3.3  Assess for bacterial infection

ASK: Is there any difficulty feeding?

Ask the mother this question. Any difficulty mentioned by the mother is important. She may need counselling or specific help with any problems she is experiencing when feeding her baby. If the mother says that the young infant is not able to feed, assess breastfeeding or watch her try to feed the young infant with a cup to see what she means by this. Any young 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 generalised or focal (an abnormal body movement that is limited to one or two parts of the body, such as twitching of the mouth and eyes, arms or legs). Focal convulsions can be faint and can easily be 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 the infant’s breathing is fast

You must count the breaths the young infant takes in one minute to decide if the infant has fast breathing. Sixty breaths per minute or more is the cut-off used to identify fast breathing in a young infant. The child must be quiet and calm when you look at and listen to his breathing. Tell the mother you are going to count her infant’s breathing. Remind her to keep her infant calm. If the infant is sleeping, do not wake him.

To count the number of breaths in one minute:

1. Use a watch with a second hand or a digital watch, look at the infant’s chest and count the number of breaths in 60 seconds.
2. Look for breathing movement anywhere on the child’s chest or abdomen. You can usually see breathing movements even in an infant who is dressed. If you cannot see this movement easily, ask the mother to lift the infant’s 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.

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. A 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 in-drawing

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 in-drawing when the infant breathes in. Look at the lower chest wall (lower ribs). The infant has chest in-drawing if the lower chest wall goes in when the infant breathes in. Chest in-drawing 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 in-drawing is present, the lower chest wall goes in when the infant breathes in. Chest in-drawing is also known as subcostal in-drawing or subcostal retraction.

If you are not sure that chest in-drawing is present, look at the infant 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 he is lying flat in her lap. If you still don’t see the lower chest wall go in when the infant breathes in the infant does not have chest in-drawing.

For chest in-drawing to be present, it must be clearly visible and present all the time. If you only see chest in-drawing when the infant is crying or feeding, the infant does not have chest in-drawing.

If only the soft tissue between the ribs goes in when the child breathes in (also called intercostal in-drawing or intercostal retraction), the infant does not have chest in-drawing.

Mild chest in-drawing is normal in a young infant because the chest wall is soft. Severe chest in-drawing is very deep and easy to see. Severe chest in-drawing is a sign of pneumonia and is serious in a young infant.

LOOK and LISTEN for grunting

Grunting is the soft, short sounds a young infant makes when breathing out. Grunting occurs when an infant is having trouble breathing.

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 (Figure 3.1). The cord usually drops from the umbilicus by one week of age.

Feel and measure

Measure the axillary (underarm) temperature (or feel for fever or low body temperature). Fever (where the axillary temperature is 37.5^°C or more) is uncommon in the first two months of life. If a young infant has a fever, this may mean the infant has a serious bacterial infection. A fever may be the only sign of a serious bacterial infection. Young infants can also respond to infection by developing hypothermia (dropping of body temperature to below 35.5^°C). Low body temperature is defined as body temperature between 35.5 and 36.4^°C.

If you do not have a thermometer, feel the infant’s stomach or axilla (underarm) and determine if it feels hot or unusually cool.

LOOK for skin 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 fewer 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 the 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.

A young infant who is awake will normally move his arms or legs or turn his head several times in a minute if you watch him closely. You should observe the infant’s movements while you do the assessment. Look and see if the young infant moves when gently shaken by the mother, or when you clap your hands or gently stimulate the young infant. If the young infant moves only when stimulated, or does not move even when stimulated, this is a sign that the young infant could have an infection.