F imnci management of sick young infant

How to take care of a sick young infant admitted in a hospital

1. MANAGEMENT OF A SICK YOUNG INFANT B.SUDHA PROFESSOR VMCON

2. Learning Objectives After completion of this section the student should be able to- • Provide appropriate fluid therapy • Manage specific conditions – Hypoglycemia , post- asphyxial state, sepsis (including pneumonia and meningitis ), tetanus neonatorum and jaundice • Monitor sick newborn • Provide follow up care after discharge

3. Fluid management Encourage the mother to breastfeed frequently to prevent hypoglycemia . If unable to feed, give expressed breast milk by nasogastric tube. Withhold oral feeding in the acute phase lethargic or unconscious having frequent convulsions apnea , shock or having moderate to severe respiratory distress. bowel obstruction necrotising enterocolitis or the feeds are not tolerated e.g. indicated by increasing abdominal distension or vomiting everything.

4. Give IV fluids Fluid requirement of neonates (ml/per kg body weight) Day of Life Birth Weight ≥1500 g Birth Weight <1500 g 1 60 80 2 75 95 3 90 110 4 105 125 5 120 140 6 135 150 7 150 150

5. Type of fluid • First 2 days : 10% dextrose in water • After 2 days: Use either commercially available pediatric maintenance fluid containing 25mmol/L of sodium(e.g . Isolyte -P) otherwise prepare the fluid by adding 20 ml NS + 1ml Kcl+79 mL of 10% dextrose to make 100ml fluid. irh Weight

6. Monitoring Monitor the IV infusion very carefully. • Use a monitoring sheet • Calculate drip rate • Check drip rate and volume infused every hour • Check for edema /puffiness of eyes (could indicate volume overload) • Weigh baby daily to detect excessive weight gain (excess fluid) or loss (insufficient fluid); adjust IV fluids appropriately . • Adjust daily IV maintenance fluids appropriately if baby is receiving dopamine or any other infusions.

7. ll. Hypoglycemia If hypoglycaemia detected ( defined as < 45 mg/dl for young infants), give 2 ml/kg IV bolus dose of 10% dextrose. • Start infusion of glucose at the daily maintenance volume - provide 6 mg/kg/min of glucose in all cases of neonatal hypoglycemia . • Recheck the blood glucose in 30 minutes. If it is still low, repeat the bolus of glucose (above) and increase infusion rate of glucose to 8 mg/kg/min . If blood sugar still remains low, then increase to 10 mg/kg/min . Once normal, monitor blood sugar every 4-6 hourly . Do not discontinue the glucose infusion abruptly. It can cause rebound hypoglycemia . • Glucose infusion rates ≥ 10mg/kg/min can result in glucose concentration > 13% in the infused fluid. Under such circumstances infusion through peripheral veins is not recommended. It would require infusion through umbilical vein . If you cannot cannulate the umbilical vein refer the baby to a higher health facility. • After the blood sugar has been stabilized step down the concentration of glucose by 2 mg/kg/min every 4-6 hourly ensuring that blood sugar remains normal. Allow the baby to begin breastfeeding. If the baby cannot be breastfed, give expressed breast milk using an alternative feeding method.

8. Post Resuscitation care of Asphyxiated new born Lack of oxygen supply to organs before, during or immediately after birth results in asphyxia which is recognized by either delayed onset of breathing/cry with/without need for assisted ventilation. Clinical features that these babies could manifest with during the first 2-3 days of life include irritability or coma, hypotonia or hypertonia, convulsions , apnea , poor suck and feeding difficulty. Additional problems that these newborns may have include hypoglycemia , shock, renal failure.

9. Management 1 . Check for emergency signs and provide emergency care 2. Place these babies under radiant warmer to maintain normal temperature as they usually have difficulty in maintaining normal body temperature. 3. Check blood sugar and if hypoglycemia is detected, treat it 4 . If convulsions are present, then follow management guidelines If the baby needed an anticonvulsant drug (ACD) to control convulsions review the baby after 72 hrs . When to stop anticonvulsant medication? If the baby has been free of convulsions and is neurologically normal after 72 hrs , then stop the ACD. If at 72 hrs , the baby has hypertonia, continue ACD and refer for assesment .

10. 5. Fluids: In a baby with emergency signs (breathing difficulty, shock, coma or convulsions), provide maintenance intravenous fluids according to age , after initial stabilization of emergency signs. After 24 hrs of hospitalization, if the baby has not lost weight or has gained weight, then restrict maintenance fluid to 60% of requirement. 6. Feeding : If the baby has no emergency signs or abdominal distension, consider enteral feeding. If the baby is sucking well, initiate breast feeding or else initiate gavage feeding with breast milk in those with poor/no sucking. Initiate feeding with 15 ml/kg/day and increase by 15 ml/kg/day for next few days while gradually tapering off IV fluids.

11. Septicemia Common systemic bacterial infections in young infants include sepsis, pneumonia and meningitis and all these may present alike .(signs of bacterial infection) More specific localizing signs of infection which indicate serious bacterial infection include • Painful joints, joint swelling, reduced movement, and irritability if these parts are handled • Many skin pustules/big boil (abscess) • Umbilical redness extending to the periumbilical skin or umbilicus draining pus

12. Treatment of Septicemia • Admit O btain blood cultures before starting antibiotics. • Provide supportive care and monitoring for the sick neonate • Start antibiotics ; give Injection ampicillin and gentamicin. • Give cloxacillin ( if available) instead of ampicillin if extensive skin pustules or abscesses as these might be signs of Staphylococcus infection. • Most bacterial infections in neonates should be treated with antibiotics for at least 7-10 days except meningitis, arthritis , deep abscesses and staphylococcal infections which would require 2-3weeks of therapy. • If not improving in 2–3 days the antibiotic treatment may need to be changed, preferably as per microbial culture reports

13. Supportive care of a septic neonate 1 . Provide warmth, ensure consistently normal temperature 2. Provide bag and mask ventilation with oxygen if breathing is inadequate. 3. Start oxygen by hood or mask, if cyanosed or grunting. 4. Provide gentle physical stimulation, if apneic . 5. Start intravenous line. 6. Infuse glucose (10 percent ) 2 ml/kg stat. 7. If perfusion is poor as evidenced by capillary refill time (CRT) of more than 3 seconds, manage shock as described earlier. 8. Inject Vitamin K 1 mg intramuscularly. 9. Consider use of dopamine if perfusion is persistently poor. 10. Avoid enteral feed if very sick, give maintenance fluids intravenously

14. Meningitis Suspect meningitis in an infant of septicemia if any one of the following signs are present: • Drowsiness, lethargy or unconscious • Persistent irritability • High pitched cry • Apnoeic episodes • Convulsion • Bulging fontanelle To confirm the diagnosis of meningitis a lumbar puncture should be done immediately unless the young infant is convulsing actively or is hemodynamically unstable .

15. Treatment for meningitis Give antibiotics • Give ampicillin and gentamicin or a combination of an aminoglycoside with third generation cephalosporin, such 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.

16. Diarrhoea Diarrhoea may be a sign of systemic sepsis or UTI. Assess for: • Signs of dehydration • Duration of diarrhoea • Blood in stool Treatment : Blood in stool No signs of sepsis: Inj.Vit K Possible Signs: Treat for sepsis/NEC Abd.mass /crying with pallor: surgical reference

17. Treat severe persistent diarrhoea • Admit the young infant. • Manage dehydration if present. • Investigate and treat for sepsis: Start Inj. ampicillin & gentamicin • Encourage exclusive breastfeeding. Help mothers who are not breastfeeding to re-establish lactation. If only animal milk must be given, give a breast milk substitute that is low in lactose. • Give supplement vitamins and minerals for at least 2 weeks

18. Tetanus Neonatorum Causes :Not immunized during the pregnancy ,history of unclean cord cutting practice at birth. Diagnosis: Neonatal tetanus is diagnosed by the presence of: • Onset at 3-14 days • Difficulty in breast feeding • Trismus • Spasms which are provoked by external stimuli eg . touch Treatment Tetanus immunoglobulin ( TIG): TIG - neutralize the circulating toxin. A single dose of 500 units IM is given at admission. Antibiotics Crystalline penicillin - 100,000 unit/kg/day 12 hourly IV to eliminate the source of toxin i.e. Clostridium tetani . An alternative is oral erythromycin (by nasogastric tube) 40 mg/kg/day 12 hourly. Antibiotic therapy is given for 7-10 days.

19. Control of Spasms This is the most important part of management as most deaths occur due to uncontrolled spasms resulting in hypoxic damage . Diazepam is the drug of choice initiated at a dose of 0.1-0. 2 mg/kg/dose given every 3-6 hours. Initially - IV intermittently and later as the spasms are controlled - orally. If spasms are not controlled - diazepam can be increased up to 0.4 -0.6 mg/kg/dose . Chlorpromazine can also be added at a dose of 1-2mg/kg/day in 4 divided doses orally by NG tube. Once spasms are controlled, diazepam is decreased by 10% of its dose every third day. Ensure appropriate supportive care including temperature maintenance, care of airway, breathing, circulation, fluids and nutrition. Provide a quiet and comfortable environment for the baby as stimulation by light, sound and touch induce spasms. Immunization : The neonate at discharge should be advised the standard immunization schedule.

20. Management of Jaundice Treatment Treatment of pathological jaundice is usually phototherapy or an exchange transfusion

21. Monitoring a sick young infant Checklist for monitoring sick young infant (Mnemonic for monitoring: T.A.B.C.F.M.F.M.C.F.)

22. Providing follow-up care 1 . Infants who are discharged from the hospital should return for follow-up care 2. Mother should be advised to return immediately if the Young Infant develops any of the following signs: • Breastfeeding or drinking poorly • Becomes sicker • Develops a fever or feels cold to touch • Fast breathing, Difficult breathing • Diarrhoea with blood in stool • Yellow palms & soles 3. Remind the mother of the Young Infant’s next immunization visit

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