Facilitator Guide

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MANAGEMENT OF THE SICK YOUNG INFANT AGE UP TO 2 MONTHS

2019

Facilitator Guide

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MANAGEMENT OF THE SICK YOUNG INFANT AGE UP TO 2 MONTHS

2019

Facilitator Guide

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WHO/MCA/19.03

© World Health Organization 2019

Suggested citation. Integrated Management of Childhood Illness: Facilitator Guide. Management of the Sick Young Infant Age up to 2 Months. Geneva: World Health Organization; 2019 WHO/MCA/19.03. Licence: CC BY-NC-SA 3.0 IGO.

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3. DRILL: Review of cutoffs for determining

fast breathing 7

4. EXERCISE A: Part 1: Video demonstration – Assessing a young infant for Possible Serious Bacterial Infection or Very Severe Disease, Pneumonia, and

Local Bacterial infection. 8

5. EXERCISE A: Part 2: Group discussion of photographs of a young infant’s umbilicus and skin pustules; then ask participants to read

sections 1.2 through 1.5 10

6. EXERCISE B: Individual work followed by individual feedback – Assess and classify sick young infants for Possible Serious Bacterial Infection, Very Severe Disease, Pneumonia, Local Bacterial

Infection, Jaundice, Diarrhoea, and HIV 12 7. Exercise C, Part 1: Video demonstration –

How to check for jaundice and optional demonstration on assessing and classifying

dehydration 20

8. Exercise C, Part 2: Video case study and discussion of assessing and classifying a young infant for Possible Serious Bacterial Infection or Very Severe Disease, Local Bacterial Infection,

Jaundice, and Diarrhoea 21

9. DRILL: Reading a weight for age chart

for young infants 22

10. EXERCISE D, Part 1: Video demonstration

of breastfeeding assessment 23

11. EXERCISE D, Part 2: Group discussion of example photographs. Then individual work followed by individual feedback – Recognizing

signs of good attachment 23

12. EXERCISE E: Individual work followed by individual feedback – Assess and classify feeding problem and weight for age in

case studies 25

13. Participants read sections 2.0 up

through section 3.2. 33

14. Introduce section 3.3 and the table on page 13 of the Chart Booklet, “Where Referral is Refused or Not Feasible, Further Assess and Classify

the Sick Young Infant.” 33

15. Participants read sections 3.3 through 4.1 Give an Intramuscular Injection of Gentamicin,

up to Exercise F. 35

16. Exercise F, Part 1: Video demonstration – Preparing gentamicin for injection and

giving intramuscular injections 35

19. Video demonstration of preparing

and giving oral amoxicillin 36

20. Drill: Determining the correct amount of gentamicin, ampicillin, and amoxicillin

to give per dose 37

21. EXERCISE G: Individual work followed by individual feedback – Determine whether young infant needs referral and identify treatments needed, including antibiotics with dosages; further assess and classify a young infant who needs referral but referral is not feasible; list the actions to take, including any treatments, dosages and schedule for antibiotics, and advice to give to the mother 37 22. Participants read sections 4.9 through 4.13. 46 23. EXERCISE H: Part 1 – Video demonstration

of how to help a mother to improve her baby’s

positioning and attachment for breastfeeding 46 24. EXERCISE H: Part 2 – Photographs – Group

discussion of example photographs. Individual work, then group discussion – Recognizing

signs of good positioning 47

25. EXERCISE I: Video demonstration of showing a mother how to express breast milk, keep a young infant warm at home, feed by cup,

and how to treat thrush 49

26. EXERCISE J: Individual work followed by individual feedback – Describing treatment for young infants, including treatment for

local infection and home care 49

27. DRILL: Review of points of advice for mothers

of young infants 50

28. Participants read section 5.0 Give follow up

care for the sick young infant and conclusion. 52 29. Summary of the module and review of

the Conclusion 52

ANNEX A: PREPARING FOR THE COURSE 53

ANNEX B: INSTRUCTIONS FOR CLINICAL PRACTICE 54

ANNEX C: FACILITATION TECHNIQUES 56

ANNEX D: RECORDING FORM 60

ANNEX E: SKILL OBSERVATION FORM FOR CLINICAL PRACTICE: SICK YOUNG INFANTS

AGED 0 UP TO 2 MONTHS 61

ANNEX F: GROUP CHECKLIST OF SIGNS IN

YOUNG INFANTS AGE 0 UP TO 2 MONTHS 62

ANNEX G: INSTRUCTIONAL MATERIALS, SUPPLIES AND MEDICINES NEEDED

FOR THE COURSE 63

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TOPICS METHOD/ FEEDBACK TIME IN HOURS

DAY 1

1. Opening session: Distribute and introduce

the module. Plenary 0.5

2. Participants read the Introduction and

section 1.0 up to Exercise A (8 pages). Individual 0.5

3. Lead a drill on cut-offs for determining fast

breathing in infants and in children. Drill 0.25

4. Exercise A, Part 1: Video – Show WHO video – Assessing a young infant for Possible Serious Bacterial Infection or Very Severe Disease, Pneumonia, and Local Bacterial infection.

Group discussion 0.75

5. Exercise A, Part 2: Photographs – Discuss photographs of local infections.

Introduce Recording Form (front side) if needed

Give each participant 7 copies of the Young Infant Recording Form to use in Exercise B.

6. Participants read sections 1.2 through 1.5 (9 pages) and work individually on Exercise B: Assess and classify a sick young infant.

Individual 1.25

7. Exercise C, Part 1: WHO video

demonstration Check for Jaundice (optional WHO video Assess and classify for

dehydration)

8. Exercise C, Part 2: show the WHO video case study – assess and classify possible serious bacterial infection or very severe disease, jaundice, and diarrhoea.

9. Participants read through section 1.6 and 1.6.1. (2 pages) Lead a drill on reading a weight for age chart for young infants.

Individual Drill

0.25

10. Participants read section 1.6.2 (2.5 pages).

For Exercise D, Part 1 – Show the WHO video on breastfeeding assessment.

Individual Group discussion 0.75

11. Participants study the example

photographs in Exercise D, Part 2. Lead a brief group discussion of example photographs.

CLINICAL PRACTICE (ASSESS and

CLASSIFY – conduct at a convenient time) Small groups 1.5 to 2

METHODS AND TIME SCHEDULE

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5

Exercise E: Assess and classify feeding problem and weight for age.

13. Participants read sections 2.0 up through

section 3.2 Refer the Young Infant (5.5 pages). Individual 0.5 14. Introduce section 3.3 and the table in Chart

Booklet, “Where Referral is Refused or Not Feasible, Further Assess and Classify the Sick Young Infant.”

15. Participants read sections 3.3 through 4.1 up to Exercise F (8.5 pages – some pictures).

Individual 0.5

16. Exercise F, Part 1: Video – Show GHM video on preparing gentamicin and giving intramuscular injections.

17. CLINICAL PRACTICE – Exercise F,

Part 2: Lead participants through practicing preparation of and giving gentamicin injections

Small groups 1.0

18. Participants read sections 4.2 through 4.8 (9.5 pages – possibility to save time – summarize rehydration plans A,B,C)

Introduce back side of the Recording Form if needed

Individual 0.75

19. Show GHM video Preparing and giving oral

amoxicillin Group discussion 0.25

20. Lead a drill on determining the correct dose

of gentamicin, ampicillin, and amoxicillin Drill 0.25

DAY 3

Review of Day 2 Plenary 0.5

CLINICAL PRACTICE (Decide on referral and practice BF techniques – conduct at a convenient time)

Small groups 1.5–2

21. Participants work individually on Exercise G:

Determine whether young infant needs referral and identify treatments needed, including antibiotics with dosages; further assess and classify a young infant who needs referral but referral is not feasible; list the actions to take, including any treatments, dosages and schedule for antibiotics, and advice to give to the mother.

Individual 0.5

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Annexes (to be referred to as necessary)

Annex A: Preparing for the course Annex B: Instructions on clinical practice Annex C: Facilitation techniques

Annex D: Young infant recording form Annex E: Clinical skills monitoring Checklist Annex F : Group Checklist for Clinical signs

Annex G : Instructional materials, supplies, medicines required

TOPICS METHOD/ FEEDBACK TIME IN HOURS

22. Participants read sections 4.9 through 4.13

(6 pages) Individual 0.5

23. Exercise H, Part 1 – Show the WHO video (Helping a mother to improve her baby’s positioning and attachment for breastfeeding).

24. Exercise H, Part 2 – Participants study the photographs. Facilitator leads group discussion of example photographs.

Participants work individually on rest of photographs.

25. Participants read section 4.14. For Exercise I – Show WHO/GHM video of showing a mother how to express breast milk, keep a young infant warm at home, feed by cup, and how to treat thrush

Individual Group discussion 0.5

26. Participants read sections 4.15 (1 page) and

work individually on Exercise J. Individual 1.0

27. Lead a drill on points of advice for mothers

of young infants. Drill 0.25

28. Participants read section 5.0 and

Conclusion (6 pages). Individual 0.5

29. Summarize the module and review the

Conclusion. Closing. Group discussion 1.0

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7

sick child. Point to the relevant sections of the Young Infant Chart Booklet while outlining the tasks to be learned:

• Assess, classify, and identify treatment

• Treat the young infant and counsel the mother

• Give follow-up care for the young infant

Explain that there are differences because the problems and treatments of young infants are somewhat different from older infants and children. For example, when young infants are sick, they may have only non-specific signs of illness such as few movements, fever, or low body temperature. Mild chest indrawing is normal, so only severe chest indrawing is a serious sign.

Young infants may need different antibiotics than older infants.

2. Ask participants to read the Introduction and section 1.0 up to Exercise A.

3. DRILL: Review of cutoffs for determining fast breathing

Conduct this drill at any convenient time after this point in the module. You may wish to do it while participants are gathered to watch the video, or at another time when they need a break from reading and writing.

Tell participants that this drill will review the cutoffs for determining fast breathing in children and young infants.

State or ask participants to state the three age groups that you must keep in mind when determining fast breathing and the respiratory rate threshold for each:

• Young infants (age 0 to 59 days) = 60 breaths per minute or more is fast breathing

• Infants 2 months up to 12 months = 50 breaths per minute or more is fast breathing

• Children 12 months up to 5 years = 40 breaths per minute or more is fast breathing Then ask the questions in the left column. Participants should answer in turn.

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WHAT IS FAST BREATHING IN AN INFANT OR CHILD: ANSWER

age 4 weeks? 60 breaths per minute or more

age 6 weeks? 60+

age 2 months? 50+

age 6 months? 50+

age 12 months 40+

age 11½ months 50+

age 1 month? 60+

age 4 months? 50+

age 3 weeks? 60+

age 3 years? 40+

age 3 months? 50+

age 5 weeks? 60+

age 10 months? 50+

DOES THIS INFANT OR CHILD HAVE FAST BREATHING?

IF THE BABY IS AGE: AND BREATHING RATE IS: DOES THE INFANT OR CHILD HAVE FAST BREATHING?

3 weeks 55 no

4 weeks 63 yes

2 weeks 59 no

18 months 44 yes

2 months 48 no

12 months 40 yes

3 years 37.5 no

12 months 37.5 no

3 years 42 yes

12 months 49 yes

11 months 49 No

6 months 52 Yes

6 weeks 65 Yes

14 months 45 Yes

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Use WHO Video entitled demonstration video.

This video shows how to assess a young infant for Very Severe Disease or Local Bacterial Infection, how to check for Jaundice, and for Eye Infection (optional). Show the first part: How to assess a young infant for Very Severe Disease or Local Bacterial Infection (section 00:00 – 9:57). Classifications are not included in this video.

When all the participants are ready, arrange for them to move to where the video exercise will be shown. Make sure they bring their manuals and chart booklets.

To show the video:

1. Tell participants that they will watch a demonstration of how to assess a young infant for Possible Serious Bacterial Infection or Very Severe Disease, Pneumonia, and Local Bacterial Infection. The video will show examples of abnormal signs. Explain to the participants that they will see the assessment of all signs needed for the classification according to 2018 WHO management guidelines although only classifications “Very severe disease” and “Local bacterial infection” are mentioned in the video.

2. Ask if participants have any questions before you start the video. When there are no additional questions, start the video.

3. Show the video. Follow the instructions given in the video. Pause the video and give explanations or discuss what the participants are seeing as needed to be sure the participants understand how to assess these signs.

4. At the end of the video, lead a short discussion. If participants are not clear about the assessment of any signs, rewind the video and show the relevant portions again.

Important points to emphasize about the assessment in this video are:

• It is particularly difficult to count breathing in a young infant because of irregular breathing.

Repeat any count which is 60 or more.

Note to Facilitator:

No thresholds for high body temperature/fever or low body temperature are mentioned in the video clip. The axillary high body temperature according to WHO 2018 guidelines is 38°C or above. This is higher than fever in previous guidelines for the young infant or in current guidelines for an older infant or child (37.5°C). This was done to increase the specificity of the sign.

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5. EXERCISE A: Part 2: Group discussion of photographs of a young infant’s umbilicus and skin pustules; then ask participants to read sections 1.2 through 1.5

Talk about each of the first 3 photographs, pointing out or having participants point out and tell how they can recognize the signs.

Then ask participants to work individually to study the rest of the photographs for this exercise and write the answers in the Participant Manual.

Give feedback in a group discussion: For each photograph, ask a participant to explain what he sees in the photograph. Discuss as necessary so that participants understand how to recognize an infected umbilicus.

Give the participants a copy of the answer sheet.

After the discussion, ask participants to continue working in the manual. They should read sections 1.2 through 1.5, referring to the Chart Booklet when they are asked to. Then they should work individually on Exercise B. Give each participant 7 copies of the Recording Form to use in Exercise B.

If the participants have not been previously trained in the integrated management of sick children up to 5 years, you need to introduce the Recording Form.

To do so, mention each part of the form and its purpose. For example:

• Look at the top of the front side of the form. (Point to each space as you speak). Explain that there are spaces for writing: the child’s name, age, weight and temperature, the mother’s answer about the child’s problems, whether this is an initial visit or follow-up visit.

• Look at how the Recording Form is arranged. Notice that the form is divided into two columns:

one is for “Assess” and the other is for “Classify.” These two columns relate to the Assess and Classify columns on the ASSESS & CLASSIFY chart in the Chart Booklet.

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Part 2 – Photographs

Photograph 1: Normal umbilicus in a newborn Photograph 2: A red umbilicus

Photograph 3: A red umbilicus

Photograph 4: Normal umbilicus in a newborn Photograph 5: Pus discharge

Photograph 6: skin pustules

UMBILICUS NORMAL REDNESS OR DRAINING PUS

REDNESS EXTENDING TO

THE SKIN OF

ABDOMEN SKIN

PUSTULES

Photograph 1



Photograph 2



Photograph 3



Photograph 4



Photograph 5



(pus discharge)

Photograph 6



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6. EXERCISE B: Individual work followed by individual feedback – Assess and classify sick young infants for Possible Serious Bacterial Infection, Very Severe Disease, Pneumonia, Local Bacterial Infection, Jaundice, Diarrhoea, and HIV

Watch to see when participants have finished reading section 1.5 and are beginning Exercise B. Be sure that each participant has 7 copies of the Young Infant Recording Form and understands that he should record the information about each case in Exercise B on these forms. If any participant seems confused, explain or show him individually how to use the Recording Forms, so that he can get started on the exercise without delay.

Compare the participant’s Recording Forms with the Answer Sheets for Exercise B. Where the participant has recorded something different, discuss why he did that, and go back to the case study as needed to verify the reason for the answer. Give the participant a copy of the answer sheet to keep.

Tell the participant that later exercises in this module will continue these same 7 case studies. The participant will continue completing the same 7 Recording Forms as he continues to work through the module.

In order to better understand the participant’s work situation, discuss with the participant whether he sees sick young infants at his clinic.

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Name: Age: Sex: Weight: Temperature:

ASK: What are the infant’s problems? Initial visit? Follow-up Visit?

ASSESS (Circle all signs present) CLASSIFY

CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE DISEASE or PNEUMONIA or LOCAL BACTERIAL INFECTION

PSBI OR VERY SEVERE DISEASE Is the infant having

difficulty feeding?

Has the infant had convulsions?

• Count the breaths in one minute. breaths per minute Repeat if (≥ 60) elevated Fast breathing?

• Look for severe chest indrawing

• Measure temperature

High body temperature (temperature > 38°C) or Low body temperature (below 35.5°C)

• Look at young infant’s movements.

Does the infant move only when stimulated?

Does the infant not move at all?

• Look at umbilicus. Is it red or draining pus?

• Look for skin pustules CHECK FOR JAUNDICE • Is skin yellow?

And infant is less than 24 hours of age?

• Are the palms or soles yellow? NO JAUNDICE

DOES THE YOUNG INFANT HAVE DIARRHOEA?

Yes No If yes, ASK:

• Look at the young infant’s general condition.

Is the infant restless and irritable?

• Look for sunken eyes.

Pinch the skin of the abdomen. Does it go back:

Very slowly (longer than 2 seconds)? Slowly?

CHECK FOR HIV INFECTION

ASK: HIV status of the mother? Positive Negative Unknown HIV serological test of the infant? Positive Negative Unknown HIV virology test of the infant? Positive Negative Unknown

HIV INFECTION UNLIKELY

Henri 6 hrs M

70 74

3.0kg 36.5oC

no crying at birth, difficulty breathing



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Answers to Exercise B: Case 2

IMCI Recording Form: MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS

LOCAL BACTERIAL

INFECTION Is the infant having

difficulty feeding?

Sashie 1 w F

55

3.4kg 37oC

rash



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15

PNEUMONIA Is the infant having

difficulty feeding?

Ebai 2 wks M

70 65

3.5kg 36.5oC

fast breathing



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Answers to Exercise B: Case 4

IMCI Recording Form: MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS

INFECTION UNLIKELY Is the infant having

difficulty feeding?

• Are the palms or soles yellow?

SEVERE JAUNDICE DOES THE YOUNG INFANT

HAVE DIARRHOEA?

HIV EXPOSED:

POSSIBLE HIV INFECTION

Robert 1 wk M

58

2.2kg 36.0oC

skin colour changed



 



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difficulty feeding?

• Are the palms or soles yellow? JAUNDICE

Alice 10 days

52

3.2kg 36.7oC

yellow eyes



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Answers to Exercise B: Case 6

IMCI Recording Form: MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS

difficulty feeding?

SOME DEHYDRATION

HIV EXPOSED:

POSSIBLE HIV INFECTION

Jenna 7 wks F

50

3.0kg 36.4oC

diarrhoea



 



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PSBI OR VERY SEVERE DISEASE

LOCAL INFECTION Is the infant having

difficulty feeding?

Neera 3 wk F

50

4.2kg 36.2oC

stopped feeding well



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7. Exercise C, Part 1: Video demonstration – How to check for jaundice and optional demonstration on assessing and classifying dehydration

When all the participants are ready, arrange for them to move to where the video demonstration and exercise will be shown. Make sure they bring their chart booklets.

Video demonstration: Check for Jaundice

Show Demonstration: How to Check for Jaundice in the video used for Exercise A.

To conduct the video demonstration:

1. Tell participants that they will watch a demonstration of how to assess and classify a young infant for jaundice.

2. Ask if participants have any questions before you start the video. When there are no additional questions, show the video. Pause the video and give explanations or discuss what the participants are seeing as needed to be sure the participants understand how to assess the jaundice.

3. At the end of the video, lead a short discussion. If participants are not clear about the assessment or classification of jaundice, show the relevant portions again.

Optional video demonstration: on assessing and classifying dehydration

You need to decide if the background of the participants on assessing and classifying dehydration warrants additional demonstration using WHO IMCI video entitled “How to assess a child for diarrhoea (duration 9:30)” If yes, conduct the demonstration as follows.

To conduct the video demonstration:

1. Tell participants that they will watch a demonstration of how to assess and classify a child for diarrhoea. Tell the participants that the assessment of a young infant is similar to the assessment for an older infant or young child, but fewer signs are checked and you will explain the differences when watching the video.

2. Ask if participants have any questions before you start the video. When there are no additional questions, show the video. Pause the video after each section and explain what the participants are seeing and how it is different when assessing a young infant. Discuss as needed to be sure the participants understand how to assess the dehydration in a young infant.

3. At the end of the video, lead a short discussion. If participants are not clear about the assessment or classification of dehydration, show the relevant portions again.

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Show WHO video Case study Ikram: Assess and classify the young infant for very severe disease or local bacterial infection, jaundice, and diarrhoea (duration 12:33).

To conduct the video exercise:

1. Tell participants that during this exercise they will watch a case study of a young infant. The young infant will be assessed for serious bacterial infection or very severe disease and local bacterial infection, jaundice, and diarrhoea.

The video includes assessment of all signs needed for classification of “Possible serious bacterial infection or very severe disease”, “Pneumonia” or “Local bacterial infection”

according to 2018 WHO management guidelines although only classifications “Very severe disease” and “Local bacterial infection” are mentioned in the video clip. “Fever 37.5°C or above” was changed to “High body temperature 38°C or above” in order to increase specificity.

In the video, Ikram is 10 days old. He weighs 3 kg, temperature is 35.7°C and he is sick. He was feeding well but not since 2 days. He has no convulsions. Respiratory rate is 44 per minute.

He has difficulty feeding, severe chest indrawing, umbilicus not red or draining pus. No skin pustules. He moves on his own. He has no jaundice.

Participants should record their assessment results on the recording form in the Participant’s Manual. They will be given time to classify the young infant and write the classifications on the form.

2. Ask if participants have any questions before you start the video. When there are no additional questions, start the video.

3. At the end of the video, lead a short discussion. If participants are not clear about the assessment of any signs, rewind the video and show the relevant portions again. Review how to assess any of the signs that were not on the video.

The classifications should be: Possible Severe Bacterial Infection or Very Severe Disease; no jaundice; no dehydration. If there are any questions about the classifications, review the infant’s signs and how they were classified, referring to a classification table.

Ask the participants to read section 1.6 and 1.6.1 and to let you know when they have finished. Then lead a drill.

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9. DRILL: Reading a weight for age chart for young infants

Conduct this drill when participants have finished reading section 1.6.1 or at any convenient time during work on this module.

Tell participants that in this drill they will practice determining whether a young infant is low weight for age. Ask them to take out their chart booklets and turn to the Weight for Age charts. Boys and girls have different charts.

Ask the question in the left column. Participants should answer in turn.

QUESTIONS ANSWERS

Which curve do you use to assess weight for

age in a young infant? Low weight for age or -2 Z-score line If a young infant’s weight is on the curve for low

weight for age, is he low weight for age? No-Below the curve is low weight. On or above the curve is not.

Does the bottom of the Weight for Age chart

show age in weeks or months? Both weeks and months; in weeks up to age 13 weeks; in months after 3 months.

IS THE YOUNG INFANT LOW WEIGHT FOR AGE?

IF THE INFANT IS: AND WEIGHS: LOW WEIGHT FOR AGE?

3 weeks old boy 3 kg yes

6 weeks old girl 4 kg no

7 weeks old boy 3 kg yes

4 weeks old boy 2.5 kg yes

5 weeks old girl 3.25 kg yes

6 weeks old boy 3.75 kg no

Ask the participants to read section 1.6.2.

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23

Tell participants that they will see a demonstration of assessing feeding. In particular, they will see how to assess breastfeeding. Point to the enlargement and review the steps of assessing breastfeeding. (Or, ask participants to turn in the chart booklet and read over the steps to assess feeding of a young infant.) The video will show examples of the signs of good and poor attachment and effective and ineffective suckling.

Ask if participants have any questions before you start the video. When there are no additional questions, start the videotape.

At the end of the video, lead a short discussion. If participants are not clear about the assessment of any signs, rewind the video and show the relevant portions again.

Important points to emphasize in the discussion are:

• The four signs of good attachment. (Point to these on the enlargement as you review them.)

• An infant who is well attached does not cause any pain or discomfort to the breast. Good attachment allows the infant to suckle effectively. Signs of effective suckling are:

– the infant suckles with slow deep sucks – you may see or hear swallowing

• An infant who is suckling effectively may pause sometimes and then start suckling again.

Remember that the mother should allow her baby to finish the feed and release the breast himself. A baby who has been suckling effectively will be satisfied after a breastfeed.

11. EXERCISE D, Part 2: Group discussion of example

photographs. Then individual work followed by individual feedback – Recognizing signs of good attachment

Talk about each of the first 5 photographs, pointing out or having participants point out and tell how they can see each sign of good or poor attachment. Participants should refer to the descriptions of each photograph in their module.

Then ask participants to work individually to study the rest of the photographs for this exercise and write the answers in the chart. They should look for the signs of good attachment present in each photograph and make an overall assessment of the infant’s attachment.

To give individual feedback on this exercise, compare the participant’s answers with the answers on the answer sheet. If the participant had a different answer, look at the photograph together and discuss how to recognize the sign.

Then look at photographs 22 and 23 (thrush) with the participant. Answer any questions that the participant may have about these photographs.

Give the participant a copy of the answer sheet for this exercise.

Ask the participant to read sections 1.7 through 1.11 and then work individually on Exercise E.

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24

MANAGEMENT OF THE SICK YOUNG INFANT

Answers to Exercise D

Photo

Signs Of Good Attachment

Assessment Comments More Areola

Seen Above Mouth

Mouth Wide Open

Lower Lip Turned Outward

Chin Touching

Breast

13 Yes (almost) Yes Yes Yes Good attachment

14

(equal above No

and below) No Yes No Not well attached

15 Yes No No Yes Not well attached Lower lip turned in

16 No No No No Not well attached Cheeks pulled in

17 Cannot see Yes Yes Yes Good attachment

18

(equal above No

and below) No Yes No Not well attached

19 Yes Yes Yes Yes Good attachment

20 Yes Yes Yes Yes

(Almost) Good attachment

21 No

(more below) No No Yes Not well attached Lower lip turned in

Photographs 22 and 23: White patches (thrush) in the mouth of an infant.

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25

needed to verify the reason for the answer provided on the answer sheet.

Note to Facilitators:

The section ASSESS FEEDING, WHEN HIV POSITIVE MOTHER IS NOT BREASTFEEDING was omitted in the Recording Forms in the Answer Sheets for this exercise due to space constraints.

Explain that Case 3 (Ebai), who is 14 days old, should get OPV 0 today. If an infant is even one day older than 2 weeks of age, he should not get OPV 0.

Ask the participant to read sections 2.0 Identify Appropriate Treatment through Section 3.2 Refer the Young Infant.

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Answers to Exercise E: Case 1

IMCI Recording Form: MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS

PSBI OR VERY SEVERE DISEASE

• Is the infant having difficulty feeding?

• Has the infant had convulsions?

HIV INFECTION UNLIKELY THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE

Not assessed

• Is the infant breastfed? Yes No If Yes, how many times in 24 hrs? times

• Does the infant receive any other foods or drinks?

Yes No

If Yes, how often? times

If yes, what do you use to feed the infant?

• Determine weight for age.

Very low weight (<2 kg )

Low weight for age ( < -2 Z score) NOT low weight for age

• Look for ulcers or white patches in the mouth (thrush).

If the infant has any difficulty feeding, is feeding < 8 times in 24 hours, is taking any other food or drinks, or is low weight for age,

AND has no indications to refer urgently to hospital: ASSESS BREASTFEEDING:

• Has the infant breastfed in the previous hour?

• If infant has not fed in the previous hour, ask the mother to put her infant to the breast.

Observe the breastfeed for 4 minutes.

• 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 able to attach? To check attachment, look for:

–More areola seen above than below the mouth Yes No

–Mouth wide open Yes No

–Lower lip turned outward Yes No –Chin touching breast Yes No

Good attachment Poor attachment No attachment at all

• Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?

Suckling effectively not suckling effectively not suckling at all

CHECK THE YOUNG INFANT’S IMMUNIZATION STATUS Circle immunizations needed today.

BCG Hep B0 OPV0 DPT1+Hib1+Hep B1 OPV-1 Rotavirus-1 PCV-1

Return for next immunization on:

ASSESS OTHER PROBLEMS:

COUNSEL THE MOTHER ABOUT HER OWN HEALTH

Henri 6 hrs M

70 74

3.0kg 36.5oC



no crying at birth, difficulty breathing

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LOCAL BACTERIAL

INFECTION

NO FEEDING PROBLEM

Yes No

At 6 weeks old ASSESS OTHER PROBLEMS:

55

9-10 v



  



 



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Answers to Exercise E: Case 3

IMCI Recording Form: MANAGEMENT OF THE SICK YOUNG INFANT AGE BIRTH UP TO 2 MONTHS

PNEUMONIA

FEEDING PROBLEM

Yes No

ASSESS OTHER PROBLEMS:

Ebai 2 wks M

70 65

6–7

3.5kg 36.5oC



 



fast breathing