Download Sepsis

IMCI
young infants aged
between 7 days and 2 months
MAJID MOHAMMADIZADEH MD
ASSISTANT PROFESSOR OF PEDIATRICS
ISFAHAN UNIVERSITY OF MEDICAL SCIENCES
DEPARTMENT OF PEDIATRICS
DIVISION OF NEONATOLOGY
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Elements of
complete IMCI case management process
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Assess a child
• Check first for danger signs (or possible
bacterial infection in a young infant)
• Ask questions about common conditions
• Examine the child
• Check nutrition and immunization status
• Check the child for other health problems
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Classify a child’s illnesses using a colour-coded
triage system
Because many children have more than one
condition, each illness is classified according
to whether it requires:
urgent pre-referral treatment and referral
specific medical treatment and advice
simple advice on home management
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Identify specific treatments for the child
• If a child requires urgent referral, give essential
treatment before the patient is transferred
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If a child needs treatment at home:
– develop an integrated treatment plan for the child
– give the first dose of drugs in the clinic
• If a child should be immunized, give immunizations
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Provide practical treatment instructions for caretaker
• Teach how to:
• give oral drugs
• feed and give fluids during illness
• treat local infections at home
• Ask to return for follow-up on a specific date
• Teach how to recognize signs indicating the
child should return immediately to health facility
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Assess feeding
• Assess breastfeeding practices
• Counsel to solve any feeding problems found
• Counsel the mother about her own health
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Give follow-up care
• Give it according to the problem(s) found in
the first visit
• If necessary, reassess the child for new
problems
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The common practice in all steps
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• The IMCI guidelines address most, but not all, of the
major reasons a sick child is brought to a clinic
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A child returning with chronic problems or less
common illnesses may require special care which is
not described in this session
• The guidelines do not describe the management of
trauma or other acute emergencies due to
accidents or injuries.
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• This session is focused on young infants aged
between 7 days and 2 months
• Infants in this age group are susceptible to
particular infectious agents and when ill, often
show less specific clinical signs
• Conditions in the first 6 days of life (mainly
related to prematurity and complications in
delivery) should be discussed separately
‫محتوای جزوه آموزشی ارزیابی‪ ،‬طبقه بندی و درمان‬
‫شیرخواران بدحال یک هفته تا دو ماه‬
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• As previously mentioned, young infants aged
between 7 days and 2 months are susceptible to
particular infectious agents and, when ill, often
show less specific clinical signs, compared with
children in other age groups.
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• Infections are an important cause of both
morbidity and mortality in this age group
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• Infections are especially important because the
deaths they cause are potentially preventable:
– either by prophylaxis (e.g. tetanus immunization during
pregnancy)
– or early diagnosis and appropriate treatment (e.g. for
pneumonia or sepsis)
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Burden of disease
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• According to WHO estimates in the year 2000
conditions arising in the neonatal period
accounted for about 23% of all child deaths
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• Infections are estimated to cause:
• about 42% of deaths from birth up to 28 days of
age in developing countries
• an even higher proportion of those in the second
month of life
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• The most important, potentially lethal infections
during the first 28 days of life:
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pneumonia
septicemia
meningitis
tetanus
diarrhea
• With the exception of tetanus, which occurs mostly
during the first 2 weeks of life, the same infections
are also the most important causes of mortality for
infants aged 28 days to 2 months
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• Other important infections during the first month
involve :
– umbilical stump
– Skin
– eyes
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• These infections are acquired :
– from a colonized maternal genital tract during
labor and delivery (typically with onset during the
first week of life)
– from contact after birth with organisms in the
newborn’s environment (typically with onset after
the first week of life)
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Serious bacterial infection
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Serious bacterial infections:
• pneumonia
• sepsis
• meningitis
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• The clinical features of young infants with
septicaemia, meningitis or pneumonia are often
nonspecific and overlapping
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Typically, signs and symptoms develop within a few
hours or 1–2 days
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Signs & symptoms
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Temperature (axillary) >37.5 °C or <35.5 °C
Lack of spontaneous movement
Altered mental state (agitation, lethargy, or coma)
Poor feeding
Respiratory rate >60 breaths/minute
Lower chest wall indrawing
Grunting
Cyanosis
A history of convulsions
A bulging fontanel
Slow digital capillary refill
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some other signs & symptoms
• Pallor
• Jaundice
• Episodes of apnea
• Abdominal distention
• Hepatosplenomegaly
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• If there is a feeding problem:
– assess the infant’s position (attachment) and
suckling during breastfeeding
– check the mouth for thrush
• In the absence of a clear cause such as thrush, the
appearance of a feeding problem can be an
important sign of a serious bacterial infection
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• A newborn in the first week of life or young infant
with hypoxic-ischemic encephalopathy may have
some of the above signs
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• Consider neonatal tetanus in a previously
well newborn who at 3–10 days after birth
presents with:
– irritability
– difficulty in sucking
– trismus
– muscle spasms or convulsions
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Bulging fontanelle
sign of meningitis in young infants with an open fontanel
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Bacteria isolated from blood of infants with sepsis
(WHO Young Infants Study Group -multicountry1999)
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Bacteria isolated from CSF of infants with sepsis
(WHO Young Infants Study Group -multicountry1999)
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Diagnosis and management
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• There is real urgency in recognizing illness in a
newborn or young infant and ensuring that the child
has access to trained health care workers for
assessment and most importantly, treatment with
lifesaving antibiotics
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• Such care is most likely to be available at a
well supplied health center or hospital
• Village health workers- especially trained in
home-based neonatal care- can provide
treatment and reduce deaths
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• If skin pustules are present, examine the pus after
Gram staining or culture the pus
• When a bacterial infection is suspected and there
are no localizing signs of infection carry out a
blood culture and urine microscopy or culture
• If meningitis is suspected, carry out a lumbar
puncture and CSF examination
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Supportive care
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• proper maintenance of body temperature (to
avoid hypo- or hyperthermia)
• attention to fluid status
• continued nutrition
• prevention or treatment of hypoglycemia
• attention to respiratory status (airway and
oxygen, if needed and available)
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Thermal environment
• Keep the young infant dry and well wrapped.
• A bonnet or cap is helpful to reduce heat loss.
• Keep the room warm (at least 25 °C)
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As the condition of the young infant improves, keep the
child close to the mother’s body
Keeping the young infant in close skin-to-skin contact
with the mother (“kangaroo mother care”) for 24 hours a
day is as effective as using an incubator or external
heating device to avoid chilling
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Thermal environment
• Pay special attention to avoid chilling the infant
during examination or investigation
• Regularly check that the infant’s temperature is
maintained in the range 36.5–37.5 °C rectal, or
36.0–37.0 °C axillary
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Kangaroo Mother Care
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Thermal environment
• If there is considerable experience with the use of incubators
or indirect heating sources (such as hot water bottles or
heating pads, covered with several layers of cloth or other
insulation), these may be used
• However, they are no more effective than the simple measures
noted above
• Prevent overheating or burns by being especially careful if you
have to use a hot water bottle or heating pad
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Water bottles get cold and must be frequently replaced
• The use of heat lamps is not recommended
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High fever
• Do not use antipyretic agents such as paracetamol
for controlling fever in young infants
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Control the environment
• If necessary, undress the child
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Fluid and nutritional management
• Encourage the mother to breastfeed frequently,
unless the child is in respiratory distress or too sick
to suck from the breast
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In these cases:
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help the mother to express breast milk regularly
• give it to the infant (20 ml/kg body weight) by
dropper (if able to swallow) or by nasogastric tube
6 (8) times a day (or 8–12 times in newborns aged
1–2 weeks)
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Fluid and nutritional management
• Give a total of 120 ml/kg/day
• Give 10 ml/kg expressed breast milk before
departure
• If the mother is not able to express breast milk,
prepare a breast milk substitute or give diluted
cow's milk with added sugar
• If feeding is not possible -even by nasogastric tubemonitor the blood glucose 6 hourly and if
necessary, set up an IV line to administer glucose.
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Fluid and nutritional management
• If it is essential to give IV fluids (e.g. as a vehicle
for IV antibiotics), take care to avoid the risk of
heart failure from fluid overload
• Do not exceed daily fluid requirements
• Monitor the IV infusion very carefully and use an
infusion chamber of 100–150 ml where possible
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Hypoglycaemia
• Check for hypoglycaemia using a capillary blood
dextrostix test
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If the blood glucose is <45 mg/dl treat with 10 ml/kg
of 10% glucose, given by nasogastric tube, and
prevent recurrences by frequent feeding
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Oxygen
• central cyanosis
• grunting with every breath
• difficulty in feeding due to respiratory distress
• severe lower chest wall indrawing
• head nodding
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Oxygen
• Nasal prongs are the preferred method for
delivery of oxygen to this age group, with a
flow rate of 0.5 liter per minute
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Oxygen
• Thick secretions from the throat may be
cleared by intermittent suction, if they are
troublesome and the young infant is too
weak to clear them
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Oxygen
• Oxygen should be stopped when the infant’s
general condition improves and the above
signs are no longer present
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Vitamin K
• Give all sick infants aged <2 weeks 1mg of
vitamin K (IM)
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Treatment of convulsions
• IM phenobarbital (a loading dose of 20 (15) mg/kg)
• If they persist, continue with phenobarbital IM (10
mg/kg per dose) up to a maximum of 40 mg/kg
• If needed, continue with phenobarbital at a
maintenance dose of 5 mg/kg/day
• If there is no response to this treatment, phenytoin
can be given
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Parenteral antibiotics
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• for sepsis when the precise diagnosis
is not established
• for meningitis when the diagnosis of
meningitis has been established or is
strongly suspected
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• These should be given as soon as a diagnosis of
serious bacterial infection is suspected
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• IM administration of antibiotics is recommended
• However, IV administration may be preferable if
there is very good monitoring to ensure that fluid
overload does not occur
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WHO 2000
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Sepsis
• IM ampicillin plus IM gentamicin
• If ampicillin is not available: give IM benzylpenicillin
plus IM gentamicin
• If gentamicin is not available: give instead kanamycin
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Sepsis
• Continue treatment until the infant has remained
well for at least 4 days
• Once the infant’s condition has substantially
improved, oral amoxicillin plus IM gentamicin can be
given
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Sepsis
• Give IM cloxacillin plus IM gentamicin as the
first-line treatment:
– if the infection is hospital-acquired
– if Staphylococcus aureus is known to be an
important cause of neonatal sepsis locally
– if there are signs suggestive of severe
staphylococcal infection such as widespread skin
infection, abscesses or soft tissue infection
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Sepsis
• If there is no response to treatment in the first 48
hours or if the child’s condition deteriorates, add IM
chloramphenicol
• Chloramphenicol should not be used in premature
infants (born before 37 weeks of gestation) and
should be avoided in infants in the first week of life
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If the response to treatment is poor and
pneumococci are resistant to penicillin, change to
IM or IV cefotaxime plus IM ampicillin
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Sepsis
• For neonates in the first week of life, the dosage
regimens may be different to those given above for
young infants
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Meningitis
• IM ampicillin plus IM gentamicin
• An alternative regimen is IM ampicillin plus IM
chloramphenicol
• If gentamicin is not available, kanamycin can be used
instead
• If there is no response to treatment in the first 48 hours
or if the child’s condition deteriorates give
a third-generation cephalosporin such as ceftriaxone
or cefotaxime
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Meningitis
• If accurate bacteriology reporting of CSF specimens is
available and the results are known, continue treatment
with the antibiotic to which the organism is sensitive
• Treatment should be continued for 14 days or until the
young infant has remained well for 4 days, whichever is
longer
• Treatment should be continued IM throughout the course
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WHO 2004
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Sepsis
• ampicillin (or benzyl penicillin) plus gentamicin (or
kanamycin)
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Meningitis
• In infants and young children chloramphenicol plus
ampicillin or chloramphenicol plus benzylpenicillin
are usually effective against S. pneumoniae,
H. influenzae and N. meningitidis
• Increasing resistance to these antibiotics especially
among S. pneumoniae and H. influenzae may
require the use of other agents
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Third-generation cephalosporins such as
ceftriaxone or cefotaxime are effective alternatives
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Meningitis
• It’s important to know the local bacterial resistance
patterns and to follow national guidelines as to
which antibiotics to use
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Meningitis
• In neonates, the most effective antibiotic is
ceftriaxone or Cefotaxime
• Alternatives are gentamicin plus ampicillin or
chlopramphenicol plus ampicillin
– Both combinations, however, have shortcomings:
• Gentamicin does not penetrate well into CSF
• chloramphenicol is ineffective for many E. coli and
some Salmonella
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WHO 2008
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Sepsis
• IM benzylpenicillin plus IM gentamicin
• Treat with antibiotics for at least a total of 10 days
(up to 3 weeks)
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Sepsis
• Continue the IM/IV treatment until the infant has
been well for at least 3 days
• Then substitute the IM/IV treatment with an
appropriate oral antibiotic such as amoxicillin
• Continue to give IM gentamicin until a minimum
treatment of 5 days has been given
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Sepsis
• If there is no response to the treatment after 48
hours or if the infant's condition deteriorates, then
give IV/IM chloramphenicol (but not in
premature/low weight neonates)
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Meningitis
• IM gentamicin AND IM ampicillin if available OR with
IM/IV ceftriaxone
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Treat for 21 days
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Monitoring
• The young infant should be assessed by the
nurse every 6 hours (3 hourly, if very sick)
and by a doctor daily
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Diarrhea
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Notice
• The normally frequent or loose stools of a breastfed
baby are not diarrhea
• The mother of a breastfed baby should be able to
recognize diarrhea by the fact that the consistency
or frequency of the stools will be different from
normal
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Assessment
• The assessment is similar to the assessment of
diarrhea for an older infant or young child but fewer
signs are checked
• Thirst is not assessed
• This is because it is not possible to distinguish
thirst from hunger in a young infant
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Classification
• Diarrhea in a young infant is classified in the same
way as in an older infant or young child
• There is only one possible classification for
persistent diarrhea in a young infant
– This is because any young infant who has persistent
diarrhea has suffered with diarrhea a large part of his
life and should be referred
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Importance
• When diarrhea occurs in young infants the risk of
death is high
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Dehydration is the immediate threat to a young
infant with acute diarrhoea
• Exclusive breastfeeding for the first six months
provides substantial protection against diarrhoea
and diarrhoea-associated mortality
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special points for treatment
• Frequent breastfeeding is essential
• Encourage the mother to breastfeed more
often and for longer
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special points for treatment
• If the young infant has some dehydration give 200–
400 ml ORS solution by cup within the first 4 hours
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Encourage the mother to breastfeed the infant
whenever the infant wants to, and then resume
giving ORS solution
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Give a young infant with some dehydration, who is
not breastfeeding, an additional 100–200 ml of clean
water during this period
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Omphalitis
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Importance
• The necrotic umbilical stump is a particularly good
medium for bacterial growth
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Although inflammation that is immediately adjacent
to the umbilical stump is not lifethreatening, the
close proximity to the umbilical vessels gives
bacteria potential access to the bloodstream, which
increases the risk of bacterial septicaemia
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Severity
• How far down the umbilicus the redness extends
determines the severity of the infection
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If the redness extends to the skin of the abdominal
wall, it is a serious infection
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Treatment
• Peri-umbilical skin redness that does not extend to
the abdominal wall should be treated with
antiseptics applied to the affected area and with an
oral antimicrobial such as amoxicillin for 5 days
• The infant with local skin infection can be treated at
home
• The infant should return for follow-up in 2 days to be
sure the infection is improving
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Treatment
• Parenteral antibiotics and treatment in hospital are
essential if:
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redness extends to the abdominal wall
• induration develops
• the umbilicus drains pus
• the infant develops signs of serious bacterial
infection
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Skin infections
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Treatment
• When these are few isolated and with little or no
surrounding redness, they may be treated by:
• washing carefully with soap and water
• applying a local antiseptic
• giving an oral antimicrobial such as amoxicillin
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Treatment
• If there are numerous pustules or furuncles or they
coalesce to form expanding lesions:
• treatment should be given in hospital with parenteral
antibiotics effective against S. aureus, Str. pyogenes
and Gram-negative pathogens such as the
combination of cloxacillin and gentamicin
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Ophthalmia neonatorum
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Definition
• purulent conjunctivitis in the first 28 days of life
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Etiology
• The most important causes:
– Neisseria gonorrhoeae
– Chlamydia trachomatis
– Staphylococcus aureus
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Infection with N. gonorrhoeae and C. trachomatis is
acquired from an infected mother during passage of
the infant through the birth canal
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Etiology
• In some countries, the prevalence of STDs is very
low and ophthalmia neonatorum is mainly caused by
staphylococcal and Gram-negative organisms
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Gonococcal ophthalmia
• often develops soon after birth, is more severe than
chlamydial ophthalmia and if untreated, can lead to
corneal scarring and blindness
• Because it is a preventable cause of blindness, it is
critical that gonococcal ophthalmia be diagnosed
and treated promptly
• The risk of neonatal infection is related directly to
the prevalence of maternal infection in the area and
inversely to the frequency of antimicrobial eye
prophylaxis
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Chlamydial conjunctivitis
• Rarely causes permanent eye damage
• It correlates with the occurrence of nasopharyngeal
colonization with this agent and with an increased
risk of chlamydial pneumonia in the first few months
of life
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Diagnosis
• Gram stain ofconjunctival pus may reveal Gramnegative diplococci (N.gonorrhoeae) or Grampositive cocci (S. aureus)
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Treatment
• In areas where gonorrhoea is prevalent and where
laboratory diagnosis (eye culture and/or Gram stain)
is not possible, all neonates with ophthalmia should
be treated for presumed gonococcal infection
• Staphylococcal ophthalmia should be treated with
cloxacillin (50 mg/kg, every 6–8 hours depending on
the age of the young infant)
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Local treatment
• Clean the newborn’s eyes with 0.9% saline or
clean water (boiled, then cooled)
• Wipe from the inside to the outside edge, using
a clean swab for each eye
• Wash the hands before and after this treatment
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Assess for possible bacterial infection
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Assess for possible bacterial infection
• It is important to assess the signs in the order on
the chart and to keep the young infant calm
• The young infant must be calm and may be asleep
while you assess the first signs, that is, count
breathing and look for chest indrawing, nasal flaring
and grunting
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Assess for possible bacterial infection
• To assess the next few signs you will pick up the
infant and then undress him, look at the skin all over
his body and measure his temperature
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By this time he will probably be awake and you can
see if he is lethargic or unconscious as observe his
movements
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Assess for possible bacterial infection
• If you find a reason that a young infant needs urgent
referral, you should continue the assessment
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However, skip the breastfeeding assessment
because it can take some time
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COUNT THE BREATHS IN ONE MINUTE
• If the first breath count is 60 breaths or more,
repeat the count
• This is important because the breathing rate of
a young infant is often irregular
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LOOK FOR SEVERE CHEST INDRAWING
• mild chest indrawing is normal in a young
infant because the chest wall is soft
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MEASURE TEMPERATURE
• Fever is uncommon in the first two months of life.
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If a young infant has fever, this may mean the infant
has a serious bacterial infection
• fever may be the only sign of a serious bacterial
infection
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MEASURE TEMPERATURE
• If you do not have a thermometer, feel the infant’s
stomach or axilla (underarm) and determine if it
feels hot or unusually cool
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LOOK FOR SKIN PUSTULES
• A severe pustule is large or has redness extending
beyond the pustule
• Many or severe pustules indicate a serious infection
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SEE IF THE YOUNG INFANT IS LETHARGIC OR UNCONSCIOUS
• Young infants often sleep most of the time and this
is not a sign of illness
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Even when awake, a healthy young infant will
usually not watch his mother and a health worker
while they talk
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SEE IF THE YOUNG INFANT IS LETHARGIC OR UNCONSCIOUS
• A lethargic young infant is not awake and alert
when he should be. He may be drowsy and may
not stay awake after a disturbance
• An unconscious young infant cannot be wakened
at all
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The common practice in all steps
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Urgent referral
• Possible serious bacterial infection
• Severe dehydration with possible serious
bacterial infection
• Severe dehydration without possible serious
bacterial infection, if the caregiver can not give
IV therapy
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check a young infant for feeding problem or low weight
• The assessment has two parts:
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In the first part: you determine:
– if the mother is having difficulty feeding the infant,
what the young infant is fed and how often by asking
her questions
– weight for age
• In the second part: if the infant has any problems
with breastfeeding or is low weight for age, you
assess how the infant breastfeeds
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There is no need to assess breastfeeding if the infant:
• is exclusively breastfed without difficulty and is
not low weight for age
• is not breastfed at all
• has a serious problem requiring urgent referral
to a hospital
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• If needed, observe:
• a whole breastfeed if possible
• for at least 4 minutes
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Assess other problems
• Assess any other problems mentioned by the
mother or observed by you
• Refer to other guidelines on treatment of
those problems
• Refer the infant to hospital if you:
• think the infant has a serious problem
• do not know how to help the infant
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