Course Management of Prevalent Infections in Children Following a Disaster

Assessment of the sick infant 0 to 2 months of age

As mentioned previously, newborn and infants under 2 months of age are very vulnerable to infections, with high morbidity and mortality rates associated with very severe clinical conditions including sepsis, meningitis, and pneumonia. Thus, if an infant under 2 months is suspected of having a severe neonatal illness or a possible severe bacterial infection, there is no time to lose in laboratory studies. It is extremely important to start antibiotic therapy immediately and to refer the patient to a hospital if needed resources are not available.

Infants weighing less than 2,000 g who are brought to the primary health care facility with a possible infection should be referred to a hospital for specialized treatment, regardless of the severity of the condition, because they are more vulnerable due to their immaturity. The assessment of the infant 0 to 2 months ld should include the following questions:

• What is your baby doing?
• Is he/she feeding well or poorly?
• Has he/she vomited / Is he vomiting all he eats?
• Has he/she had diarrhea?
• Has he/she difficulty breathing?
• Has he/she had fever or hypothermia?
• Has he/she had seizures or shivering?

In addition, look for clinical signs that indicate the severity of the illness, from subtle signs such as “he doesn’t look good” to neurologic signs (e.g., seizures) or difficult breathing. Assessment of body temperature, hydration status, capillary refill, and fontanelle characteristics are also important, as well as looking for other problems (congenital anomalies, surgical disorders). Figure 3 shows the algorithm used by the Integrated Management of Chilhood Illness (IMCI) for assessment of sick infants 0 to 2 months of age. The IMCI strategy includes the following danger signs: not feeding, convulsions, fast breathing (more than 60 breaths per minute) severe chest indrawing, fever or low temperature, and lack of movement.

Young children having any of these signs of very severe disease is classified as Pink and should be urgently referred to the hospital with a first antibiotic dose and treatment to prevent low blood sugar. A young child with signs of umbilical infection (redness and or purulent discharge) or skin pustules is classified as yellow having a local bacterial infection and treated with an appropriate antibiotic.

Classification of the infant 0 to 2 months of age with severe illness or possible severe bacterial infection

It is difficult to distinguish between a very severe illness and a severe infection, such as sepsis or meningitis, since clinical findings are usually similar. For this reason, the classification gives both possibilities.

If the infant is suffering from a local but extensive bacterial infection, he or she should also be classified as having a possible severe bacterial infection because the local infection can disseminate and result in sepsis, due to the immaturity of the immune system. He or she needs to be referred urgently to a specialized hospital to receive different kinds of treatments, such as oxygen or parenteral antibiotics. Before transfer, administer the first dose of the adequate antibiotic. Transfer according to the guidelines for stabilization and transport. Counsel the mother or caregiver in order to clarify possible doubts and provide support.

Treatment of infants 0 to 2 months of age with infection

Infants 0 to 2 months old who need to be transferred to a hospital more than 5 hours away should receive an intramuscular (IM) dose of an adequate antibiotic.

Possible antibiotic combinations include:

• gentamicin + ampicillin
• gentamicin + G penicillin procaine

Avoid oral feeding if the infant presents with altered consciousness or difficult breathing, and administer a 5% dextrose solution through nasogastric tube to prevent hypoglycemia.

If there is no incubator available for the transfer, the “mother kangaroo” technique is advisable in order to prevent hypothermia. If available, also administer supplemental oxygen during the transfer to prevent hypoxemia.

Infants 0 to 2 months of age with a local bacterial infection should receive an adequate oral antibiotic as well as topical antibiotic therapy according to the site of infection.