Tablets(7. falciparum Age in years No.5 1 5. Chloroquine 10mg/kg (600 (600 mg mg 5mg/kg (300 mg Chloroquine base Day 1 10mg/kg Chloroquine base Day 2 Chloroquine base Dosage as per <1 Day 3 age groups Day 1 Day 2 Day -3 Age in years Tab. 1. vivax above 45 Age in year mg base mg base) < 1 No. mg base Day 1 mg base)No.5 mg 12 4 18 6 Primaquine Tablets(2. base) 0 <1 Nil 1-4 7. given as per prescribed 14 of of days* Tablets(7. of 1-4 5-8 9-14 15 & Above *Primaquine for 14 192 Primaquine On of Tablets(2.0 days should be dose for base)No.0 15.0 2 4 6 10.5 Daily mg Nil Nil 2.5 Ni l 1 2 guidelines only .5 3 1 5-8 15 6 2 9-14 30 15 & (b) P. chloroquineTab.DRUG SCHEDULE FOR TREATMENT OF MALARIA UNDER NVBDCP. ChloroquineTab. Chloroquine ½ ½ ¼ 1-4 1 1 ½ 5-8 2 2 9-14 3 3 4 4 1 1 ½ 2 15 & 2. should be given to complete 7 of treatment in patients treated with parenteral .m. then once a day.pyrimethamine (ACT) combination Age wise Dose Schedule for AS+SP Age <1 1st of Year 1-4 Day(number of tabs) tabs)*2nd Day(number of AS SP ½ ¼ ½ Nil Yeas AS SP 1 1 1 Nil 5-8 Year AS SP 2 1½ 2 Nil 9-14 Year AS SP 3 2 3 Nil 15 and above AS SP 4 3 4 Nil Strength of each Artesunate tablet: contains 50 each Sulpha Pyrimethamine (SP) tablet contain sulphadoxine/sulphalene and 25mg pyrimethamine *Artemisinin group of drugs is not recommended in pregnancy 4. then at 12 h and 24 h. the guidelines for specifc antimalarials therapy as per the WHO recommendation are given below: • • Quinine salt 20 mg/kg* body weight (bw) on admission (IV infusion or divided IM injection) followed by maintenance dose of 10 mg/kg bw 8 hourly.2 mg/kg bw i.e 20mg /kg bw on admission may not be given if the patient has already received quinine or if the clinician feels inappropriate). (*loading dose of Quinine salt i.v. parenteral treatment should be given for minimum of 48 and once the patient tolerates oral therapy. Artesunate: 2. However. Given on admission then 1. Artesunate + Sulpha . Given on admission (time=0). Note: A. tabs)3rd mg & 500mg Day(numbers ½ Ni l 1 Ni l 2 Ni l 3 Ni l 4 Ni l Severe and complicated malaria cases Severe malaria is an emergency and treatment should be given as per severity and associated complications which can be best decided by the treating physicians. Parenteral artemisinin derivatives (for non pregnant women) or quinine should be used irrespective of chloroquine resistance status of the area.4 mg/kg bw i.infusion rate should not exceed 5 mg salt / kg bw per hour. • Artemether: 3.6 mg/kg bw per day. or i.3.m. The hours 10 once children days quinine. quinine mg/kg bw three times a day with doxycycline 100 mg a day or clindamycin in pregnant women and under 8 years of age. in selective groups in high 193 . Use of mefoquine alone or in should be avoided especially in to neuropsychiatric complications associated with it.falciparum should be endemic administered only areas.B. patients treated combination with artesunate cerebral malaria due Chemoprophylaxis Chemoprophylaxis P. Full with course of artemisinin ACT should be derivatives. 5. administered to C. 5 continued Note: and years. should be administered two weeks before. It is not recommended for pregnant women less than children • For Mefoquine: four Note: started 8 2 weeks) in adults and 1. longer stay 250 mg weeks after weeklyand exposure. Hence. neuropsychiatric problems and cardiac conditions.• The For short term chemoprophylaxis Doxycycline: daily in the dose mg/kg for children (if not (less than 6 of 100 mg contraindicated). . necessary precautions should be taken and all should undergo screening before prescription of the drug. drug should be days before travel and for 4 weeks after leaving the malarious area.during and Mefoquine is contraindicated in cases with history of convulsions. 194 . but that and fuids mouth Wherever feeding the by fuids fuids that neonates.Intravenous uids The following table gives the are commercially available composition of and commonly intravenous used in children. Please fuids contains suffcient calories for some less note long-term nutritional than others. infants contain and the or nasogastric tube are possible.01121.827 Ringer’s (Hartmann’s) Normal saline (0. Composition IV uid Na+K+Cl-Ca++LactateGlucoseCalories mmol/lmmol/lmmol/lmmol/lmmol/lG/l/l lactate 1304. that none of support of children. this is preferable.9% NaCl) 5% Glucose 10% Glucose 154 - - 154 - - 50200 - - - - - - - - - 100400 . 0.45 NaCl / 5% glucose Pediatric maintenance 77-772 6 1 9 2 2 - - 50200 - 50200 195 . Fluid Management The total daily following ml/kg kg. 800 x fuid requirement of a formula: 100 ml/kg for for the For ml is frst calculated 10 kg. thereafter25 example. Body weight of child (10 Maintenance uid requirements Fluid (ml/day) 200 2 kg 4 kg 400 8 kg 600 800 10 kg 12 kg 14 kg 1200 1300 18 kg 20 kg 1400 1500 22 kg 24 kg 1550 1600 26 kg 1650 6 kg 1000 1100 16 kg Give the sick (increase the 50 10 50) next child the child by more than 10% for the above amounts every 1º C of if there is fever). an 8 kg baby receives 8 x 100 ml = per day. fever . with then ml/kg for each subsequent kg. a 15 kg child x 100) + (5 = 1250 ml per day. 196 . safe container. In younger or severely malnourished children. Remove the needle and press with cotton wool. give the injection in the outer thigh or in the upper. • • • • • • Safe injection practices Wash your hands thoroughly. Give the drug end. or over the deltoidmuscle in the upper arm. withdraw slightly and try again). Carefully check the dose of the drug given and draw the correctamount into Expel the air from the syringe before Alwaysrecord the name and amount of Discard disposable syringes in a possible. the drug given. reusable needles and syringes. Or else. Push the a 45°angle into the deep to enter the underlying to make sure there is no blood (if by pushing the plunger slowly till the frmly over the injection site . as described above for needle (23–25 gauge)under the skin at subcutaneous fatty tissue. intramuscular injection.Give the drug by pushing the plunger slowly till the end. Push the needle (23–25 gauge)into the muscle at a 90°angle (45°angle in the thigh). withdraw slightly and try again). • Clean site with a spirit/alcohol swab in a from the centre to the periphery. Subcutaneous Select the site. Draw back the plunger to make sure there is no blood (if there is. Wait to allow the spirit to dry. Wear gloves if Use disposable needles and syringes. use the outer side of the thigh midway between the hip and the knee. well away from the sciatic nerve. outer quadrant of the buttock. injecting. sterilize the chosen circular fashion for 30 seconds to be the syringe.ANNEXURE: 8 PROCEEDURES &SKILLS: 1. Do not go muscle. Remove the needle and press frmly over the injection site with a small swab or cotton wool. Intramuscular In >2-year-old children. Draw back the plunger there is. slowly insert the needle (25 gauge). for about 2 mm just under and almost parallel to the surface of the skin. Stretch the skin between the thumb and forefnger of one hand.Intradermal For an intradermal injection. 197 . blanched bleb showing the surface of the hair follicles is a sign that the injection has been given correctly. select an undamaged and uninfected area of skin (e.g. Considerable resistance is felt when injecting intradermally. A raised. with the other. bevel upwards. over the deltoid in the upper arm). If fever persists for more than 24 hours. taken not palpation. Blood puncture. <2 limb Scalp Veins These are young • Find the often used in infants. Apply insert most of its a splint with the wrist slightly fexed).g. antibiotic should be skin is given. cloxacillin. Procedures for giving parenteral ?uids Insertion of an indwelling IV cannula in a peripheral vein Select a suitable vein to place the cannula butterfy needle. to If cannulate an there should be artery. Fix the catheter securely with in appropriate an the around the limb. this is usually the cephalic vein in the antecubital fossa or the fourth interdigital vein on the dorsum of the hand. then vein and tape. The skin at infection the may cannula lead to site a is thrombophlebitis which vein result in fever. a suitable forehead. or in the above or midline behind the necessary and clean the skin with assistant should occlude the vein syringe with normal saline and fush the end of the above. or gauge 21 or Peripheral Vein • • Identify an accessible peripheral vein. The surrounding reduce the risk will occlude the red and tender. Fill a Disconnect the syringe the butterfy needle and as leave described best in of ear). This may require the splinting of neighbouring joints to limit the movement of the catheter.2. and the treatment cannula to (effective against staphylococci) of 23 . Remove the further spread of the infection. In young children aged >2 months. Care of the Cannula Secure the cannula when introduced. withdraw the needle and apply pressure until the bleeding stops. introduce the cannula into length. Apply a warm moist compress to the site for 30 minutes every 6 hours. Common Complications Superfcial infection of the commonest complication.g. Introduce fowing back slowly Care should be recognized by years but work (usually area. the children aged scalp vein temporal • the • Shave area if antiseptic solution. an or antiseptic solution (such as 70% alcohol solution). An assistant should keep the position of the limb steady and should act as a tourniquet by obstructing the venous return • with his fngers Clean the surrounding spirit. The the site of the butterfy set. tubing open. which is a pulsatile spurting of blood. Fill the cannula with heparin solution or normal saline immediately after the initial insertion and after each injection. an proximal to through the tubing indicates that the needle is in the vein. then look for a vein. elbow extended. isopropyl lightly closed skin with alcohol. e. Keep the overlying skin clean and dry. position (e. iodine. Once all the drug has been given. with infusion through a peripheral vein or not possible.IV drug administration through an indwelling cannula Attach the syringe containing the IV drug to the injection port of the cannula and introduce the drug. blood has scalp vein give IV been is fuids to . and it is essential to keep the child alive: set up an intraosseous infusion or use a centralvein or perform a venous cut down. inject 0.5 ml heparin solution (10–100 units/ml) or normal saline expelled and If • • • 198 the into the catheter is cannula until all the flled the solution. Check that the child lies straight along the centre of the board. bone marrow needle. Measuring length /Height INFANTOMETER • • • • • • • • Measure length while supine. • Identify the insertion site (proximal end of tibia or distal end of femur): . Intraosseous access: • Participants can practice on chicken thigh bone or any other animal bone • Gather necessary supplies. • Wash hands and put on clean examination gloves. • Hold the needle (with the attached syringe if using a hypodermic needle) in the other hand at a 90-degree angle to the selected insertion site. Stop immediately when there is a sudden decrease in resistance to the needle. if possible. which indicates that the needle has entered the marrow cavity. The other person straightens the knees. The aspirate should look like blood (if in a live baby) • Secure the needle in place using tape.5 cm if > 85cm). or 2-gauge needle. and allow to dry. Hold the head with two hands and tilt upwards until the eyes look straight upwards. Work with a partner. and within eight hours. One person should stand behind the headboard. • Aspirate using the syringe to confrmthat the needle is correctly positioned. Position the crown of the head against the headboard. Place the foot piece frmly against the feet. compressing the hair. • Advance the needle using a frm. • Inspect the infusion site every hour. • Once the needle is properly positioned. • Remove the intraosseous needle as soon as alternative IV access is available. • Use a measuring board with a headboard and sliding foot piece. twisting motionand moderate. and splint the leg as for a fractured femur ensuring that the elastic bandage does not interfere with the needle or infusion set.3. angled slightly towards the foot. The site at the distal end of the femur is 2 cm above the lateral condyle • Prepare the skin over the insertion site using a swab or cottonwool ball soakedin antiseptic solution. remove the stylet (if a bone marrow or intraosseous needle was used) and attach the syringe. • Can use sterile intraosseous needle. Measurement will be most accurate if child is naked. if not possible ensure clothes do not get in the way of measurement.The site at the proximal end of the tibia is 1 cm below and 1 cm medial to the tibial tuberosity. 4. if length < 85 cm or in children too weak to stand (subtract 0. controlled force. with toes pointing . Measure the a child calves child’s fat.up. back of touching ankles to the the keep head.1 cm. the headboard the so frmly on height to the • 199 . Hold the and feet Position ahead.1 cm. vertical board. • Measure length to the last 0. STADIOMETER • • • • • • Remove Work with Help the buttocks. child’s socks partner. stand with and heels knees and & shoes. the legs straight head that the child is looking straight top of the head and compress last completed 0. Place the the hair. shoulder blades. • Give Salbutamol inhalation by MDI-Spacer 4 puffs (100mcg/puff) at 2-3 min interval. Treat the child until all the liquid in the nebuliser has been almost used up. • Allow normalbreathing for 3–5 breaths. Put the drug and 2-4 ml of normalsaline in the nebuliser compartment. 6. which usually occurs in 5-10 minutes. • Attach aerosol mask to the top of nebuliser. Spacers can be made in the following way: • Use a plastic cup or a 500 • Cut a hole in the base in mouthpiece of inhaler • Spacerdevices with a volume commercially available To use an inhaler with a spacer: • Remove the inhalercap. • • • • Use of Nebuliser Bronchodilators can be effectively given by nebulisation using an electric air compressor. Use of MDI with spacers: USE OF A SPACER • Spaceris a way of effectively delivering bronchodilator drugs • Works as well as nebuliser if correctly used • No child < 5 years should be given inhalerwithout spacer • Release a puff (100 micrograms of Salbutamol) into the spacer chamber after attaching the MDI to the other end of the spacer. • Tubing and nebuliser chamber should be washed with detergent and dried prior to reuse. A slow deep breath is preferred but may not be feasible if the child is not earlier trained. Shake the • Insert mouthpiece of inhalerthrough • The child should put the opening mouth • Press down the inhalerwhile the child • Wait for 3 to 4 breaths • For younger children place the use as a spacer in the same way ml the drink bottle or same shape/size of 750 inhalerwell the hole of the ml are in the bottle into continues to and repeat cup over the similar as the bottle his breath normally child’s mouth and .5. Continuous fow oxygen at 6 to 8 litres per minutecan also be used in place of compressor . 200 . Pulmonary Score Severity assessment (Total from 3 columns) 0–3 Mild 4–6 > 6 Moderate Severe Those children whose score is > 6 or have signs of imminent respiratory arrest .ANNEXURE: 9 Assessment of severity of acute asthma in a child upto 5years Using Pulmonary Score Index Score RespiratoryRate /minWheezing* Accessory muscleSternomast oid activity No apparent 0 <30 None activity 1 31-45 Terminal expiration Questionable with increase stethoscope 2 46-60 Entire expiration Increase apparent 3 >60 During inspiration Maximal and activity expiration without stethoscope *If no wheezing due to minimal air exchange. 201 . been Do screened not use has been out of Large volume rapid blood stored at 4° babies. Preferably and found negative for blood that has passedits the refrigerator transfusion at C may cause give packed transfusionexpiry date for more than 2 a rate >15 ml/kg/hour hypothermia. or hours. of small whole blood.ANNEXURE: 10 Blood transfusion Use blood that has transmissible infections. especially in cells if available in place of . 202 . The volume transfused Any signs of heart failure. 3-4 If give whole blood ml/kg over emergency. Septic shock if IV fuids insuffcient maintain number are on both the label and the form (in an hours preferably.· o w i n g : • • Do a baseline recording the child’s of temperature. respiratory rate I f a v . patient’sname group-specifc blood or giving O-negative blood if available. c h e c k is not pink or has large clots.General indications blood transfusion: Acute blood loss. blood pack not been more 2 than hours.· • are to circulation and in addition to antibiotic The has therapy. check the following: • The the blood is correctgroup the total blood volume has been lost and and bleeding is continuing the and Severe anaemia if packed cells are available. and the red cells do not look purple or black. • and pulse rate. D u r i n g t r a n s f u s i o n . hours. give 1mg/kg of t h e f o l l furosemide IV at the start of the transfusion in children whose circulating blood volume is normal. out of the refrigerator for adequate • The blood transfusion bag has no leaks. 20–30% for when of Blood Transfusion Before transfusion. If present. reduce the risk of incompatibility or transfusion reactions by cross-matching 20 3-4 hours. plasma the should initially be ml/kg 20 body weight of given over 3–4 whole blood. Do not inject into the blood pack. give 10 ml/kg over not. • Look for of a transfusion signs • reaction (see below). pulse and respiratory rate every 30 minutes.ailable. and the presence of any reactions.· in Recordthe time the transfusion 203 . temperature. • • Check that the blood is fowing at the correct speed. the volume of blood transfused. use an infusion device to control the rate of the transfusion the frst minutes the transfusion. particularly carefully Recordthe child’s general appearance. 15 of was started and ended. but keep the IV • Raised heart rate o line open with normal saline • • Fast breathing o Maintain airway and • Black or d give oxygen • Give dark red epinephrine (adrenaline) urine 0. or >100.restart the transfusion slowly a Life-threatening with new blood set and observe n reactions (Due to carefully • If no d haemolysis.25 mg/kg IM.25 mg/kg IM • Continue the transfusion at the normal rate if there is no progression of symptoms after Moderately severe • Severeitchy rash Stop the transfusion. but keep the reactions (Due to (urticaria) • IV line open with normal saline • d moderate Flushing Give IV o hypersensitivity. blood h sample from another site. o if wheezing • Report tor y .1 ml of 1 in a bleeding • 10000 solution b Confusion • Treat shock • Give IVo • Collapse r hydrocortisone. fuid have been present before the threatening reaction (see below). Signs and symptoms* Management Type of transfusion reaction Mild reactions • Itchy rash • Slow the transfusion (Due to mild • Give chlorpheniraamine hypersensitivity) 0.4° improvement in 15 bacterial contamination F (note: fever may minutes. non• Fever >38 ° C hydrocortisone.4 °F chlorpheniramine t pyrogens or bacterial (Note: fever 0. following to the Blood Bank: the bloodc giving set that was used. b • Restlessness• l Stop the transfusion. o overload or transfusion) and report to doctor in charge and anaphylaxis) • Rigors to the Blood Bank. • Fever>38°Cor>100. or a chlorpheniramine t IM. stop the transfusion immediately and notify the blood bank immediately.Transfusion reactions If a transfusion reaction occurs.t and septic shock.01 mg/kg (haemoglobinuria) l body weight (equal to • Unexplained 0. and a urine samples r collected over 24 g hours. treat as life. if o contamination) may have been present before the available r transfusion) • Give a • Rigors bronchodilator. If there is any discrepancy. or c hemolytic reactions. frst check the blood pack labels and patient’s identity. if i • Restlessness wheezing • Send the n • Raised heart rate. • If there e is improvement. if available • Give a bronchodilator. as soon as possible • Maintain * 204 Note be that the in only renal IV blood fow with furosemide 1mg/kg • as an unconscious child. uncontrolled bleeding signs of a life-threatening reaction. Give for antibiotic septicaemia or shock may . It to correct the anaemia and 2–3 months reverts to normal to build iron stores • good feeding practices. Assess Children become can be response to iron therapy. like UTI and given for 3-4 months. with iron (daily 14 days. once parent to return for response blood is dose acute with to needed. If more transfused. is no If there assess for the cause (inadequate dose taken. where possible. presence of infection TB). malabsorption. of iron/folate infections have the child after iron therapy. Rise in Hb by 10-14th day.After transfusion: Reassess the should be Give treatment syrup) for • Ask the the child less irritable documented child. 14 days. Treatment should takes upto 8 weeks after the haemoglobin Advise the mother about be a similar quantity tablet or iron been treated. up . diarrhoea. and have improved appetite. 205 . ANNEXURE: 11 ASSESSING NUTRITIONAL STATUS AND RECOVERY Calculating the childs weight-for-length Measuring Length Two people are needed to measure the child’s One person should: • Assist in positioning the child face-up on board. scales should be to prevent chilling in the in the weight to 10 g) pan. weighing pan. (It the board on the place the Measuring Weight • • • • • Leave a cloth child. the measuring against the the head-board. The second person should: • Support the • Lay the child • Place one hand knees and press footpiece frmly • Measure the 0. and record performed weeklyor the whenever . Standardization the scales are in the weighing pan to zero child gently child to weight (to with on settle the the cloth the cloth and the nearest of the moved. Adjust the scales Place the naked Wait for the Measure the immediately. stabilize. With the other hand. The checked for accuracy every on of the position. and does not is usual for this person to stand or kneel behind the headboard). length.1 cm) and measuring board should be month. against the heels length (to the nearest record immediately. supporting the head and placing it headboard • Position the crown of the head against compressing the hair • Check that the child lies straight along the board and is not slanted. center line change trunk as the child is positioned fat along the board on the shins above the ankles or down frmly. 206 . 611.3 6.02.72.0 8.1 7.6 9.59.9 irls’ weight (kg) SD-2 SD-1 SDMedian 2.7 4.6 8.8 3.05.19.08.02.27.33.1 2.7 5.62.4 6.95.77.8 4.58.44.28.0 3.89.1 5.211.95.88210.4 7.62.0 3.54.3 3.79.5 7.1 493.78.7 7.7 4. 8611.6 6.05.18.7 6.96.93.2 7.47.96.03.49.84.44.54.7 7.94.1 6.58.810.23.65.35.7 (cm) Median-1 SD-2 SD-3 SD-4 SD 1.6462.5 7.4 9.65.94.88.44.8 6.7 2.5 6.1575.54.6 8.82.9 4.27.8 5.9 8.3 6.1 6.16.52.62.6 9.1 6.55.32.6 6.7 8.3 4.6 7.62.8 9.0 3.77.96.6 3.08310.52.65.84.210.0534.9 5.34.56.96.411.06.75.4585.27.57.4 7.5 6.3 5.63.1 207 .5 4.75.58511.551 3.4 11.22.14.74.8 65 7.4 2.3 6.67.27.9 3.22.78.3 9.24.98.08.07.0 5.75.9 8.57.14.064 6.87.91.62.14.22.12.23.6 8.79.42.06.34.04.9 9.93.38.35.1 2.7 3.94.4 3.WHO reference weight-for-length and weight-for-height Weight-for-length Reference Card (below 87 cm) Boys’ weight (kg) Length G -4 SD-3 1.4 3.34.5 7.57.767 5.82.32.35.95.5 7.9 8.2 9.64.92.5 7.3 749.74.0605.1 8.83.16.9 8.88.6 7.8 7.3 5.75.8 6.72.3 503.010.2 6.1 3.36.6 6.8564.410.5 9.7 3.2 2.977 9.15.6 10.3 4.7 7.2 69 7.83.6 6.99.2 6.18.510.6 71 84 7.36.73.96.7 6.56.52.63.53.17.6 7.23.15.0 8.0 6.67.28.210.79.0 7.77.3 8.22.14.4 3.71.1 8.14.2 6.3 3.7769.7595.46.13.39.96.3 8.32.06.42.9 4.3 6.5 6 3 7 9.98.0 6.3 3.34.13.93.42.6 7.4452.17.0 3.82.28. 10.22.0 6.8 11.0 7.85.89.39.3 799.1 10.8 6.5 9.88.54.575 7.1 2.9483.42.08.08.52.55.48.3544.178 9.49.3 3.3616.8472.9 3.48.4 3.62.02.76.9 7.1 6.57.9 2.53.84.63.1 5.33.65.4708.0 7.37.8 8.06.37.010.510.810.9 4.05.42.54.55.83.68110.6 8.78.72.22.02.173 8. 7 8.6 3.34.82.32.14.9 8.010. 9.3 8.5 2.66.3 10.5554.3 6.28.3 9.87.22.8 636.27.19.48010.01.53.85.48.88.76.0 2.86.52.44.8523.86.07.57.12.42.02.45.7 7.5 6.1 5.1 1.28.26.7 8.9728.19.2 3.3 6.3 667.5626.85.36.4 9.4 7.92.6 6.1 3.9 8.9 7.068 7.6 8.56.15.77.6 8.53. 910.015.9 12.1 13.7 14.415.313.7 13.7 12.4 19.411520.818.9 12.512.3 11.611822.611.415.8 11.4 9.6 12.6 9.215.3 18.320.3 12.417.68912.914.6 SD-2 G irls’ SD-1 SDMedian 10.817.4 17.810.4 11.2 17.8 11.416.492 Median-1 15.1 18.017.6 17.214.0 13.820.0 11.916.6 10.6 14.5 11.713.119.812.2 11.211.916.010.6 13.814.3 10.9 12.8 19.410.815.3 11.7 17.WHO reference weight-for-length and weight-for-height Weight-for-length Reference Card (below 87 cm) Boys’ weight (kg) Length -4 SD-3 8.2 21.620.7 12.813.7 21.191 12.910.511.016.0 13.7 17.412022.413.615.9 12.818.510.315.419.9 13.3 10.816.516.48.817.6 19.6 8.212.810.8 15.1 14.414.416.818.012.8 11.1 13.320.914.718.7 10.415.910215.3 15.3 15.616.213.214.89814.2 96 SD-3 10.617.412.1 10.2 13.414.5 13.9 13.515.911.3 12.212.814.014.614.715.212.6 14.09.020.0 119 22.012.7 12.3 11.9 15.410.115.69.3 14.89.414.217.9 15.4 16.693 13.7 16.212.218.7 10.3 14.713.5 13.5 13.1 9.8 116 21.422.016.211219.9 9.022.620.512.9 208 16.7 12.8 18.8 11.2 16.515.214.2 13.9 10.0 14.6 10.216.316.411.014.1 14.015.011.1 9.9 13.0 16.5 14.4 9.814.414.013.9 15.7 12.8 10.9 11.112.911.3 10.6 97 12.28.6 15.6 12.9 11.3 11.210918.518.9 18.287 11.9 10.412.420.515.3 12.1 13.511.7 14.812.510717.2 17.315.810817.7 12.6 9.7 10.2 17.9 111 13.0 10.611.1 9.29.1 15.4 11.894 SD-2 11.810516.611.3 14.212.5 13.1 9.518.6 15.813.116.7 11.6 10.216.3 13.617.314.89.1 14.213.7 SD 10.214.516.1 12.0 117 21.1 18.111.411.48812.0 19.9 weight (kg) (cm) 11.018.2 12.2106 17.810.99012.510416.815.115.2 99 11.514.313.113.014.010.3 10.6 12.2103 11.0 19.9 17.3 16.511018.910.9 13.4 11.318.2 16.3 14.512.813.013.49.719.0 14.8 17.512.1 12.9 12.1 11.815.5 19.1 13.6113 19.412.3 14.412.513.613.514.510.3 13.413.1 16.5 13.9 13.0 11.610115.611.411.714.5 12.1 SD-4 10.8 11.0 9.3 15.718.011420.1 9.1 9.215.410015.5 17.6 .8 12.7 14.195 13.5 16. It is for a Current weight of the child in g ago in grams = 6000 g 1. Calculate average 100g/day) 3.CALCULATING WEIGHT GAIN This example shows how weight gain over 3 days: • grams = 6300 • Weight3 days Step Step Step to calculate weight gain of a child. in daily g (6300–6000 = weight gain (300g ÷ 300 3 g) days = .15kg = 16. Calculate weight gain 2. Divide by child’s average weight in kg (100 g/day ÷ 6.3 g/kg/day). 209 . Used sharps. catheter. This waste is disposed off by routine municipal council committee machinery. the waste should be disposed off in a proper way. fuids. The following are different colour drums with different color polythene for different type of waste. empty box. Yellow drums / Bags: Infected non-plastic waste Human anatomical waste requires waste. packing material. urine pieces and disposed in blue bag. bags etc. destroy the etc. Patients IV set. BT bag etc. Black drums / Bags: Left over food. To keep the environment clean. in each unit of ward. needles needle destroyer). blade and broken glass set. ET tube. This type (frst the needle in of Blue drums / Bags: Infected plastic waste Used disposable syringes. fruits feeds. placenta etc. should be cut into be autoclaved to make it non-infectious.ANNEXURE: 12 SAFE DISPOSAL OF HOSPITAL WASTE Proper disposal of hospital waste is important to keep the environment clean. blood. waste paper. body incineration. to be disposed off in a different way. vegetables. This waste will is then shredded and disposed off. This . 210 . to feed due to respiratory distress. Apnoeic seconds. Unable . call for help. malaria smear. and malnutrition Convulsing (now) SEVERE DEHYDRATION (ONLY IN CHILD WITH DIARRHOEA) Diarrhoea plus any two of these: • Lethargy • Sunken eyes • Very slow skin pinch If two signs positive check for severe acute malnutrition 70/min. Stridor in a clam child) CIRCULATION Cold hands with: • Capillary refll longer than 3 • Weak and fast pulse IF POSITIVE Check for severe acute COMA CONVULSING • Coma (AVPU) or • (Respiratory rate  Head nodding. draw blood for emergency laboratory investigations (glucose. Hb) AIRWAY AND BREATHING • Not breathing or gasping or • • Central cyanosis or Severerespiratory distress lower chest in-drawing.Proforma for Assessment of Sick Child Case Date Name--------------Age-----------Temp -----------ASK: What are the infant’s ASSESS (Circle all signs present) Recording Form Sex---------Wt------- problems? Emergency treatments • Check for head/neck trauma before treating child – do not move neck if cervical spine injury possible· • EMERGENCY SIGNS: (If any sign positive: give treatment(s). Grunting. Severe spells. PRIORITY SIGNS • Tiny baby • Respiratory • Temperature · (<2 months) distress (RR>60/min) <36.5ºC • • Bleeding Restless.5ºC or > 38. rewarm 211 . Continuously irritable. or lethargy • Trauma or other urgent surgical condition • Referral (urgent) • Pallor (severe) • Malnutrition: Visible severe wasting • Oedema of both feet • Poisoning • Burns (major) Check temperature if baby is cold to touch. •History •Immunization •Examination Temperature - Pulse Resp.depigmentation/desquamation/petichae/purpura/ecchymosis lymphadenopathy . Rate - Weight - Weight for Length/height - - Sensorium Bulging AF - Neck Rigidity Pallor - - Eye- pus/bitots - Generalized spots/corneal involvement .Pedal odema Respiratory systemCardio-vascular systemAbdominal examinationCentral nervous system•Differentialdiagnosis •LabInvestigations •Management Jaundice .Skin. 212 . NOTES: . NOTES: . 213 . 214 .