Post on 14-Nov-2014
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Session 7
:
Management Of Sick Young Infant
(1 week to 2 months)
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Learning Objectives
By the end of this session, the students will be able to:
(1) recognize the signs of possible bacterial infection(2) classify the infant based on the signs found(3) assess for diarrhea(4) assess for feeding problems(5) assess immunization status(6) assess other problems(7) identify proper treatment(8) provide proper counseling and follow-up care
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Ask the mother or caretaker about the young
If this is an INITIAL VISIT for the problem, follow the steps below.
(If this is a follow-up visit for the problem, give follow-up care according to PART VII)
Check for POSSIBLE BACTERIAL INFECTION and classify the illness.
Ask the mother or caretaker about
DIARRHOEA:
If diarrhea is present:assess the infant further for signs related to diarrhea, and classify the illness according to the signs which are present or absent.
Check for FEEDING PROBLEM OR LOW WEIGHT and classify the
Check the infant’s immunization status and decide if the infant needs any immunization today.
Assess any other problems.
Then: Identify Treatment (PART IV), Treat the Infant (PART V), and Counsel the Mother (PART VI)
SUMMARY OF ASSESS AND CLASSIFY
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CHECK FOR POSSIBLE BACTERIAL INFECTION
For ALL sick young infants check for signs of POSSIBLE BACTERIAL INFECTION
ASK:Has the infant had convulsions?
LOOK, LISTEN, FEEL:Count the breaths in one minute.
Repeat the count if elevated.Look for severe chest indrawing.Look for nasal flaringLook and listen for grunting.Look and feel for bulging fontanelle.Look for pus draining from the ear.Look at the umbilicus. Is it red or draining pus?
Does the redness extend to the skin?Measure temperature (or feel for fever or low body temperature)Look for skin pustules. Are there many or severe pustules?See if the young infant is lethargic or unconscious.
Look at the young infants’s movements. Are they less than normal?
YOUNG INFANT
MUST BE CALM
CLASSIFY the infant’s illness using the COLOUR-CODED-CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION.
Then ASK about diarrhea. CHECK for feeding problem or low weight, immunization status and for other problems.
How to check a young infant for possible bacterial infection
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Check for possible bacterial infection
Must be done for every sick infant Three important bacterial infections:
pneumoniasepsismeningitis
Assess the signs in the order Keep the young infant calm during the assessment Presence of any sign warrants referral to a hospital
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
convulsionRR > or = 60/minSevere chest indrawing
Note: mild chest indrawing is normal in a young infant because of the soft chest wall
severe chest indrawing is a sign of pneumonia and is serious in a young infant.
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Infant with retractions
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
nasal flaring: widening of the nostrils when the young infant breathes in
grunting: short sounds a young infant makes when breathing out
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The larynx, or voice box, is located in the neck and performs several important functions in the body. The larynx is involved in swallowing, breathing, and voice production. Sound is produced when the air which passes through the vocal cords causes them to vibrate and create sound waves in the pharynx, nose and mouth. The pitch of sound is determined by the amount of tension on the vocal folds.
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Nasal flaring may be an indication of breathing difficulty, or even respiratory distress in infants
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Not Nasal Flaring but Yawning
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Grunting in an Infant
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
bulging fontanelle: the infant must be in an upright position and must be calm and quiet. If the fontanel is bulging rather than flat, this may mean the young infant has meningitis.
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Bulging Fontanel
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
– pus draining from ear– erythema and discharge from the
umbilicus redness extending to the skin of the abdominal wall is a sign of serious bacterial infection
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Umbilicus
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Umbilicus
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Umbilicus
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
abnormal body temperatureFEVERaxillary T > 37.5 Crectal T > 38.0 C
HYPOTHERMIAaxillary T < 35.5 Crectal T <36.0 C
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
severe skin pustules: these are red
spots or blisters which contain pus.
A severe pustule is large or has redness extending beyond the pustule; many or severe pustules indicate a serious infection
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Skin Pustules
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
lethargy or unconsciousness: a lethargic young infant is not awake and alert when he
should be. He may be drowsy and may
not stay awake after a disturbance.
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Check for possible bacterial infection
Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
lethargy or unconsciousness: If a younginfant does not wake up during the assessment, ask the mother to wake him. An unconscious young infant cannot be awakened at all. He does not respond when he is touched or spoken to.
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Signs and Symptoms of Possible Bacterial Infection in a Young Infant:
Abnormal movements: 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. If the infant moves less than normal, this could be a sign of a possible bacterial infection.
Check for possible bacterial infection
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Convulsions orFast breathing (60 breaths per minute or more) or Severe chest indrawing or Nasal flaring or Grunting or Bulging fontanelle or Pus draining from ear or Umbilical redness extending to the skin or Fever (37.5 C* or above or feels hot) or low body temperature (less than 35.5 C* or feels cold) or Many or severe skin pustules or Lethargic or unconscious or Less than normal movement.
POSSIBLE SERIOUS
BACTERIAL INFECTION
Give first dose of intramuscular antibiotics.Treat to prevent low blood sugar.Advise mother how to keep the infant warm on the way to hospital.Refer URGENTLY to hospital
Red umbilicus or draining pus or Skin pustules.
LOCAL BACTERIAL INFECTION
Give an appropriate oral antibiotic.Teach the mother to treat local infections at home. Advise mother to give home care for the young infant.Follow-up in 2 days
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
*These thresholds are based on axillary temperature. The thresholds for rectal temperature readings are approximately 0.5 ° C higher.
CLASSIFICATION TABLE FOR POSSIBLE BACTERIAL INFECTION
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For ALL sick young infants check for signs of possible bacterial infection and then
ASK: DOES THE YOUNG INFANT HAVE DIARRHOEA?
IF YES: ASSES AND CLASSIFY the young infant’s diarrhoea using the DIARRHOEA box in the YOUNG INFANT chart. The
process is very similar to the one used for the sick child (see Chapter 8).
Then CHECK for feeding problem or low weight, immunization status and other problems.
How to assess and classify a young infant for Diarrhea
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Assess, Classify, and Treat a Young Infant with Diarrhea
The normally frequent or loose stools of a breastfed baby is not diarrhea
The mother of a breastfed baby can recognize diarrhea because the consistency or frequency of the stools is different than normal
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Assess, Classify, and Treat a Young Infant with Diarrhea
Assessment is similar to the assessment of diarrhea for an older infant or young child, but fewer signs are checked.
Thirst is not assessed. This is because it is not possible to distinguish thirst from hunger in a young infant.
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Assess, Classify, and Treat a Young Infant with Diarrhea
Diarrhea in a young infant is classified in the same way as an older infant of young child.
Classify dehydration. (See Table)
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Assess, Classify, and Treat a Young Infant with Diarrhea
Choose an additional classification if the infant has diarrhea for 14 days or more, or blood in the stool.
Note that there is only one possible classification for persistent diarrhea in a young infant. This is because any young infant who has persistent diarrhea has suffered with diarrhea in a large part of his life and should be treated.
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Classification of Dehydration
Two or more of the following signs:
-lethargic or unconscious
-sunken eyes
-skin pinch goes back very slowly
Classify as Severe Dehydration
-give fluid for severe dehydration (Plan C)
- refer to hospital with mother
giving frequent sips of ORS on the way. Continue breastfeeding.
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Two of the following signs:
-restless, irritable
-sunken eyes
-skin pinch goes back slowly
Classify as Some Dehydration
Give fluid and food for some dehydration (Plan B)
refer to hospital with mother giving frequent sips of ORS on the way. Continue breastfeeding.
Classification of Dehydration
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Not enough signs to classify as some or severe dehydration
No dehydration
give fluids to treat diarrhea at home (Plan A)
Classification of Dehydration
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Severe Persistent Diarrhea-diarrhea lasting 14 days or more
-if the young infant is dehydrated, treat dehydration before referral unless the infant has also POSSIBLE SERIOUS BACTERIAL INFECTION
-treat dehydration
-refer to hospital
Dysentery-blood in the stool
-treat for 5 days with an oral antibiotic recommended for Shigella in your area
-refer urgently to hospital with the mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding.
Advise the mother to keep the young infant warm at all times.
-follow up in 2 days
Classification of Dehydration
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For ALL sick young infants check for signs of possible bacterial infection, ask aboutdiarrhea and then CHECK FOR FEEDING PROBLEM OR LOW WEIGHT.
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
ASK: LOOK, LISTEN, FEEL:œ Is there any difficulty feeding? œ Determine weight for age.� �œ Is the infant breastfed? If yes,how many times in 24 hours?�œ Does the infant usually receive any other foods or drinks?� If yes, how often? œ What do you use to feed the infant?�
IF AN INFANT: Has any difficulty feeding, Is breastfeeding less than 8 times in 24 hours, Is taking any other foods or drinks, or Is low weight for age, AND Has no indications to refer urgently to hospital:ASSESS BREASTFEEDING:œ Has the infant If the infant has not fed in the previous hour, ask the mother to put her�breastfed in the infant to the breast. Observe the breastfeed for 4 minutes.previous hour? (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.) œ Is the infant able to attach?� no attachment at all not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:— Chin touching breast— Mouth wide open— Lower lip turned outward— More areola visible above then below the mouth(All these signs should be present if the attachment is good.)Is the infant suckling effectively (that is, slow deep sucks,sometimes pausing)?no suckling at all not suckling effectively suckling effectivelyClear a blocked nose if it interferes with breastfeeding.œ Look for ulcers or white patches in the mouth (thrush).�
CLASSIFY the infant’s nutritional status using the colour-coded classification table for feeding problem or low weight.
Then CHECK immunization status and for other problems.
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Assess and Classify a Young Infant for a Feeding Problem or Low Birth Weight
How to assess breastfeedingFirst decide whether to assess the infant’s breastfeeding:
If an infant:
Has any difficulty feeding,
Is breastfeeding less than 8 times in 24 hours,
Is taking any other foods or drinks, or
Is low weight for age, AND
Has no indications to refer urgently to the hospital:
ASSESS BREASTFEEDING:
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Problems Associated with Breastfeeding
problems with attachment
problems with sucking
blocked nose
ulcers or white patches in the mouth
Assess and Classify a Young Infant for a Feeding Problem or Low Birth Weight
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Not able to feed or No attachment at all or Not suckling at all.
NOT ABLE TO FEED POSSIBLE
SERIOUS BACTERIAL INFECTION
Give first dose of intramuscular antibiotics. Treat to prevent low blood sugar.Advise the mother how to keep the young infant warm on the way to hospital.Refer URGENTLY to hospital.
Not well attached to breast or Not suckling effectively or Less than 8 breastfeeds in 24 hours or Receives other foods or drinks or Low weight for age or Thrush (ulcers or white patches in mouth).
FEEDING PROBLEM OR LOW WEIGHT
Advise the mother to breastfeed as often and for as long as the infant wants, day and night.
-If not well attached or not suckling effectively, teach correct positioning and attachment.
-If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding.
If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or drinks, and using a cup.
–If not breastfeeding at all:
— Refer for breastfeeding counselling and possible relactation.
— Advise about correctly prepared breastmilk substitutes and using a cup.
If thrush, teach the mother to treat thrush at home. Advise mother to give home care for the young infant.Follow-up any feeding problem or thrush in 2 days. Follow-up low weight for age in 14 days.
Not low weight for age and no other signs of inadequate feeding.
NO FEEDING
PROBLEM
Advise mother to give home care for the young infant.Praise the mother for feeding the infant well.
SIGNS CLASSIFY ASIDENTIFY TREATMENT
(Urgent pre-referral treatments are in bold print.)
CLASSIFICATION TABLE FOR FEEDING PROBLEM OR LOW WEIGHT
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Identify Appropriate Treatment
Urgent referral to a hospital Young infant with possible serious bacterial infection Young infant with severe dehydration (and does not
have serious bacterial infection) the infant needs rehydration with IV fluids according to plan C.
- If IV therapy can be given, the infant can be
treated in the clinic.
- Otherwise, urgent referral is needed for IV
therapy.
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Young infant with both severe dehydration and possible severe bacterial infection (give frequent sips of ORS and continue breastfeeding while on the way to the hospital)
Prepare a referral note and explain to the mother the reasons to the referral
Identify Appropriate Treatment
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Treatment for a young infant who does not need urgent referral
Record treatment
Advise mother on what to give and when to return for a follow-up visit
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Follow-up visits:
If infant gets worse on follow up, refer to the hospital. Advise follow up after 2 days in a young infant who:
(a) receives antibiotics for local bacterial infection or dysentery(b) has a feeding problem or oral thrushin 14 days in an infant with low weight for age
Treatment for a young infant who does not need urgent referral
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Pre-Referral Treatment:
(1) give first dose of intramuscular antibiotics(2) give an appropriate oral antibiotic, e.g. first dose of
an oral antibiotic for local bacterial infection or dysentery(3) keep the infant warm on the way to the hospital ( advise the mother to wrap the infant next to her body)(4) treat to prevent low blood sugar(5) give frequent sips of ORS and continue breastfeeding
Treatment for a young infant who does not need urgent referral
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Treatment with appropriate oral or parenteral antibiotic
Local Bacterial InfectionAmoxicillin
40-50 mg/kg/day q8h for 5 days
Co-trimoxazole8-10 mg/kg/day of Trimethoprim q 12h for
5 days
NOTE: do not give to infants < 1 month old who are premature and jaundiced
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Treatment with appropriate oral or parenteral antibiotic
Dysentery
give antibiotic recommended for Shigella in your area for 5 days.
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Possible serious bacterial infection:
Needs coverage for gram-negative and gram-positive organisms (E. coli and Grp. B Strep): combination of gentamicin and Penicillin IM
Treatment with appropriate oral or parenteral antibiotic
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Treatment with appropriate oral or parenteral antibiotic
Referral is the best option for a young infant classified with possible serious bacterial infection. If referral is not possible, give benzylpenicillin & gentamicin for at least 5 days. Give Benzylpenicillin every 6h and gentamicin every 8h.
For infants in the first week of life, give gentamicin every 12h.
Benzylpenicillin 50,000 units/kg/doseGentamicin 2.5 mg/kg/dose
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Treatment of Diarrhea
Emphasize to continue breastfeeding
If an infant is exclusively breastfed, do not introduce any food-based fluid but may give additional ORS solution or clean water.
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Treatment of Diarrhea
To treat some dehydration, during the first 4 hours of rehydration, encourage the mother to pause to breastfeed whenever the infant wants, then resume giving ORS.
Give a young infant who does not breastfeed an additional 100-200 ml clean water.
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Immunization of the Sick Young Infant
Administer any Immunization that the young infant needs
Tell the mother when to bring the infant for the next immunization
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Treatment of local infections at home
Skin pustules or umbilical infections
wash hands before and after treating the infection
gently wash off pus and crusts with soap and water
dry the area paint with gentian violet
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Treatment of local infections at home
Oral thrush-ulcers or white patches in mouth
wash hands before and after wash mouth with clean, soft cloth wrapped
around the finger and wet with salt water paint the mouth with half-strength gentian
violet stop using gentian violet after 5 days
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Oral Thrush
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Correct positioning and attachment for breastfeeding
Reasons for poor attachment and ineffective suckling:
previous non-breastfeeding especially in the first few days after delivery
inexperienced mother
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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
infant’s whole body is supported
Correct positioning and attachment for breastfeeding
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Poor positioning is recognized with any of the following:
infant’s body is twisted or bent forwardinfant’s body is turned away from motherinfant’s body is not close to motheronly the infant’s head and neck are supported
Correct positioning and attachment for breastfeeding
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Positioning is important because poor positioning often results in poor attachment, especially in younger infants
Correct positioning and attachment for breastfeeding
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Teaching correct positioning and attachment for breastfeeding
Show the mother how to hold 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
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Teaching correct positioning and attachment for breastfeeding
Show her how to help the infant 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, try again
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How we can help a baby suckles
Baby well attached at breastLacteal sinuses inside mouth
Peristaltic wave moving along tongue and removing milk
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How we can see differences in good and bad attachment: observing a mother to breastfeed
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Good Attachment
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Poor or Bad Attachment
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Examples of Good and Poor Positioning
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Counseling about other feeding problems
Breastfeed as often and for as long as the infant wants, day and night
Feed the infant any other drinks from a cup, and not from feeding bottle
Breastfeed for 8 times or more in 24h
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Refer a mother who does not breastfeed for counseling and relactation
Advise a mother who does not breastfeed about choosing and correctly preparing an appropriate breast milk substitute to be given with a cup and not from a feeding bottle
Counseling about other feeding problems
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Home care for the sick young infant
Breastfeed frequently, as often and for as long as the infant wants, to provide nourishment and help prevent dehydration
Tell the mother when to return for follow up visit and when to return immediately
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Home care for the sick young infant
Return immediately if the young infant has any of these signs:
breastfeeding or drinking poorly becomes more sick develops fever fast breathing difficult breathing blood in stoolKeep the infant warm at all times
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