Module 2 Young Infant Nov 2011

Integrated Management of
Newborn and Childhood Illness
Management of Sick Young Infant

From Birth up to 2 Months
(Module 2)
November 2011
Addis Ababa, Ethiopia
INTEGRATED MANAGEMENT OF NEWBORN
AND CHILDHOOD ILLNESS
MANAGEMENT OF THE
SICK YOUNG INFANT
FROM BIRTH UP TO
2 MONTHS
November 2011
CONTENTS
Introduction ........................................................................................................................ 1
Learning objectives .............................................................................................................. 3
1.0 Give essential newborn care .................................................................................... 3
2.0 Assess for birth asphyxia ......................................................................................... 6
3.0 Assess and classify for birth weight and gestational age......................................... 7
4.0 Assess and classify the sick young infant ............................................................... 9

4.1 Check the young infant for very severe disease ........................................ 9
Exercise A ............................................................................................................ 12
4.2 Classify all sick young infants for very severe disease ............................ 13
4.3 Assess and classify jaundice ..................................................................... 15
4.4 Classify all sick young infants for jaundice ............................................. 16
4.5 Assess diarrhoea........................................................................................ 17
4.6 Classify diarrhoea ...................................................................................... 19
Exercise B ............................................................................................................. 21
Exercise C............................................................................................................. 23
4.7 Check for HIV exposure and infection ...................................................... 25

4.8 Then check for feeding problem or underweight ...................................... 26
4.8.1 Ask about feeding and determine weight for age .......................... 27
4.8.2 Assess breastfeeding ...................................................................... 29
4.8.3 Assess feeding when HIV positive mother ..................................... 32
Exercise D ........................................................................................................... 33
4.8.4 Teach correct positioning and attachment for breast feeding ........ 35
Exercise E (Part I – Video Exercise G; Part II – Photo exercises)...................... 37
4.9 Classify feeding problem or underweight ................................................ 39

4.9.1 Classify feeding in infants whose maternal HIV status is
unknown or negative ....................................................................... 39
4.9.2 Classify feeding when an HIV positive mother has decided
not to breastfeed .............................................................................. 40
5.0 Then check the young infant's immunization status ............................................. 41

6.0 Assess other problems .......................................................................................... 45
Exercise F………….. ........................................................................................... 47
Annex: Recording form: Management of the sick young infant age up to 2 months ..... 48
Management of Sick Young Infant i

INTRODUCTION
In this module you will learn how to give essential newborn care and to manage a sick young
infant age up to 2 months. Young infants have special characteristics that must be considered
when classifying their illness. They can become sick and die very quickly from serious bacterial
infections. They frequently have only general signs such as few movements, fever, or low body
temperature. For these reasons, you will asses, classify and treat the young infant somewhat
differently than an older infant (child 2 months -12 months) or young child (12 months – 5 years).
For example, mild chest indrawing is normal in young infants because their chest wall is soft.
The chart ASSESS AND CLASSIFY THE SICK YOUNG INFANT AGE UP TO 2 MONTHS
describes how to assess and classify sick young infants so that signs of disease are not
overlooked. According to the chart, you should ask the mother about the young infant’s problem
and check all young infants for very severe disease and jaundice. Then ask about diarrhoea. If
diarrhoea is present, ask additional questions to help classify diarrhoea. Check all young infants
for feeding problem or underweight. Also check young infants for HIV exposure and infection. If
you are attending the delivery or the baby is brought to you immediately after delivery, give
essential newborn care (), assess and classify for birth weight, gestational age and birth asphyxia.
Also check the young infant's immunization status and assess other problems the mother has
mentioned.
There is a special recording form for young infants. It lists signs to assess in a young infant. (A
copy of this form is in the Annex)
A mother (or other family member such as the father, grandmother, sister or brother) usually
brings a child to the clinic because the child is sick. But mothers also bring children for well-
child visits, immunization sessions and for treatment of injuries. The steps on the ASSESS &
CLASSIFY chart describe what you should do when a mother brings her child to the clinic
because the child is sick. The chart should not be used for a well child brought for immunization
or for problems such as injury or burn.
When patients arrive at most clinics, clinic staff identifies the reason for the child's visit. Clinic
staff obtains the child's weight, length and temperature and record them on a patient chart,
another written record, or on a small piece of paper. Then the mother and child see a health
worker.
When you see the mother and her sick child:
* Greet the mother appropriately and ask her to sit with her child.
You need to know the child's age so that you can choose the right case management chart.
Look at the child's record to find the child's age.
- If the child is from birth up to 2 months, assess and classify the young infant according to
the steps on the YOUNG INFANT chart.
- If the child is age 2 months up to 5 years, assess and classify the child according to the steps
on the ASSESS & CLASSIFY chart age 2 months up to 5 years. (you will learn more about
managing sick children later in the course)
_________________________________________________________________________________________
Management of Sick Young Infant
- Look to see if the child's weight, length and temperature have been measured and recorded.
If not, weigh the child and measure his temperature later when you assess and classify the
child's main symptoms. Do not undress or disturb the child now.
Ask the mother what the young infant’s problems are.
An important reason for asking this question is to open good communication with the mother.
Using good communication helps reassure the mother that her infant/child will receive good care.
When you treat the infant's illness later in the visit, you will need to teach and advise the mother
about caring for her sick infant at home. So it is important to have good communication with the
mother from the beginning of the visit.
To use good communication skills:
 Listen carefully to what the mother tells you. This will show her that you are
taking her concerns seriously.
 Use words the mother understands. If she does not understand the questions you
ask her, she cannot give the information you need to assess and classify the
infant/child correctly.
 Give the mother time to answer the questions. For example, she may need time to
decide if the sign you asked about is present.
 Ask additional questions when the mother is not sure about her answer. When
you ask about a main symptom or related sign, the mother may not be sure if it is
present. Ask her additional questions to help her give clearer answers.
Determine if this is an initial or follow-up visit for these problems. If this is a follow-up visit, you
should manage the infant according to the special instructions for a follow-up visit. These special
instructions are in the follow-up boxes at the bottom of the YOUNG INFANT chart. They are
taught in the module follow-up.
If it is an initial visit, follow the sequence of steps on the chart. This section teaches the steps to
assess and classify a sick young infant at an initial visit.
If you attend the delivery or newborn is brought to you immediately after birth you should do:
 Immediate and postnatal follow-up actions for essential newborn care.
 Check and then classify for birth asphyxia.
 Assess and classify birth weight and gestational age.
For all sick young infants:
 Check for and classify signs of very severe disease and local bacterial infection.
 Check for and classify signs of jaundice.
 Assess for diarrhoea, and classify for dehydration and/or for persistent diarrhoea and/or
dysentery if present.
 Check for HIV exposure and infection.
 Check for feeding problem or underweight. This may include assessing breastfeeding.
Then classify feeding.
 Check the young infant’s immunization status.
 Assess any other problems.
If you find a reason that a young infant needs urgent referral, you should continue the assessment.
However, skip the breastfeeding assessment because it can take some time.
Management of Sick Young Infant 2

LEARNING OBJECTIVES
This module will describe the following tasks and allow practicing some of them (some will be
practiced in the clinic):
* Giving essential newborn care.
* Assessing and classifying a young infant for birth asphyxia.
* Assessing and classifying for birth weight and gestational age.
* Assessing and classifying a young infant for very severe disease or local bacterial
infection
* Assessing and classifying for jaundice.
* Assessing and classifying a young infant with diarrhoea.
* Assessing and classifying a young infant for HIV exposure and infection.
* Checking for a feeding problem or underweight, assessing breastfeeding and classifying

feeding.
* Checking immunization status.
* Assessing other problems

__________________
1.0 GIVE ESSENTIAL NEWBORN CARE (ENC)
Most babies breathe and cry at birth with no help. The care you give immediately after birth
is simple but important. Remember that the baby has just come from the mother’s uterus. It was
warm and quiet in the uterus and the amniotic fluid and walls of the uterus gently touched the
baby. You too should be gentle with the baby and keep the baby warm. Skin-to-skin contact
with the mother keeps baby at the perfect temperature.
In the following pages you will find the steps of immediate care which should be given to all
babies at birth. Steps 4 and 5 will be interrupted by resuscitation if the baby needs help to start
breathing. Immediate care for the mother includes delivery of the placenta as soon as possible
after drying the baby and cutting the cord. Monitor the mother’s condition closely in the minutes
and hours after the birth.

Step 1. Deliver baby onto mother’s abdomen
Step 2. Dry baby’s body with dry and warm towel.
Dry the baby, including the head, immediately. Wipe the eyes. Rub up and down the baby’s back,
using a clean, warm cloth. Drying often provides sufficient stimulation for breathing to start in
mildly depressed newborn babies. Do your best not to remove the vernix (the creamy, white
substance which may be on the skin) as it protects the skin and may help prevent infection. Then
wrap the baby with another dry cloth and cover the head.
Step 3. Assess breathing and color; if not breathing, gasping or blue color of the tongue or
lips, then resuscitate.
As you dry the baby, assess its breathing. If a baby is breathing normally, both sides of the chest will
rise and fall equally at around 30-60 times per minute. Thus, check if the baby is:
1) breathing normally
2) having trouble breathing
3) not breathing at all
4) having blue tongue and lips
This step is used for assessing and classifying the newborn for birth asphyxia. If the baby needs
resuscitation quickly clamp or tie and cut the cord leaving a stump at least 10 cm long for now, stop
the subsequent steps of essential newborn care and start resuscitation. Functional resuscitation
equipment should always be ready and close to the delivery area since you must start resuscitation
within 1 minute of birth.
Step 4. Tie the cord two fingers from abdomen and another tie two finger from the 1st one (if
no clamp). Cut the cord between the 1st and 2nd tie (clamp).
1. Tie the cord securely in two places:

 Tie the first one two fingers away from the baby’s abdomen.
 Tie the second one four fingers away from the baby’s abdomen.
 Make sure that tie is well secured.
 Make sure that the thread you used to tie the cord is clean and safe.
2. Cut the cord between the ties.
 Use a new razor blade, or sterile scissors.
 Use a small piece of cloth or gauze to cover the part of the cord you are cutting
so no blood splashes on you or on others.
 Be careful not to cut or injure the baby. Either cut away from the baby or place
your hand between the cutting instrument and the baby.
3. Do not put anything on the cord stump
Step 5. Place the baby in skin-to-skin contact and on the breast to initiate breastfeeding
The warmth of the mother passes easily to the baby and helps stabilize the baby’s temperature.
1. Put the baby on the mother’s chest, between the breasts, for skin-to-skin warmth
2. Cover both mother and baby together with a warm cloth or blanket
3. Cover the baby’s head
The first skin-to-skin contact should last uninterrupted for at least 1 hour after birth or until after
the first breastfeed.
The baby should not be bathed at birth because a bath can cool him dangerously. After 24 hours,
the baby can have the first sponge bath, if the baby’s temperature is stabilized.

If everything is normal, immediately start breastfeeding and continue doing the following for
optimal breastfeeding.
1. Help the mother begin breastfeeding within the first hour of birth.
2. Help the mother at the first feed. Make sure the baby has a good position, attachment,
and suck effectively. Do not limit the time the baby feeds; early and unlimited
breastfeeding gives the newborn energy to stay warm, nutrition to grow, and antibodies to
fight infection.
Step 6. Give eye care (while the baby is held by his mother) by applying Tetracycline eye
ointment once on both eyes.
Shortly after breastfeeding and within 1 hour of age, give the newborn eye care with an
antimicrobial medication. Eye care protects the baby from serious eye infection which can result
in blindness.
Steps for giving eye care

1. Wash your hands
2. Hold one eye open and apply a rice grain size of tetracycline 1% eye ointment along the
inside of the lower eyelid. Make sure not to let the medicine dropper or tube touch the
baby’s eye or anything else.
3. Repeat this step to put medication into the other eye.
4. Do not rinse out the eye medication.
Step 7. Give Vitamin K, 1mg IM on anterior lateral thigh (while baby held by his mother)
Step 8. Weigh the baby after an hour of birth or after the first breastfeed.
This step is used for assessing and classifying the baby for birth weight and gestational age.
Additionally to the ENC steps above, give BCG and OPV0 before discharge. Provide three
postnatal visits, at 6-24 hours, 3 days and 7days.
STEPS OF IMMEDIATE NEWBORN CARE
- Deliver baby onto the mothers abdomen

- Dry, clean, stimulate and wrap with dry and warm towel
OBSERVE BREATHING
as you dry the baby
- NOT BREATHING
- GASPING - NORMAL BREATHING BABY
- COLOR IS BLUE TONGUE, LIPS
Quickly clamp or tie and cut the cord
leaving a stump at least 10 cm long for now
- Cord tie and secure

- Skin-to-skin contact and initiate
START RESUSCITATION breastfeeding
- Position
- Tetracycline eye ointment
- Clear mouth and nose with clean cloth
- Vitamin K 1 mg IM
- Bag and mask ventilation
- Weigh the baby

2.0 ASSESS FOR BIRTH ASPHYXIA
If you are attending delivery or baby is brought to you immediately after birth; assess for birth
asphyxia. Assess the baby while drying and wrapping with dry cloth. To assess for birth
asphyxia, look and listen for breathing pattern.
 ASSESS
- Is baby not breathing: This means the baby has not cried or no spontaneous
movements of the chest
- Gasping: The attempts to make some effort to breath with irregular and slow
breathing movements
- Count breaths in one minute: The normal breathing rate of the newborn baby is from
30-60 per minute. If the breathing rate is less than 30 per minute it is a sign of
asphyxia.
 CLASSIFY
There are two possible classifications:
- Birth asphyxia
- No birth asphyxia
TREATMENT
SIGNS CLASSIFY AS (Urgent pre-referral treatments are in bold print)
If any of the following sign: Start resuscitation

 Not breathing, OR  Clamp/tie and cut the cord immediately
 Gasping, OR BIRTH  Position the newborn supine with neck slightly
 Breathing poorly ASPHYXIA extended
(<30 breaths/minute), OR  Clear mouth and nose with bulb syringe
 Cyanosis (blue tongue, lips)  Ventilate with appropriate size bag & mask
 If the resuscitation is successful, continue giving
essential newborn care
 If the baby remains weak or is having irregular
breathing after 20 minutes of resuscitation; refer
urgently to hospital while continuing to resuscitate on
the way
 Stop resuscitation after 20 minutes if no response (no
spontaneous breathing)
 Monitor continuously for 6 hours
 Follow after 12 hrs, 24 hrs, 3 days ,7 days and 6 weeks
 Give cord care

• Breathing normally  Initiate skin-to-skin contact
(crying or ≥30 breaths/ NO  Give eye care
minute) BIRTH  Give Vitamin K
AND ASPHYXIA  Initiate breastfeeding
• Pink tongue & lips  Give BCG and OPV 0
 Advise mother when to return immediately
 Follow after, 6 hrs, 3 days and 7days and 6 weeks

Birth asphyxia
If the baby is not breathing or crying at all, gasping or blue discoloration of tongue and lips;
classify as birth asphyxia and start resuscitation. For bag and mask ventilation, use a proper size
(covering the infant’s mouth and nose) mask to cover the baby’s mouth and nose.
To ventilate: - hold the mask with one hand to ensure an air-tight seal using one or two fingers of
the same hand to hold the chin and keep the head slightly extended.
- Squeeze the bag with the other hand using the thumb on one side and the index and middle
finger on the other side of the bag.
- Ventilate about 40 times in 1 minute. After one minute, stop to see if the baby starts
breathing independently. Continue ventilation until the baby spontaneously cries or breaths.
o If he responds, continue with essential new born care.
o If not responding at all after 20 minutes discontinue resuscitation.
o If the baby is responding partially but still remains weak or breathing irregularly,
How
refer urgently to hospital while to ventilate
continuing to resuscitate on the way.
• Squeeze bag with 2 fingers or whole

hand, 2-3 times
How to Ventilate
• Observe for rise of chest.
 Squeeze
• bagCHEST
IF with 2 fingers
IS NOT orRISING:
whole hand, 2-3 times
 Observe for rise of chest.the head
– reposition
 IF CHEST – IS NOT mask
check RISING: seal
o Reposition the head
• Squeeze bag harder with whole hand
o Check mask seal
 Squeeze
• bag harder
Once goodwith
sealwhole
and hand
chest rising,
 ventilate at 40 squeezes per minute
Once good seal and chest rising, ventilate at 40
squeezes per minute
• Observe the chest while ventilating:
 Observe the chest while ventilating:
– is it moving with the ventilation?
o –Is itismoving with the ventilation?
baby breathing spontaneously?
o Is baby breathing spontaneously?
ENCC - 8 11
No birth asphyxia
Breathing normally (crying or 30-60 breaths/minute) and pink tongue and lips. In this case
continue with essential newborn care steps.
3.0 ASSESS AND CLASSIFY FOR BIRTH WEIGHT AND

GESTATIONAL AGE
If you are attending delivery or baby brought to you within 7 days after birth; assess for birth
weight and gestational age.
 ASSESS
- Ask the gestational age; duration of the pregnancy in weeks. Use the mother’s word or
last menstrual period (LMP) to estimate gestational age. If this is not possible use the
weight to classify the newborn.
- Weigh the baby; if you do not have the birth weight (weight taken within 24 hrs of life),
the weight taken in the first 7 days of life may be used for the classification of birth
weight.

 CLASSIFY
There are three possible classifications;
- Very low birth weight and/or very preterm
- Low birth weight and/or preterm
- Normal weight and/or term
SIGNS CLASSIFY AS TREATMENT

 Continue breast feeding ( if not sucking feed
• Weight < 1,500gm VERY LOW expressed breast milk by cup).
OR BIRTH WEIGHT  Start Kangaroo Mother Care
• Gestational age < 32 AND/OR  Give Vitamin K 1mg IM on anterior mid thigh, if not
weeks VERY PRETERM already given
 Refer URGENTLY with mother to hospital with
KMC position
 KMC if <2,000gm
• Weight 1,500 — 2,500 gm LOW  Counsel on optimal breastfeeding
OR BIRTH WEIGHT  Counsel mother on prevention of infection
• Gestational age 32-37 AND/OR  Give Vitamin K 1mg IM on anterior mid thigh
weeks PRETERM  Provide follow-up for KMC
 If baby ≥ 2,000gms follow-up visits
at age 6 –24hrs, 3 days,7days & 6 wks
 Give 1st dose of vaccine
• Weight ≥ 2,500 gm  Counsel on optimal breastfeeding

OR NORMAL  Counsel mother/family on prevention of infection
• Gestational age ≥ 37 BIRTH WEIGHT  Provide follow-up visits at age 6-24 hrs,
weeks AND/OR 3 days, 7 days & 6 wks
TERM  Give 1st dose of vaccine
 Give Vitamin K 1mg IM on anterior mid thigh

4.0 ASSESS AND CLASSIFY THE SICK YOUNG INFANT
4.1 CHECK THE YOUNG INFANT FOR VERY SEVERE DISEASE

and LOCAL BACTERIAL INFECTION
This assessment step is done for every sick young infant. In this step you are looking for signs of
bacterial infection, especially a very severe disease. A young infant can become sick and die very
quickly from very severe disease such as pneumonia, sepsis and meningitis.
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 three signs, that is, count
breathing and look for chest indrawing.
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. By this time he will probably be awake. Then you
observe his movements.
ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS ARE
 Determine if this is an initial or follow-up visit for this problem.

- If follow-up visit, use the follow-up instruction on the bottom of this chart.
- If initial visit, assess the young infant as follows:
CHECK FOR VERY SEVERE DISEASE
Ask Look, Listen, Feel:

 Is the infant having difficulty in  Count the breaths in one minute. YOUNG
feeding? - Repeat the count if ≥ 60/min INFANT
 Look for severe chest indrawing. MUST BE
 Has the infant had convulsions?  See if the young infant is not feeding.
CALM
 See if the infant is convulsing now.

 Look at the umbilicus. Is it red or draining pus?
 Measure temperature (or feel for fever or low body
temperature)
 Look for skin pustules.
 Look at the young infant’s movements.
- Infant move on his/her own
- Infant move only when stimulated
- Infant doesn’t move even when
stimulated
How to assess each sign is described below.
ASK: Is there any difficulty of feeding?

Ask the mother this question. Any difficulty mentioned by the mother is important. This mother
may need counseling or specific help with a difficulty. If the mother says that the infant is not
able to feed, assess breast feeding or watch her try to feed the infant with a cup to see what she

means by this. Any infant who is not able to feed may have a serious infection or other life
threatening problem.
ASK: Has the infant had convulsions?

Convulsions can be generalized or focal. Focal convulsions can be subtle and could be easily
missed. They can present with twitching of the fingers, toes or mouth or rolling of the eyes.
LOOK: Count the breaths in one minute. Repeat the count if elevated.
You must count the breaths the infant takes in one minute to decide if the infant has fast
breathing. The child must be quiet and calm when you look and listen to his breathing. Tell the
mother that you are going to count her infant’s breathing. Remind her to keep her infant calm. If
the infant is sleeping, do not wake the infant.
To count the number of breaths in one minute:
1. Use a watch with a second hand or a digital watch, and you look at the infants’ chest
and count the number of breaths in 60 seconds.
2. Look for breathing movement anywhere on the child's chest or abdomen. Usually you
can see breathing movements even on an infant who is dressed. If you cannot see this
movement easily, ask the mother to lift the infant shirt. If the infant starts to cry, ask
the mother to calm the infant before you start counting.
If you are not sure about the number of breaths you counted (for example, if the infant was
actively moving and it was difficult to watch the chest, or if the infant was upset or crying),
repeat the count. 60 breaths per minute or more is the cut off used to identify fast breathing in a
young infant.
If the first count is 60 breaths or more, repeat the count. This is important because the breathing
rate of a young infant is often irregular. The young infant will occasionally stop breathing for a
few seconds, followed by a period of faster breathing. If the second count is also 60 breaths or
more, the young infant has fast breathing.
LOOK for severe chest indrawing.

If you did not lift the infant's shirt when you counted the infant's breaths, ask the mother to lift it
now.
Look for chest indrawing when the infant breathes IN. Look at the lower chest wall (lower ribs).
The infant has chest indrawing if the lower chest wall go IN when the infant breathes IN. Chest
indrawing occurs when the effort the infant needs to breathe in is much greater than normal. In
normal breathing, the whole chest wall (upper and lower) and the abdomen move OUT when the
infant breathes IN. When chest indrawing is present, the lower chest wall goes IN when the
infant breathes IN.
If you are not sure that chest indrawing is present, look again. If the infant's body is bent at the
waist, it is hard to see the lower chest wall move. Ask the mother to change the infant's position
so that he is lying flat in her lap. If you still do not see the lower chest wall go IN when the infant
breathes IN, the infant does not have chest indrawing.
For chest indrawing to be present, it must be clearly visible and present all the time. If you only
see chest indrawing when the infant is crying or feeding, the infant does not have chest
indrawing.

If only the soft tissue between the ribs goes in when the child breathes in (also called intercostal
indrawing or intercostal retractions), the infant does not have chest indrawing. In this assessment,
chest indrawing is lower chest wall indrawing. This is the same as "subcostal indrawing" or
"subcostal retractions”. It does not include "intercostal indrawing."
Mild chest indrawing is normal in a young infant

because the chest wall is soft. Severe chest indrawing
is very deep and easy to see. Severe chest indrawing is
a sign of pneumonia and is serious in a young infant.
LOOK at the umbilicus – is it red or draining pus?
There may be some redness of the end of/around the umbilicus or the umbilicus may be draining
pus. The cord usually drops from the umbilicus by one week of age.
FEEL: Measure axillary temperature (or feel for fever or low body temperature).
Fever (axillary temperature 37.50C or more) is uncommon in the first two months of life. If a
young infant has fever, this may mean the infant has a serious bacterial infection. In addition,
fever may be the only sign of a serious bacterial infection. Young infants can also respond to
infection by dropping their body temperature to below 35.5 0C. Low body temperature is defined
as body temperature between 35.5 and 36.40C.
If you do not have a thermometer, feel the infant’s abdomen or axilla (underarm) and determine if
it feels hot or unusually cool.
LOOK for skin pustules. Are there pustules?

Examine the skin on the entire body. Skin pustules are red spots or blisters which contain pus.
LOOK at the young infant’s movements. Are they less than normal?
Young infants often sleep most of the time, and this is not a sign of illness. Even when awake, a
healthy young infant will usually not watch his mother and a health worker while they talk, as an
older infant or young child would. If a young infant does not wake up during the assessment, ask
the mother to wake him.
An awake young infant will normally move his arms or legs or turn his head several times in a
minute if you watch him closely. Observe the infant's movements while you do the assessment.
Look and see if the young infant moves when the mother talks or gently shakes the young infant
or when you clap your hands or gently stimulate the young infant.
Does the young infant move only when stimulated?
Does the young infant not move even when stimulated?
NB: - Observation of a young infant’s movement (spontaneous or after stimulation) has been
found to be more objective in assessing the general condition (mental status) of young infants
replacing the previous terminologies of lethargy (infant moving only when stimulated) and
unconsciousness (young infant not moving even when stimulated).

EXERCISE A
Part 1 - Video
You will watch a video of young infants. This will demonstrate how to assess a young infant for
very severe disease and local bacterial infection and show examples of the signs.
Part 2 - Photographs
Study the photographs numbered 60 – 62 in the booklet. Read the explanation below for each
photo.
Photograph 60: Normal umbilicus in a newborn

Photograph 61: An umbilicus with redness
Photograph 62: Skin pustules
Study the photographs numbered 63 – 65. Tick your assessment of the umbilicus of each of these
young infants.
Umbilicus Normal Redness or

draining pus
Photograph 63
Photograph 64
Photograph 65
The group will discuss the video and photographs.

CLASSIFICATION TABLES
Now your facilitator will show you how to use the classification tables.
Signs of illness and their classifications are listed on the ASSESS & CLASSIFY THE SICK
YOUNG INFANT chart in classification tables. Most classification tables have three rows.
Classifications are colour coded into pink, yellow or green. The colour of the rows tells you
quickly if the young infant or the child has a serious illness. You can also quickly choose the
appropriate treatment.
 A classification in a pink row needs urgent attention and referral or admission for
inpatient care. This is a severe classification.
 A classification in a yellow row means that the young infant or the child needs an
appropriate antibiotic or other treatment. The treatment includes teaching the mother how
to give the oral drugs or to treat local infections at home. The doctor advises her about
caring for the young infant or child at home and when she should return.
 A classification in a green row means the young infant or child does not need specific
medical treatment such as antibiotics. The doctor teaches the mother how to care for her
young infant or child at home. For example, you might advise her on feeding her sick
young infant or child or giving fluid for diarrhoea.
Example: Look at the classification table for VERY SEVERE DISEASE AND LOCAL
BACTERIAL INFECTION in infants on page 4 of the chart booklet. The pink row is VERY
SEVERE DISEASE, the yellow row is LOCAL BACTERIAL INFECTION and the green row is
SEVERE DISEASE OR LOCAL INFECTION UNLIKELY.
Depending on the combination of the young infant's signs and symptoms, the young infant is
classified in either the pink, yellow, or green row. The infant is classified only once in each
classification table.
4.2 CLASSIFY ALL SICK YOUNG INFANTS FOR VERY SEVERE

DISEASE AND LOCAL BACTERIAL INFECTION
Classify all sick young infants for bacterial infection. Compare the infant's signs to signs listed
and choose the appropriate classification. If the infant has any sign in the top row, select VERY
SEVERE DISEASE. If the infant has any sign in the second row, select LOCAL BACTERIAL
INFECTION. An infant who has none of the signs gets classification of SEVERE DISEASE OR
LOCAL BACTERIAL INFECTION UNLIKELY.

Here is the classification table for very severe disease.

(Urgent pre-referral treatments are in bold print)
 Not feeding well, OR  Give first dose of intramuscular Ampicillin and
 History of Convulsions/convulsing now, Gentamycin
OR VERY  Treat to prevent low blood sugar
 Fast breathing (≥60 breaths per SEVERE  Warm the young infant by skin-to-skin contact if
minute), OR DISEASE temperature is less than 36.5°C (or feels cold to
 Severe chest indrawing, OR touch) while arranging referral
 Fever (≥37.5°C* or feels hot), OR  Advise mother how to keep the young infant
 Low body temperature (< 35.5°C* or warm on the way to the hospital
feels cold), OR  Refer URGENTLY to hospital
 Movement only when stimulated or no
movement even when stimulated.
 Red umbilicus or draining pus, OR  Give Amoxycillin for 5 days
LOCAL  Teach the mother to treat local infections at home
 Skin pustules BACTERIAL  Advise mother when to return immediately
INFECTION  Follow-up in 2 days
 None of the signs of Very Severe SEVERE  Advise mother to give home care for the young infant
Disease, or Local bacterial infection DISEASE,
OR
LOCAL
INFECTION
UNLIKELY
 Temperature from 35.5°C – 36.4°C  Treat to prevent low blood sugar

(both values inclusive) LOW  Warm the young infant using skin-to-skin contact
BODY for one hour and reassess. If temperature remains
TEMPERATURE same or worse, refer. (Advise mother to continue
feeding and keep the infant warm on the way to
the hospital).
 Follow-up in 2 days
How to use the classification table: After you have completed the assessment of the young infant
for very severe disease, classify all young infants for very severe disease:
VERY SEVERE DISEASE

A young infant with signs in this classification may have a serious disease and be at high risk of
dying. The infant may have pneumonia, sepsis, meningitis or asphyxia. It is difficult to
distinguish between these infections in a young infant. Fortunately, it is not necessary to make
this distinction.
The young infant who is not able to feed has a life-threatening problem. This could be due to a
bacterial infection or another sort of problem. This young infant is classified as VERY SEVERE
DISEASE. The infant requires immediate attention.

A young infant with any sign of VERY SEVERE DISEASE needs urgent referral to hospital.
Before referral, give a first dose of intramuscular antibiotics and treat to prevent low blood sugar.
Malaria is unusual in infants of this age, so give no treatment for possible severe malaria.
Advising the mother to keep her sick young infant warm is very important. Young infants have
difficulty to maintain their body temperature. Low temperature alone can kill young infants.
LOCAL BACTERIAL INFECTION

Young infants with this classification have an infected umbilicus or a skin infection. Treatment
includes giving an appropriate oral antibiotic at home for 5 days. The mother will also treat the
local infection at home and give home care. She should return for follow-up in 2 days to be sure
the infection is improving. Bacterial infections can progress rapidly in young infants.
SEVERE DISEASE OR LOCAL BACTERIAL INFECTION UNLIKELY

A young infant with this classification does not require any specific treatment. Advise mother to
give home care for the young infant.
LOW BODY TEMPERATURE

In the absence of signs of possible serious bacterial infection and severe jaundice, if the axillary
temperature of a young infant is between 35.5-36.4°C (both values inclusive), the baby may not
be sick enough to be referred. Low body temperature in such a case may be due to environmental
factors and may not be a manifestation of infection. Such an infant should be warmed using skin-
to-skin contact (Kangaroo Mother Care) for 1 hour. Treat to prevent low blood sugar. The young
infant should be reassessed after 1 hour for signs of possible serious bacterial infection and the
temperature should be recorded again.
4.3 ASSESS AND CLASSIFY JAUNDICE

This assessment step is done for every sick young infant. In this step you are looking for
signs of jaundice.
CHECK FOR JAUNDICE

 Look for jaundice:
• Is skin on the face or eyes yellow?
• Are the palms and soles yellow?
How to look for Jaundice
Jaundice is yellow discolouration of skin. Almost all newborns may have ‘physiological jaundice’
during the first week of life due to several physiological changes taking place after birth.
Physiological jaundice usually appears between 48-72 hours of age; maximum intensity is seen
on 4-5th day in term and 7th day in preterm neonates and disappears by 14 days. Physiological
jaundice does not extend to palms and soles, and does not need any treatment. However, if
jaundice appears on first day, persists beyond 14 days and extends to palms and soles it is severe
jaundice and requires urgent attention.
To look for jaundice, press the infant’s skin over the forehead with your fingers to blanch,
remove your fingers and look for yellow discoloration under natural light. If there is yellow
discoloration, the infant has jaundice. Look also in to the eyes of the infant for yellowish
discoloration. To assess for severity, repeat the process over the palms and soles too.

4.4 CLASSIFY ALL SICK YOUNG INFANTS FOR JAUNDICE
Classify all sick young infants for jaundice. Compare the infant’s signs to signs listed and
choose the appropriate classification. If the infant has any sign in the top row select SEVERE
JAUNDICE. If the infant has any sign in the last row select JAUNDICE.
Here is the classification table for jaundice.
• Palms and/or soles yellow, OR • Treat to prevent low blood sugar

• Skin and eyes yellow and baby is • Warm the young infant by skin-to-skin contact
< 24 hrs old, OR SEVERE if temperature is less than 36.5°C (or feels cold
• Skin and eyes yellow and baby is JAUNDICE to touch) while arranging referral
≥14 days old • Advise mother how to keep the young infant
warm on the way to the hospital
• Refer URGENTLY to hospital
• Only skin on the face or eyes • Advise mother to give home care for the young
yellow, AND JAUNDICE infant
• Infant aged 2-13 days old • Advise mother when to return immediately
• Follow-up in 2 days
• No yellowish discoloration of the NO • Advise mother to give home care for the infant
eye or skin JAUNDICE
SEVERE JAUNDICE
A sick young infant with SEVERE JAUNDICE is at risk of suffering from bilirubin
encephalopathy (kernicterus), or might need surgical intervention for neonatal cholestasis.
Therefore, such an infant needs to be referred to appropriate health facility where the young
infant can be investigated and appropriately treated. Such infants also need to be treated to
prevent low blood sugar, to be kept warm while referral is being arranged and on the way to the
hospital.
JAUNDICE
A sick young infant with JAUNDICE may be having physiological jaundice. However jaundice
in such infants can increase and need to be followed up. The mother is given advise on home care
for the young infant, told when to return immediately and followed up in 2 days to asses level of
jaundice.
Continuation of EXERCISE A Part 1

Video Demonstration on How to Assess Jaundice
You will watch a video of young infants. This will demonstrate how to assess a young infant for
jaundice and show examples of the sign.

4.5 ASSESS DIARRHOEA
Diarrhoea occurs when stools contain more water than normal. Diarrhoea is also called loose or
watery stools. Frequent passing of normal stools is not diarrhoea. The number of stools normally
passed in a day varies with the diet and age of the child. Diarrhoea is defined as three or more
loose or watery stools in a 24-hour period. It is common in children, especially those between 6
months and 2 years of age. It is more common in babies under 6 months who are drinking cow’s
milk or infant feeding formulas.
Mothers usually know when their children have diarrhoea. They may say that the child’s stools
are loose or watery. Mothers may use a local word for diarrhoea.
Babies who are exclusively breastfed often have stools that are soft; this is not diarrhoea. The
mother of a breastfed baby can recognize diarrhoea because the consistency or frequency of the
stools is different than normal.
If the mother says that the young infant has diarrhoea, assess and classify for diarrhoea. The
normally frequent or loose stools of a breastfed baby are not diarrhoea. The mother of a breastfed
baby can recognize diarrhoea because the consistency or frequency of the stools is different than
normal. The assessment is similar to the assessment of diarrhoea for an older infant or young
child, but fewer signs are checked. Thirst is not assessed since it is not possible to distinguish
thirst from hunger in a young infant. General condition is assessed by observing movement and
whether the young infant is restless and irritable.
A young infant with diarrhoea is assessed for:
 how long the child has had diarrhoea
 blood in the stool to determine if the young infant has dysentery, and
 signs of dehydration.
Look at the following steps for assessing a child with diarrhoea:
Does the young infant has diarrhea?
IF YES, ASK: LOOK AND FEEL:
 For how long?  Look at young infant’s general condition.

Infant moves only when stimulated
Infant does not move even when stimulated
Is the infant restless and irritable?
 Is there blood in the stool?
 Look for sunken eyes.
 Pinch the skin of the abdomen.
Does it go back:
 Very slowly (longer than 2 seconds)?
 Slowly?
Ask about diarrhoea in ALL young infants:
ASK: Does the young infant have diarrhoea?

Use words for diarrhoea the mother understands. If the mother answers NO, you do not need to
assess the child further for signs related to diarrhoea. If the mother answers YES, then assess the
child for signs of dehydration, dysentery and persistent diarrhoea.

ASK: For how long?
Diarrhoea which lasts 14 days or more is persistent diarrhoea. Give the mother time to answer the
question. She may need time to recall the exact number of days.
ASK: Is there blood in the stool?

Ask the mother if she has seen blood in the stools at any time during this episode of diarrhoea.
Next, check for signs of dehydration.

When a young infant becomes dehydrated, he/she is at first restless and irritable. If dehydration
continues, the infant’s spontaneous and stimulated movements will be decreased. As the child's
body loses fluids, the eyes may look sunken. When pinched, the skin will go back slowly or very
slowly.
LOOK and FEEL for the following signs:
LOOK at the young infant’s movements. Are they less than normal?
Observe the infant's movements while you do the assessment. Look and see if the young infant
moves when the mother talks or gently shakes the young infant or when you clap your hands or
gently stimulate the young infant.
Does the young infant move only when stimulated?
Does the young infant not move even when stimulated?
A young infant has the sign restless and irritable if the infant is restless and irritable all the time
or every time he is touched and handled. If an infant is calm when breastfeeding but again
restless and irritable when he stops breastfeeding, he has the sign "restless and irritable".
LOOK for sunken eyes.

The eyes of a young infant who is dehydrated may look sunken. Decide if you think the eyes are
sunken. Then ask the mother if she thinks her infant’s eyes look unusual. Her opinion helps you
confirm that the infant’s eyes are sunken.
PINCH the skin of the abdomen.

Does it go back: Very slowly (longer than 2 seconds)? Slowly?
Ask the mother to hold the young infant so he is lying flat on her lap. Locate the area on the
child's abdomen halfway between the umbilicus and the side of the abdomen. To do the skin
pinch, use your thumb and first finger. Do not use your fingertips because this will cause pain.
Place your hand so that when you pinch the skin, the fold of skin will be in a line up and down
the child's body and not across the child's body. Firmly pick up all of the layers of skin and the
tissue under them. Pinch the skin for one second and then release it.
When you release the skin, look to see if the skin pinch goes back:
- Very slowly (longer than 2 seconds)
- Slowly
- Immediately
If the skin stays up for even a brief time after you release it, decide that the skin pinch goes back
slowly.

4.6 CLASSIFY DIARRHOEA
To assess for diarrhea compare the infant’s signs to the signs listed and choose one classification
for dehydration. Choose an additional classification if the infant has diarrhoea for 14 days or
more, or blood in the stool.

(Urgent pre-referral treatments are in bold print)
Two of the following signs: ► If infant has another severe classification:
 Movement only when stimulated, or SEVERE - Refer URGENTLY to hospital with mother giving
no movement even when stimulated DEHYDRATION frequent sips of ORS on the way
 Sunken eyes - Advise mother to continue breastfeeding more
 Skin pinch goes back very slowly frequently
- Advise mother how to keep the young infant warm on
the way to hospital
► If infant does not have any other severe classification; give
fluid for severe dehydration (Plan C).
Two of the following signs:  If infant has another severe classification:

 Restless, irritable SOME - Refer URGENTLY to hospital with mother giving
 Sunken eyes DEHYDRATION frequent sips of ORS on the way
 Skin pinch goes back slowly - Advise mother to continue breastfeeding more
frequently
- Advise mother how to keep the young infant warm on
the way to hospital
 If infant does not have any other severe classification;
- Give fluid for some dehydration (Plan B)
- Advise mother when to return immediately
- Follow-up in 2 days
 Not enough signs to classify as NO  Advise mother when to return immediately
some or severe dehydration DEHYDRATION  Follow-up in 5 days if not improving
 Give fluids to treat diarrhoea at home (Plan A)
 Diarrhoea lasting 14 days or more SEVERE  Give first dose of IM Ampicillin and Gentamycin
PERSISTENT  Treat to prevent low blood sugar
DIARRHOEA  Advise how to keep infant warm on the way to the
hospital
 Refer to hospital
 Blood in stool DYSENTERY  Give first dose of IM Ampicillin and Gentamycin

 Treat to prevent low blood sugar
 Advise how to keep infant warm on the way to the
hospital
 Refer to hospital
Note that there is only one possible classification for persistent diarrhoea in a young infant. This
is because a young infant who has persistent diarrhoea has suffered with diarrhoea a large part of
his life and should be referred.

Using the Young Infant Recording Form
You will learn to record information about the sick young infant on a special form. This form is
called a Recording Form. The front of the Recording Form is similar to the ASSESS &
CLASSIFY chart. It lists the questions to ask the mother and the signs for which you should look,
listen and feel.
Now your facilitator will show you a Young Infant Recording form.
Below is part of a Young Infant Recording Form.

The top lines are for recording name, age, sex, weight, temperature, the infant’s problems and
whether this is an initial or follow up visit.
The next sections are for assessing and classifying BIRTH ASPHYXIA, BIRTH WEIGHT AND
GESTATIONAL AGE, VERY SEVERE DISEASE, JAUNDICE, DIARRHOEA and
FEEDING PROBLEM AND UNDERWEIGHT. Study the example below. It has been
completed to show part of the assessment results and classifications for the infant Jemal.
MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS

Name: ______Jemal_____ Age: __3___ weeks Sex:_M___ Weight: __3000__ gm Length: __50__ cm Temperature: _37___°C
ASK: What are the infant’s problems? _______diarrhea and rash_______________________ Initial visit? ___ Follow-up Visit? ___
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR BIRTH ASPHYXIA (immediately after birth) Not breathing Gasping
Is breathing poorly (< 30 per minute)
Blue tongue & lips
ASSESS FOR BIRTH WEIGHT AND GESTATIONAL AGE
(the first7 days of life) Weigh the baby:
Ask gestational age; <32 weeks, 32-37weeks, ≥ 37weeks <1,500gms, 1,500 - 2,500gms, ≥2,500gms
CHECK FOR VERY SEVERE DISEASE and LOCAL BACTERIAL INFECTION
· Count the breaths in one minute. 55__breaths per minute Local bacterial
- Is the infant having feeding difficulty? Yes No  Repeat if (≥ 60) elevated ________ Fast breathing? infection
· Look for severe chest indrawing
· Look if the Infant is convulsing now.
- Has the infant had convulsions? Yes No  · Look at umbilicus. Is it red or draining pus?
· Fever (temperature > 37.5°C or feels hot) or body temperature below 35.5°C
(or feels cool) or body temperature between 35.5-36.4°C.
· Look for skin pustules.
· Look at young infant’s movements.
Does the infant move only when stimulated?
Does the infant not move even when stimulated?
CHECK FOR JAUNDICE Are skin on the face or eyes yellow? No jaundice
Are the palms and soles yellow?
DOES THE YOUNG INFANT HAVE DIARRHOEA?Yes ____ No ____ ·Look at the young infant’s general condition.
· For how long? __2_____ Days Does the infant not move even when stimulated? Some
Is the infant restless or irritable?
Look for sunken eyes.
dehydration
· Is there blood in the stools? Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Slowly?

EXERCISE B
Note: This picture means you will do a written exercise. You will read case studies describing
signs and symptoms in sick children. You will use the Recording Form to record the child's signs
and how you classified the illness. When you finish the exercise, a facilitator will discuss your
work with you. The facilitator can also answer your questions about information in the module or
on the chart.
* * *
In this exercise you will practice recording assessment results on Young Infant Recording Form.
You will classify the infants for possible bacterial infection and diarrhoea.
Get 3 blank Young Infant Recording Forms from a facilitator. Also, turn to the YOUNG INFANT
chart in your chart booklet.
To do each case:
1. Label a recording form with the young infant’s name.
2. Read the case information. Write the infant’s age, sex, weight, temperature and problem.
check “Initial Visit”. (All the infants in this exercise are coming for an initial visit).
3. Record the assessment results on the form.
4. Classify the infant for very severe disease and diarrhoea.
5. Then go to the next case.
Case 1: Ababu
Ababu is a 3-weeks-old male neonate. His weight is 3.6 kg and his length is 50 cm His
axillary temperature is 36.5ºC. He is brought to the clinic because he is having difficulty
breathing. The health worker first checks the young infant for signs of very severe
disease. His mother says that Ababu has not had convulsions. The health worker counts
74 breaths per minute. He repeats the count. The second count is 70 breaths per minute.
He has mild chest indrawing. The umbilicus is normal, and there are no skin pustules.
Ababu is calm and awake, and his movements are normal. He does not have diarrhoea.

Case 2: Shashie
Shashie is 5 weeks old female infant. Her

weight is 4 kg and length is 50 cm. Her
axillary temperature is 37°C. Her mother
brought her to the clinic because she has a
rash. The health worker assesses for signs of
very severe disease. Shashie’s mother says
that there were not convulsions. Shashie’s
breathing rate is 55 per minute. She has no
chest indrawing. Her umbilicus is normal. The
health worker examines her entire body and
finds a red rash with just a few skin pustules
on her buttocks. She is awake, and her movements are normal. She does not have
diarrhoea.
Case 3: Hana
Hana is 7 weeks old female infant. Her weight is 3 kg and her length 51 cm. Her axillary
temperature is 36.4ºC. Her mother has brought her because she has diarrhoea. The health
worker first assesses her for signs of very severe disease. Her
mother says that she has not had convulsions. Her breathing
rate is 58 per minute. She was sleeping in her mother’s arms
but awoke when her mother unwrapped her. She has slight
chest indrawing. Her umbilicus is not red or draining pus. She
has a rash in the area of her diaper, but there are no pustules.
She is crying and moving her arms and legs.
When the health worker asks the mother about Hana’s

diarrhoea, the mother replies that it began 3 days ago, and
there is blood in the stool. Hana is still crying. She stopped
once when her mother put her to the breast. She began crying
again when she stopped breastfeeding and is moving actively
without stimulation. Her eyes look normal, not sunken. When the skin of her abdomen is
pinched, it goes back slowly.
When you have completed this exercise, please discuss your

answers with a facilitator.
Note: Keep the recording forms for these 3 young infants. You will continue to assess, classify
and identify treatment for them later in this module.

EXERCISE C
This exercise is a video case study of a young infant. You will practice assessing and
classifying the young infant for very severe disease and diarrhoea. Write your assessment
results on the recoding form on the next page. Then record the infant’s classifications.

Name: _____________________________________ Age: _____ weeks Sex:____ Weight: _______ gm Length: _______ cm Temperature: ____°C
ASK: What are the infant’s problems? ________________________________________________________________ Initial visit? ___ Follow-up Visit? ___
Blue tongue & lips
· Count the breaths in one minute. ____breaths per minute
- Is the infant having feeding difficulty? Repeat if (≥ 60) elevated ________ Fast breathing?
- Has the infant had convulsions? · Look if the Infant is convulsing now.
· Look at umbilicus. Is it red or draining pus?
· Fever (temperature > 37.5°C or feels hot) or body temperature below 35.5°C
(or feels cool) or body temperature between 35.5-36.4°C.
CHECK FOR JAUNDICE Are skin on the face or eyes yellow?
DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes ____ No ____ ·Look at the young infant’s general condition.
· For how long? _______ Days Does the infant not move even when stimulated?
CHECK FOR HIV INFECTION
ASK: HIV status of the mother? Positive_____ , Negative____ , Unknown _____
Antibody HIV status of the infant? Positive_____, Negative____ , Unknown _____
DNA/PCR HIV status of the infant? Positive_____ , Negative____ , Unknown _____
THEN CHECK FOR FEEDING PROBLEM OR UNDERWEIGHT
- Is there any difficulty of feeding? Yes _____ No _____ - Determine weight for age.
- Is the infant breastfed? Yes _____ No _____ If Yes, how many times in 24 hrs? _____ times Underweight ___
- Do you empty one breast before switching to the other? Yes___ No__ NOT Underweight ___
- Do you increase frequency of breastfeeding during illness? Yes___ No___ - Look for ulcers or white patches in the mouth (oral thrush).
- Does the infant receive any other foods or drinks? Yes ___ No ___ If Yes, how often?_____ times
- What do you use to feed the child?
If the infant has no indications to refer urgently to hospital and is on breastfeeding: ASSESS BREASTFEEDING:
- Has the infant breastfed in the previous hour? - Is the infant able to attach? To check attachment, look for:
- If infant has not fed in the previous hour, ask the mother to put her infant - Chin touching breast Yes ___ No ___
to the breast. Observe the breastfeed for 4 minutes. - Mouth wide open Yes ___ No ___
- If the infant was fed during the last hour, ask the mother if she can wait - Lower lip turned outward Yes ___ No ___
and tell you when the infant is willing to feed again - More areola above than below the mouth Yes ___ No ___
Good attachment_____ Poor attachment______ No attachment at all ____
- Is the infant positioned well? To check positioning, look for:
- Infant’s head and body straight Yes ___ No ___ - Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
- Facing the breast Yes ___ No ___ Suckling effectively_____ not suckling effectively______ not suckling at all____
- Infant’s body close to her body Yes ___ No ___
- Supporting the whole body Yes ___ No ___
Good Positioning_____ Poor positioning________
ASSESS FEEDING, WHEN HIV POSITIVE MOTHER NOT BREAST FEEDING
- Is there any difficulty feeding?
- What milk are you giving?__________________
- How many times during the day and night? - Determine weight for age:
- How much is given at each feed? Underweight ___
- How are you preparing the milk? NOT Underweight ___
- Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant - Look for ulcers or white patches in the mouth (oral thrush).
- Are you giving any breast milk at all?
- What foods or fluids in addition to the replacement feeding is given?
- How is the milk being given? Cup or bottle?
- How are you cleaning the feeding utensils
CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS Circle immunizations needed today. Return for next
__________ ____________ ___________ _______________ ____________ immunization on:
OPV 0 BCG OPV 1 DPT1-HepB1-Hib1 PCV1 ______________
ASSESS OTHER PROBLEMS:
COUNSEL THE MOTHER ABOUT HER OWN HEALTH

4.7 CHECK THE YOUNG INFANT FOR HIV EXPOSURE and
INFECTION
The exact prevalence of HIV in children is not known; however, there were nearly 80,000
children under 14 years living with HIV/AIDS in Ethiopia at the end of 2010. Mother-to-child
transmission of HIV (MTCT) is the main way (90%) through which children are infected with
HIV. The average risk of HIV transmission from mother to child is about one-third and
transmission can occur during pregnancy, labour and delivery and postnatally through
breastfeeding. There is a 15-20% risk of HIV transmission through breastfeeding only if an HIV
positive mother feeds her infant breastmilk for 24 months. If HIV positive women feed their
infants breastmilk exclusively for 6 months only, the risk of transmission of HIV through
breastfeeding gets less. Studies have shown that exclusive breastfeeding carries a smaller risk of
HIV transmission when compared with mixed feeding.
Early diagnosis of HIV infection & treatment in infants and children is important since the
disease progresses rapidly in children with 50% & 75%mortality by age two and five
respectively. Passively transferred maternal HIV antibodies make interpretation of positive
antibody tests difficult in children less than 18 months of age. In order to diagnose HIV infection
definitively in these group of children, assays that detect the virus or its components (i.e.
virologic tests) are required. DNA PCR is the preferred method of choice for HIV diagnosis in
infants and children under 18 months. Use of Dried Blood Spots (DBS) for DNA PCR has been
shown to be a reliable means of increasing access to infant HIV diagnosis since it is easier to
obtain, store and transport for centralized testing. In children 18 months and older, rapid antibody
Tests reliably diagnose HIV infection.
Look at the chart on assessing and classifying the sick young infant for HIV infection.
ASK:
1. What is the HIV status of the mother?
• Positive • Negative • Unknown
2. What is the HIV status of the young infant?

HIV Antibody test:
DNA PCR test:


CLASSIFY the sick young infant for HIV infection based on the test result:
SIGN CLASSIFY AS TREATMENT
 Young infant DNA PCR ► Give Cotrimoxazole Prophylaxis from 6 weeks of age
positive HIV ► Assess feeding and counsel
INFECTED ► Advise on home care
► Refer to ART clinic for immediate ART initiation and care
► Ensure mother is tested and enrolled for HIV care and
treatment
 Mother HIV positive, AND ► Give Cotrimoxazole Prophylaxis from 6 weeks of age
young infant DNA PCR HIV ► Assess feeding and counsel
negative/unknown EXPOSED ► If DNA PCR test is unknown, test as soon as possible
OR starting from 6 weeks of age
 Young infant HIV antibody ► Refer to ART clinic for follow-up
positive ► Ensure mother is tested & enrolled in HIV care and
treatment
 Mother and young infant not HIV ► Counsel the mother for HIV testing for herself and the
tested STATUS infant
UNKNOWN ► Advise on home care of infant
► Assess feeding and counsel
 Mother or young infant HIV HIV ► Advise on home care of infant
antibody negative INFECTION ► Assess feeding and counsel
UNLIKELY ► Advise the mother on HIV prevention
4.8 CHECK FOR FEEDING PROBLEM OR UNDER WEIGHT

Adequate feeding is essential for growth and development. Poor feeding during infancy can have
lifelong effect. Growth is assessed by determining weight for age. It is important to assess a
young infant’s feeding and weight so that feeding can be improved if necessary.
The best way to feed a young infant is to breastfeed exclusively. Exclusive breastfeeding means
that the infant takes only breast milk, and no additional food, water or other fluids (Medicines and
vitamins are exceptions).
Exclusive breastfeeding gives a young infant the best nutrition and protection from disease. If
mothers understand that exclusive breastfeeding gives the best chances of good growth and
development, they may be more willing to breastfeed. They may be motivated to breastfeed to
give their infants a good start in spite of social or personal reasons that make exclusive
breastfeeding difficult or undesirable.
The assessment has two parts. In the first part, you ask the mother questions. You determine if
she is having difficulty of feeding the infant, what the young infant is fed and how often. You
also determine weight for age and check for mouth ulcers or white patches.

In the second part, if the infant is breastfeeding and has no urgent referral problem, then assess
breast feeding.
4.8.1 Ask About Feeding and Determine Weight for Age
The first part of the assessment is shown in the box below.
THEN CHECK FOR FEEDING PROBLEM OR UNDERWEIGHT:
Ask Look, Feel:

 Is there any difficulty of feeding?  Determine weight for age
 Is the infant breastfed? If yes?  Look for ulcers or white patches in the
How many times in 24 hours? mouth (thrush)
 Do you empty one breast before switching to the other?
 Do you increase frequency of breastfeeding during illness?
 Does the infant receive any other foods or drinks? If yes,
how often?

Any difficulty mentioned by the mother is important. This mother may need counseling or
specific help with a difficulty. Breastfeeding difficulties mentioned by a mother may include: her
infant feeds too frequently, or not frequently enough: she does not have enough milk; her nipples
are sore; she has flat or inverted nipples; or the infant does not want to take the breast.
If a mother says that the infant is not able to feed, assess breastfeeding or watch her try to feed
the infant with a cup to see what she means by this. An infant who is not able to feed may have a
serious infection or other life-threatening problem and should be referred urgently to hospital.
ASK: Is the infant breastfed? If yes, how many times in 24 hours?

The recommendation is that the young infant be breastfed as often and for as long as the infant
wants, day and night. This should be 8 or more times in 24 hours.
ASK: Do you empty one breast before switching to the other?

One breast has to be emptied before switching to the other for maximal production of milk and
for maximal delivery of protein, calories and water to the infant.
ASK: Do you increase frequency of breastfeeding during illness?

Frequency of feeding has to be increased during illness because of an increased demand of an
infant’s body during illness.
ASK: Does the infant receive any other foods or drinks? If yes, how often?
A young infant should be exclusively breastfed. Find out if the young infant is receiving any
other foods or drinks such as other milk, juice, tea, thin porridge, dilute cereal, or even water. Ask
how often he receives it and the amount. You need to know if the infant is mostly breastfed, or
mostly fed on other foods.
ASK: What do you use to feed the infant?

If an infant takes other foods or drinks, find out if the mother uses a feeding bottle, cup or others.

LOOK: Determine weight for age
Use appropriate weight for age chart (for boys or girls) to determine if the young infant is
underweight. Young infants whose weight for age lies below the -2 Z-score are underweight,
while those whose weight for age is at -2 Z-score and above are not underweight.
Since the age of a young infant is usually stated in weeks, remember to use the weight for age
chart labeled in weeks. Some young infants who are underweight were born with low birth
weight. Some did not gain weight well after birth.
EXAMPLE: A young female infant is 6 weeks old and weighs 3 kg. Here is how the health
worker checked weight for age of the infant.
This is the line for 3 kgs This is where the two lines meet
This is the line for 6 weeks
LOOK for ulcers or white patches in the mouth (thrush)

Look inside the mouth at the tongue and inside of the cheek. Thrush looks like milk curds on the
inside of the cheek, or a thick white coating of the tongue. Try to wipe the white off. The white
patches of thrush will remain.
[
Your facilitator will lead a drill to give you practice reading a weight for age chart for a
young infant.

4.8.2 Assess Breastfeeding
This is the second part of the feeding assessment.
First decide whether to assess the infant’s breastfeeding:
* If the infant is not breastfed at all, do not assess breastfeeding.
* If the infant has a serious problem requiring urgent referral to a hospital, do not assess
breastfeeding.
Otherwise, assess breast feeding in all young infants. Observe a breastfeed as described below:
IF AN INFANT:
Is on breastfeeding, AND
Has no indication to refer urgently to hospital
ASSESS BREASTFEEDING: Has the infant breastfed in the previous hour?
- If the infant has not fed in the previous hour, ask the mother to put her infant to the breast.
Observe the breastfeed for 4 minutes.
- If the infant was fed during the last hour, ask the mother if she can wait and tell you
when the infant is willing to feed again.
- Is the infant well positioned?
- Is the infant able to attach?
To check the positioning, look for To check the attachment, look for:
- Infant’s head and body straight - Chin touching the breast
- Facing her breast - Mouth wide open
- Infant’s body close to her body - Lower lip turned outward
- Supporting the infant’s whole body (all of - More areola visible above than below the mouth
these signs should be present if the positioning (all of these signs should be present if the
is good) attachment is good)
 Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
Not suckling at all Not suckling effectively Suckling effectively
Clear blocked nose if it interferes with breastfeeding.
Assessing breastfeeding requires careful observation.

ASK: Has the infant breastfed in the previous hour?
If so, ask the mother to wait and tell you when the infant is willing to feed again. In the
meantime, complete the assessment by assessing the
infant’s immunization status. You may also decide
to begin any treatment that the infant needs, such as
giving an antibiotic for LOCAL BACTERAL
INFECTION or ORS solution for SOME
DEHYDRATION.
If the infant has not fed in the previous hour, he may

be willing to breastfeed. Ask the mother to put her
infant to the breast. Observe a whole breastfeed if
possible, or observe for at least 4 minutes.
Sit quietly and watch the infant breastfeed.

LOOK: Is the infant well positioned?
The four signs of good positioning are:
 Infant’s body straight
 Head and body facing breast
 Infant’s body close to mother’s body
 Supporting infant’s whole body
If all of the above are present, the infant has good positioning.
LOOK: Is the infant able to attach?

The four signs of good attachment are:
 Chin touching breast (or very close)
 Mouth wide open
 Lower lip turned outward
 More areola visible above than below the mouth
If all of these four signs are present, the infant has good attachment.
Good attachment
G
If attachment is not good, you may see:
- chin not touching breast

- mouth not wide open lips pushed forward
- lower lip turned in, or
- more areola (or equal amount) visible below infant’s
mouth than above it
Poor attachment
If you see any of these signs of poor attachment, the infant is not well attached.

If a very sick infant cannot take the nipple into his mouth and keep it there to suck, he has no
attachment at all. He is not able to breastfeed at all.
If an infant is not well attached, the results may

be pain and damage to the nipples. Or the
infant may not remove breastmilk effectively
which may cause engorgement of the breast.
The infant may be unsatisfied after breastfeeds
and want to feed very often or for a very long
time. The infant may get too little milk and not
gain weight, or the breastmilk may dry up. All
these problems may improve if attachment can
be improved.
Baby’s body away from mother,
Baby’s body close, facing breast neck twisted
LOOK: Is the infant suckling effectively?

The infant is suckling effectively if he suckles with slow deep sucks and sometimes pauses. You
may see or hear the infant swallowing. If you can observe how the breastfeed finishes, look for
signs that the infant is satisfied. If satisfied, the infant releases
the breast spontaneously (that is, the mother does not cause
the infant to stop breastfeeding in any way). The infant
appears relaxed, sleepy, and loses interest in the breast. To assess breast feeding:
1. Check for positioning
An infant is not suckling effectively if he is taking only 2. Check for attachment
rapid, shallow sucks. You may also see indrawing of the 3. Check for effective sucking
cheeks. You do not see or hear swallowing. The infant is not 4. Check for ulcers or white
patches in the infant’s
satisfied at the end of the feed, and may be restless. He may mouth
cry or try to suckle again, or continue to breastfeed for a long
time.
An infant who is not suckling at all is not able to suck breastmilk into his mouth and swallow.
Therefore he is not able to breastfeed at all.
If a blocked nose seems to interfere with breastfeeding, clear the infant’s nose. Then check
whether the infant can suckle more effectively.

4.8.3 Assess Feeding When HIV Positive Mother Has Decided Not to
Breastfeed (in infants receiving no breast milk)
This is an alternative chart for use when an HIV positive mother has decided not to breastfeed her
infant.
THEN CHECK FOR FEEDING PROBLEM OR UNDERWEIGHT:
ASK LOOK, FEEL:
 Is there any difficulty feeding?  Determine weight for age

 What milk are you giving?  Look for mouth ulcers or
 How many times during the day and night? white patches in the mouth
 How much is given at each feed? (oral thrush).
 How are you preparing the milk?
- Let the mother demonstrate or explain how a
feed is prepared, and how it is given to the infant.
 Are you giving any breastmilk?
 What foods or fluids in addition to the
replacement feeding is given?
 How is the milk being given? Cup or bottle?
 How are you cleaning the utensils?
ASK: What milk are you giving?

 Home-prepared formula (cows milk, other animal milk, other food stuff)
 Commercial infant formula
ASK: How many times during the day and night?
The recommendation is that the young infant be fed as often and for as long as the infant
wants, day and night. This should be 8 or more times in 24 hours.
ASK: How much is given at each feed?

- Compare the amount with the standard recommendations.
ASK: How are you preparing the milk?

- Let the mother demonstrate or explain how a feed is prepared, and how it is given to
the infant
ASK: Are you giving any breastmilk at all?

- This information helps to find out whether the mother is practicing mixed feeding
which is a risk for mother to child transmission of HIV.
ASK: What foods or fluids in addition to the replacement feeding is given?
ASK: How is the milk being given? Cup or bottle?
ASK: How are you cleaning the utensils?

- Let the mother explain how the feeding materials are cleaned and handled.
LOOK, FEEL
• Determine weight for age
• Look for mouth ulcers or white patches in the mouth (oral thrush).

EXERCISE D: Photo Exercise
In this exercise you will practice recognizing signs of good and poor attachment during
breastfeeding as shown in photographs.
Photographs
1. Study photographs numbered 66 through 70 of young infants at the breast. Look for each
of the signs of good attachment. Compare your observations about each photograph with
the answers in the chart below to help you learn what each sign look like. Notice the
overall assessment of attachment.
2. Now study photographs 71 through 74. In each photograph, look for each of the signs of
good attachment and mark on the chart whether each is present. Also write your overall
assessment of attachment.
Signs of Good Attachment

Chin Mouth Lower Lip More Areola
Touching Wide Turned Showing Assessment Comments
Photo Breast Open Outward Above
66 Yes Yes Yes Yes Good
(almost) attachment
No (equal Not well
67 No No Yes above and attached
below)
68 Yes No No Yes Not well Lower lip
attached turned in
69 No No No No Not well Cheeks

attached pulled in
70 Yes Yes Yes Cannot see Good

attachment

Signs of Good Attachment
Chin Mouth Lower Lip More Areola
Touching Wide Turned Showing Assessment Comments
Photo Breast Open Outward Above
71
72
73
74
3. Study photographs 75 and 76. These photographs show white patches (thrush) in the
mouth of an infant.
When you finished assessing the photographs, discuss your


4.8.4 TEACH CORRECT POSITIONING AND ATTACHMENT FOR
BREASTFEEDING
Reasons for Poor Attachment and Ineffective Suckling
There are several reasons that an infant may be poorly attached or not able to suckle effectively.
He may have had bottle feeds, especially in the first few days after delivery. His mother may be
inexperienced. She may have had some difficulty and nobody to help or advise her. For example,
perhaps the infant was small and weak, the mother’s nipples were flat or there was a delay
starting to breastfeed.
The infant may be poorly positioned at the breast. Positioning is important because poor
positioning often results in poor attachment, especially in younger infants. If the infant is
positioned well, the attachment is likely to be good.
Good positioning is recognized by the following signs:

 Infant’s neck is straight or bent slightly back
 Infant’s body is turned towards the mother
 Infant’s body is close to the mother, and
 Infant’s whole body is supported.
Poor positioning is recognized by any of the following signs:

 Infant’s neck is twisted or bent forward
 Infant’s body is turned away from mother
 Infant’s body is not close to mother, or
 Only the infant’s head and neck are supported
Improving Positioning and Attachment
If in your assessment of breastfeeding you found any difficulty with attachment or suckling, help
the mother position and attach her infant better. Make sure that the mother is comfortable and
relaxed, for example, sitting on a low seat with her back straight. Then follow the steps in the box
below.
 Teach Correct Positioning and Attachment for Breastfeeding

 Show the mother how to hold/position her infant
- with the infant’s head and body straight
- facing her breast, with infant’s nose opposite her nipple
- with infant’s body close to her body
- supporting infant’s whole body, not just neck and shoulders.
 Show her how to help the infant to attach. She should:

- touch her infant’s lips with her nipple
- wait until her infant’s mouth is opening wide
- move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple.
 Look for signs of good attachment and effective suckling if the attachment or suckling is not good by again.

Always observe a mother breastfeeding before you help her, so that you understand her situation
clearly. Do not rush to make her do something different. If you see that the mother needs help,
first say something encouraging, like:
“She really wants your breast milk, doesn’t she?”
Then explain what might help and ask if she would like you to show her. For example, say
something like,
“Breastfeeding might be more
comfortable for you if your baby took a
larger mouthful of breast. Would you like
me to show you how?”
If she agrees, you can start to help her.
As you show the mother how to position and

attach the infant, be careful not to take over from
her. Explain and demonstrate what you want her
to do. Then let the mother position and attach the
infant herself.
Then look for signs of good attachment and

effective suckling again. If the attachment or Infant ready to attach. Nose is opposite
suckling is not good, ask the mother to remove the nipple, mouth is open wide.
infant from her breast and to try again.
When the infant is suckling well, explain to the mother that it is important to breastfeed long
enough at each feed. She should not stop the breastfeeding before the infant wants to.
Counseling about other feeding problems
 If a mother is breastfeeding her infant less than 8 times in 24 hours, advise her to increase
the frequency of breastfeeding. Breastfeed as often and for as long as the infant wants,
day and night.
 If the infant receives other foods or drinks, counsel the mother about breastfeeding more,
reducing the amount of the other foods or drinks, and if possible, stopping altogether.
Advise her to feed the infant any other drinks from a cup, and not from a feeding bottle.
 If the mother does not breastfeed at all, consider referring her for breastfeeding
counseling and possible relactation. If the mother is interested, a breastfeeding counselor
may be able to help her to overcome difficulties and begin breastfeeding again.
Advise a mother who does not breastfeed about choosing and correctly preparing an
appropriate breastmilk substitute (see section 3.1 of Counsel the Mother module). Also
advise her to feed the young infant with a cup, and not from a feeding bottle.
Follow-up any young infant with a feeding problem in 2 days. This is especially important if you
are recommending a significant change in the way the infant is fed.

Exercise E
Part 1 – Video Demonstration
There are three video demonstrations in this video session.
The first part of these videos (Demonstration: Check for Feeding problem or Low Weight for
Age) will show how to check for a feeding problem and assess breastfeeding. It will show the
signs of good and poor attachment and effective and ineffective suckling.
The second part (Video Ex G Part 1: Teach the Mother Correct Positioning and Attachment) will
show a video demonstration of the steps to help a mother improve her baby’s positioning and
attachment for breastfeeding.
The third part (Demonstration: Teach the Mother How to Express Breast Milk) will “show how to
express breast milk”.
Part 2 - Photographs
In this exercise you will study photograph to practice recognizing signs of good or poor
positioning and attachment for breastfeeding. When everyone is ready, there will be a group
discussion of each of the photographs. You will discuss what the health worker could do to help
the mother improve the positioning and attachment for breastfeeding.
1. Study photographs numbered 77 through 79 of young infants at the breast. Look for each
of the signs of good positioning. Compare your observations about each photograph with
the answers in the chart below to help you learn what good or poor positioning looks like.
2. Now study photographs 80 through 82. In these photographs, look for each of the signs of
good positioning and mark on the chart whether each is present. Also decide if the
attachment is good.

Signs of Good Positioning Assessment
of
Photo Infant’s Head and Infant’s Supporting positioning Comments on
Head and Body Body Infant’s (good, poor) Attachment
Body Facing Close to Whole Body
Straight Breast Mother’s
77 Yes Yes Yes Yes
78 Yes Yes Yes Yes
79 Not well
No- neck No No- No attached:
turned so turned mouth not wide
not away open, lower lip
straight from not turned out,
with body mother’s areola equal
body above and
below
80
81
82
Part 3 - Demonstration and Practice of correct Positioning using an infant doll

4.9 CLASSIFY FEEDING PROBLEM OR UNDERWEIGHT
4.9.1 Classify Feeding for Infants Whose Maternal HIV Status is Unknown
or Negative (infants receiving breast milk)
Compare the young infant’s signs to the signs listed in each row and choose the appropriate
classification.
SIGN CLASSIFY AS TREATMENT

If any of the following signs:  Advise the mother to breastfeed as often and for as long
as the infant wants, day and night
 Not well positioned or
 If not well positioned, attached or not suckling
 Not well attached to breast or effectively, teach correct positioning and attachment
 If breastfeeding less than 8 times in 24 hours, advise
 Not suckling effectively or to increase frequency of feeding
 Empty one breast completely before switching to the
 Less than 8 breastfeeds in 24 FEEDING other
hours or PROBLEM  Increase frequency of feeding during and after illness
OR
 Switching the breast frequently or UNDERWEIGHT  If receiving other foods or drinks, counsel mother on
exclusive breast feeding.
 Not increasing frequency of  If not breastfeeding at all:
breastfeeding during illness or  Counsel on breastfeeding and relactation
 If no possibility of breastfeeding:* Advise about correct
 Receives other foods or drinks or preparation of breast milk substitutes and using a cup
 The mother not breastfeeding at all  If thrush, teach the mother to treat thrush at home
or  Advise mother to give home care for the young infant
 Ensure HIV testing in the infant
 Underweight  Follow-up any feeding problem or thrush in 2 days
 Follow-up for underweight in 14 days
 Thrush (ulcers or white patches in
mouth)
 Not UNDERWEIGHT and no NO FEEDING  Advise mother to give home care for the young infant
other signs of FEEDING PROBLEM AND  Praise the mother for feeding the infant well
PROBLEM NOT
UNDERWEIGHT
*If no possibility of breastfeeding use the box in section 4.7.2 “Check for feeding problem or underweight when an HIV
positive mother has decided not to breast feed OR no chance of breast feeding by any reason”

FEEDING PROBLEM OR UNDERWEIGHT
This classification includes infants who are underweight or infants who have some sign that their
feeding needs improvement. They are likely to have more than one of these signs.
NO FEEDING PROBLEM
A young infant in this classification is exclusively and frequently breastfed. “Not underweight”
means that infant’s weight for age is not below the -2 Z-score line for “UNDERWEIGHT”. Even
though these infants are not underweight and not in the high risk category the trend of their
weight gain should be followed and regularly counseled on feeding.
4.9.2 Classify Feeding When an HIV Positive Mother has Made Informed
Decision Not to Breastfeed (in infants receiving no breastmilk) or No
Chance of Breastfeeding by any other reason
The classification of feeding problems for infants having replacement feeds is similar in principle
to breastfed infants. Any infant whose feeds are being given sub-optimally is classified as
FEEDING PROBLEM OR UNDERWEIGHT and feeding counseling is given and the child is
followed up. Compare the young infant’s signs to the signs listed in each row and choose the
appropriate classification

If any of the following signs:
 Counsel on optimal replacement feeding
 Milk incorrectly or unhygienically  Identify concerns of the mother and the family
prepared or about feeding. Help the mother gradually
 Giving inappropriate withdraw other foods or fluids
replacement milk or other  If mother is using a bottle, teach cup feeding
foods/fluids or  If thrush, teach the mother to treat thrush at
 Giving insufficient replacement home
feeds or  Advise mother to give home care for the
 Mother mixing breastmilk and FEEDING young infant
other feeds or PROBLEM  Follow-up any feeding problem or thrush in 2
 Using a feeding bottle or OR days
 Underweight UNDERWEIGHT  Follow-up underweight in 14 days
 Thrush (ulcers or white patches
in mouth)
 Not UNDERWEIGHT and no NO  Advise mother to give home care for the young
other signs of FEEDING FEEDING infant
PROBLEM PROBLEM  Praise the mother for feeding the infant well
&
NOT UNDERWEIGHT

5.0 THEN CHECK THE YOUNG INFANT’S IMMUNIZATION
STATUS
USE A RECOMMENDED IMMUNIZATION SCHEDULE
Look at the ASSESS & CLASSIFY chart and locate the recommended immunization schedule.
Refer to it as you read how to check a child's immunization status.
THEN CHECK THE CHILD’S IMMUNIZATION AND VITAMIN A STATUS

Immunization schedule
AGE VACCINE
Birth BCG OPV-1
6 weeks DPT1-HepB1-Hib1 OPV-1 PCV-1
10 weeks DPT2-Hep2-hib-2 OPV-2 PCV-2
14 weeks DPT-3Hep3-hib-3 OPV-3 PCV- 3
9 months Measles
BCG vaccine protects infants against tuberculosis. BCG vaccine comes in powder form. It must
be reconstituted with a diluent supplied with the vaccine. It is administered once at birth, intra-
dermal at a dose of 0.05ml at the left outer upper arm. After about two weeks, a red sore forms
which remains for another two weeks and then heals leaving a small scar, about 5 mm in
diameter. This is a sign that the child has been effectively immunized. Rarely local abscess and
regional lymphadenitis may occur following vaccination.
Oral polio vaccine (OPV) protects against the virus that causes polio. It is a liquid vaccine
administered at birth, 6, 10 and 14 weeks of age at a dose of 2 drops. OPV causes almost no side-
effects. Less than 1% of individuals develop a headache, diarrhoea, or muscle pain.
DPT-HepB+Hib vaccine is called a pentavalent vaccine because it protects against five

diseases: Diphtheria, Pertussis, Tetanus, Hepatitis B (HepB), and Haemophilus influenzae type b
(Hib).
Hepatitis B Virus (HBV) and Hemophilus influenzae b (Hib) infections are important public
health problems in Ethiopia.
Hepatitis B is a virus that causes liver disease. Infection in young children is usually
asymptomatic, only a small proportion can be severe and lead to death. However, a larger
proportion of children may become chronic carriers resulting in serious complications later in
life, including chronic hepatitis, cirrhosis, liver failure, and liver cancer.
Hib is a significant cause of childhood morbidity and mortality causing serious infections like
pneumonia, sepsis, meningitis, epiglottitis, acute otitis media and bone/ joint infections especially
in children younger than five years of age.
DPT-HepB+Hib vaccine comes in two-dose vials and it must be reconstituted before use; the
freeze-dried Hib component is reconstituted with the liquid DPT-HepB component. It is given
deep intra-muscular at a dose of 0.5ml at left upper outer thigh. The vaccine may cause swelling
and tenderness at injection site, mild systemic complaints like fever and irritability in few
children.

Usually, reactions to pentavalent vaccine are mild. Fever which disappear within a day and local
soreness (pain, redness, or swelling at the injection site) are observed in up to half of the children
who received the vaccine. Note that a fever that begins more than 24 hours after pentavalent
vaccination is not likely to be a reaction to the vaccine. More severe reactions occurring rarely
include convulsions and hypotonic–hyporesponsive episodes. Anaphylactic reactions are
extremely rare.
Pneumococcal vaccine is a vaccine that provides protection against Streptococcus pneumoniae

bacteria which is a common cause of pneumonia, blood infections (bacteremia), and meningitis. It
is a safe and effective vaccine that protects against 10 common serotypes that cause pneumococcal
diseases and is therefore referred to as PCV10. PCV10 is a liquid vaccine that is provided in a 2-dose
vial. PCV is administered intramuscularly on the right upper outer thigh at a dose of 0.5 ml at 6, 10
and 14 weeks.
Mild reactions to PCV such as irritability/crying and low grade fever are common; local soreness
is observed in 50% while transient fever >39˚C occurs in about 5% of children receiving the
vaccine. Severe reactions such as convulsions, anaphylactic shock and allergic reactions
(dermatitis) are very rare. PCV should not be administered to children with a known severe
hypersensitivity reaction to a previous dose of the vaccine.
Measles vaccine is a live attenuated vaccine provided as a powder, with a diluent in a separate
vial. It is given once at the age of 9 months, 0.5ml subcutaneously over the left upper arm. Mild
reactions to the vaccine are not uncommon. These include: local soreness which develops within
24 hours of immunization and which resolve spontaneously within 2-3 days, moderate fever and
rash which usually lasts a day or two in about 5% of children. Severe reactions to measles
vaccine such as anaphylaxis and severe allergic reactions are extremely rare. Reconstituted
Pentavalent, Pneumococcal and Measles vaccines must be discarded after six hours or at the end
of the immunization session, whichever comes first.
The recommended vaccine1 should be given when the child is the appropriate age for each dose.
When given early, protection may not be adequate and any delay increases the risk of getting
disease.
All children should receive all the recommended immunizations before their first birthday. If the
child does not come for an immunization at the recommended age, give the necessary
immunizations any time after the child reaches that age. Give the remaining doses at least 4
weeks apart. You do not need to repeat the whole schedule.
OBSERVE CONTRAINDICATIONS TO IMMUNIZATION
In the past it was believed that minor illnesses were a contraindication to immunization. As a
result, mothers of sick children were advised to bring them back when they were well. This is a
bad practice because it delays immunization. The mother may have travelled a long distance to
bring her sick child to the clinic and cannot easily bring the child back for immunization at
another time. The child is left at risk of getting measles, polio, diphtheria, pertussis, tetanus or
1
In exceptional situations where measles morbidity and mortality before nine months of age represent a significant
problem (more than 15% of cases and deaths), an extra dose of measles vaccine is given at 6 months of age. This is in
addition to the scheduled dose given as soon as possible after 9 months of age. This schedule is also recommended for
groups at high risk of measles death, such as infants in refugee camps, infants admitted to hospitals, infants affected by
disasters and during outbreaks. Check if this is according to EPI

tuberculosis. No sick child, including the malnourished should miss immunization, unless there
is a clear contraindication.
There are only few situations at present, which are contraindications to immunization:
* Do not give BCG to a child known to have AIDS.
* Do not give DPT2-HepB2-Hib2 or DPT3-HepB3-Hib3 to a child who has had convulsions or

shock within 3 days of the most recent dose.
* Do not give DPT-HepB-Hib to a child with recurrent convulsions or another active

neurological disease of the central nervous system.
* Do not give DPT-HepB-Hib and PCV vaccines for infants who had generalized itching skin
rash, difficulty in breathing, swelling of the mouth and the throat, or shock following
previous immunization.
In all other situations, here is a good rule to follow:
There are no contraindications to immunization of a

sick child if the child is well enough to go home.
For a child who is to be referred, immunization does not have to be given before referral. The
hospital staff at the referral site should make the decision about immunizing the child when the
child is admitted. This will avoid delaying referral.
Children with diarrhoea who are due for OPV should receive a dose of OPV (oral polio vaccine)
during this visit. However, the dose should not be counted. The child should return in 4 weeks
for an extra dose of OPV.
The mother should be advised to be sure the other children in the family are immunized. Give the
mother tetanus toxoid, if required.
To decide if the child needs an immunization today:
LOOK at the child's age on the clinical record.
If you do not have the child's age on the clinical record, ask about the child's age.
ASK the mother if the child has an immunization card.
If the mother answers YES, ask her if she has brought the card to the clinic today.
* If she has brought the card with her, ask to see the card.
* Compare the child's immunization record with the recommended immunization schedule.
Decide whether the child has had all the immunizations recommended for the child's age.
* On the Recording Form, check all immunizations the child has already received. Write the
date of the immunization the child received most recently. Circle any immunizations the child
needs today.

* If the child is not being referred, the mother needs to be advised that the child should to
receive an immunization (or immunizations) today.
If the mother says that she does NOT have an immunization card with her:
* Ask the mother to tell you what immunizations the child has received.
* Use your judgment to decide if the mother has given a reliable report. If you have any doubt,
immunize the child. Give the child OPV, DPT-HepB-Hib, pneumococcal vaccine and
measles vaccine according to the child's age.
Give an immunization card to the mother and ask her to please bring it with her each time she
brings the child to the clinic.
Remember that you should not give OPV 0 to an infant who is more than 14 days old. Therefore,
if an infant has not received OPV 0 by the time he is 15 days old, you should wait to give OPV
until he is 6 weeks old. Then give OPV 1 and DPT1-HepB1-Hib1 and pneumococcal vaccine1.

6.0 ASSESS OTHER PROBLEMS
Assess any other problems mentioned by the mother or observed by you. Refer to any guidelines
on treatment of the problems. If you think the infant has a serious problem, or you do not know
how to help the infant, refer the infant to a hospital.
Using the Young Infant Recording Form

Below is the bottom half of a Young Infant Recording Form. This is where you record the
assessment and classification of feeding and weight. This may include an assessment of
breastfeeding. At the bottom are sections for recording immunizations and any other problems.
Study the example below. It has been completed to show the rest of the assessment of the infant
Jemal.
THEN CHECK FOR FEEDING PROBLEM OR UNDERWEIGHT Feeding
- Is there any difficulty of feeding? Yes _____ No ___ - Determine weight for age. problem
- Is the infant breastfed? Yes ___ No _____ If Yes, how many times in 24 hrs? __5_ times Underweight __
- Do you empty one breast before switching to the other? Yes___ No_ NOT Underweight ___ OR
- Do you increase frequency of breastfeeding during illness? Yes__ No___ - Look for ulcers or white patches in the mouth (oral Underweight
- Does the infant receive any other foods or drinks? Yes _ No ___ If Yes, how often?__1_ times thrush).
- What do you use to feed the child? Feeding Bottle
If the infant has any difficulty feeding, is feeding < 8 times in 24 hours, is taking any other food or drinks, or is underweight for age,
AND has no indications to refer urgently to hospital: ASSESS BREASTFEEDING: Infrequent Breast
- Has the infant breastfed in the previous hour? - Is the infant able to attach? To check attachment, look for: feeding.
- If infant has not fed in the previous hour, ask the mother to put her infant - Chin touching breast Yes _ No ___
to the breast. Observe the breastfeed for 4 minutes. - Mouth wide open Yes _ No ___
- If the infant was fed during the last hour, ask the mother if she can wait - Lower lip turned outward Yes _ No ___ Not exclusively
Good attachment__ Poor attachment______ No attachment at all ____
breastfed
- Is the infant positioned well? To check positioning, look for:
- Infant’s head and body straight Yes _ No ___ - Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
- Facing the breast Yes _ No ___
Bottle feeding
Suckling effectively____ not suckling effectively____ not suckling at all____
- Infant’s body close to her body Yes __ No ___
- Supporting the whole body Yes __ No ___
Good Positioning_ Poor positioning________
- Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant - Look for ulcers or white patches in the mouth (oral
- Are you giving any breast milk at all? thrush).
__________ ____________ ___________ _______________ ____________ immunization on:
OPV 0 BCG OPV 1 DPT1-HepB1-Hib1 PCV1 In 3 weeks

EXERCISE F
This exercise is a continuation of Exercise B. Get out the Recording Form of Case 2 (Shashie)
that you used in Exercise B. Refer to the YOUNG INFANT chart and the Weight for Age chart as
needed.
For this case:
1. Read the description of the rest of the assessment of the infant.

Record the additional assessment results on the infant’s form.
2. Use the Weight for Age chart to determine if the infant is underweight.
3. Classify feeding.
4. Check the infant’s immunizations status. Record immunizations needed today and when
the infant should return for the next immunization.
Case 2: Shashie
Shashie’s mother was tested for HIV during pregnancy, and she was negative. Shashie’s
was not tested for HIV.
When asked if Shashie has any difficulty feeding, the mother says no. She says that
Shashie breastfeeds 9 or 10 times in 24 hours and drinks no other fluids. She empties one
breast before switching to the other and the mother breastfeeds her more frequently
during and after illness. Then the health worker refers to Shashie’s weight and age
recorded at the top of the recording form. He uses the Weight for Age chart to check
Shashie’s weight for age. The health worker decides that there is no need to assess
breastfeeding.
Shashie’s mother has an immunization card. It shows that she received BCG and OPV 0
at birth in the hospital. When the health worker asks the mother if Shashie has any other
problems, she says no.
When you have completed this exercise, please discuss your


ANNEX
RECORDING FORM:
Management of the Sick Young Infant Birth up to 2 Month

Name: _____________________________________ Age: _____ weeks Sex:____ Weight: _______ gm Length: _______ cm Temperature: ____°C
ASK: What are the infant’s problems? _________________________________________________________________ Initial visit? ___ Follow-up Visit? ___
Blue tongue & lips
· Count the breaths in one minute. ____breaths per minute
- Is the infant having feeding difficulty? Repeat if (≥ 60) elevated ________ Fast breathing?
· Look if the Infant is convulsing now.
- Has the infant had convulsions?
· Look at umbilicus. Is it red or draining pus?
· Fever (temperature > 37.5°C or feels hot) or body temperature below
35.5°C (or feels cool) or body temperature between 35.5-36.4°C.
CHECK FOR JAUNDICE Are skin on the face or eyes yellow?
DOES THE YOUNG INFANT HAVE DIARRHOEA? Yes ____ No ____ ·Look at the young infant’s general condition.
· For how long? _______ Days Does the infant not move even when stimulated?
CHECK FOR HIV INFECTION
ASK: HIV status of the mother? Positive_____ , Negative____ , Unknown _____
Antibody HIV status of the infant? Positive_____, Negative____ , Unknown _____
DNA/PCR HIV status of the infant? Positive_____ , Negative____ , Unknown _____
THEN CHECK FOR FEEDING PROBLEM OR UNDERWEIGHT
- Is there any difficulty of feeding? Yes _____ No _____ - Determine weight for age.
- Is the infant breastfed? Yes _____ No _____ If Yes, how many times in 24 hrs? _____ times Underweight ___
- Do you empty one breast before switching to the other? Yes___ No__ NOT Underweight ___
- Do you increase frequency of breastfeeding during illness? Yes___ No___ - Look for ulcers or white patches in the mouth (oral
- Does the infant receive any other foods or drinks? Yes ___ No ___ If Yes, how often?_____ times thrush).
- What do you use to feed the child?
If the infant has any difficulty feeding, is feeding < 8 times in 24 hours, is taking any other food or drinks, or is underweight for age,
AND has no indications to refer urgently to hospital: ASSESS BREASTFEEDING:
- Has the infant breastfed in the previous hour? - Is the infant able to attach? To check attachment, look for:
- If infant has not fed in the previous hour, ask the mother to put her infant - Chin touching breast Yes ___ No ___
to the breast. Observe the breastfeed for 4 minutes. - Mouth wide open Yes ___ No ___
- If the infant was fed during the last hour, ask the mother if she can wait - Lower lip turned outward Yes ___ No ___
Good attachment_____ Poor attachment______ No attachment at all
- Is the infant positioned well? To check positioning, look for: ____
- Infant’s head and body straight Yes ___ No ___
- Facing the breast Yes ___ No ___ - Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?
- Infant’s body close to her body Yes ___ No ___ Suckling effectively____ not suckling effectively______ not suckling at all____
- Supporting the whole body Yes ___ No ___
Good Positioning_____ Poor positioning________
- Let the mother demonstrate or explain how a feed is prepared, and how it is given to the infant - Look for ulcers or white patches in the mouth (oral
- Are you giving any breast milk at all? thrush).
__________ ____________ ___________ _______________ ____________ immunization on:
OPV 0 BCG OPV 1 DPT1-HepB1-Hib1 PCV1 ______________

TREAT
Return for follow-up in:_____________________
Give any immunizations needed today:________

Contact Address
Federal Ministry of Health
Health Promotion and Disease Prevention General Directorate
E-mail: moh@ethionet.et
Tel: +251-11-515 99 78; +251-11-515 0407
Fax: 552 45 49
P.O.Box: 1234

Module 2 Young Infant Nov 2011

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Module 2 Young Infant Nov 2011

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Integrated Management of

Newborn and Childhood Illness

Management of Sick Young Infant

Learning objectives .............................................................................................................. 3

1.0 Give essential newborn care .................................................................................... 3

2.0 Assess for birth asphyxia ......................................................................................... 6

4.0 Assess and classify the sick young infant ............................................................... 9

4.7 Check for HIV exposure and infection ...................................................... 25

Exercise E (Part I – Video Exercise G; Part II – Photo exercises)...................... 37

4.9 Classify feeding problem or underweight ................................................ 39

5.0 Then check the young infant's immunization status ............................................. 41

Exercise F………….. ........................................................................................... 47

Management of Sick Young Infant i

When you see the mother and her sick child:

To use good communication skills:

Management of Sick Young Infant 2

* Giving essential newborn care.

* Assessing and classifying a young infant for birth asphyxia.

* Assessing and classifying for birth weight and gestational age.

* Assessing and classifying for jaundice.

* Assessing and classifying a young infant with diarrhoea.

* Checking for a feeding problem or underweight, assessing breastfeeding and classifying

* Checking immunization status.

* Assessing other problems

1.0 GIVE ESSENTIAL NEWBORN CARE (ENC)

Management of Sick Young Infant 3

Step 2. Dry baby’s body with dry and warm towel.

1. Tie the cord securely in two places:

Management of Sick Young Infant 4

Steps for giving eye care

STEPS OF IMMEDIATE NEWBORN CARE

- Deliver baby onto the mothers abdomen

- Cord tie and secure

Management of Sick Young Infant 5

If any of the following sign: Start resuscitation

 Give cord care

Management of Sick Young Infant 6

• Squeeze bag with 2 fingers or whole

3.0 ASSESS AND CLASSIFY FOR BIRTH WEIGHT AND

Management of Sick Young Infant 7

SIGNS CLASSIFY AS TREATMENT

• Weight ≥ 2,500 gm  Counsel on optimal breastfeeding

Management of Sick Young Infant 8

4.1 CHECK THE YOUNG INFANT FOR VERY SEVERE DISEASE

ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS ARE

 Determine if this is an initial or follow-up visit for this problem.

CHECK FOR VERY SEVERE DISEASE

Ask Look, Listen, Feel:

 See if the infant is convulsing now.

ASK: Is there any difficulty of feeding?

Management of Sick Young Infant 9

ASK: Has the infant had convulsions?

To count the number of breaths in one minute:

LOOK for severe chest indrawing.

Management of Sick Young Infant 10

Mild chest indrawing is normal in a young infant

LOOK at the umbilicus – is it red or draining pus?

LOOK for skin pustules. Are there pustules?

Management of Sick Young Infant 11

Photograph 60: Normal umbilicus in a newborn

Umbilicus Normal Redness or

The group will discuss the video and photographs.

Management of Sick Young Infant 12