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Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva: World Health Organization; 2009.

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Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals.

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SESSION 5Continuing support for infant and young child feeding

5.1. Support for mothers in the community

Health workers do not always have the opportunity to ensure that mothers successfully establish breastfeeding. Mothers may give birth at home, or they may be discharged from a maternity facility within a day or so after delivery. Difficulties may arise in the first few weeks with breastfeeding, and later on when complementary foods are needed. Illness of infants and young children is often associated with poor feeding. Families and friends are usually a mother's main source of advice about feeding her children, but this advice is sometimes fraught by misconceptions.

Mothers need continuing support to maintain exclusive and continued breastfeeding, to implement other methods of infant feeding when breastfeeding is not possible, and to establish adequate complementary feeding when the child is 6 months of age and older (1). If a child becomes ill, the mother may require skilled support from a health worker to continue feeding her child. This support can be provided by trained personnel in the community, and in various other settings, such as a primary care facility or a paediatric department in a hospital.

There should be no missed opportunities for supporting feeding in any contact that a mother and child have with the health system, whether it involves doctors, midwives, nurses or community health workers. Lay or peer counsellors who have the skills and knowledge to support optimal infant and young child feeding can also contribute to improved feeding practices (2). Collectively, all these providers should ensure a continuum of care from pregnancy through the postnatal period into early childhood. When they help a mother, they should also talk to other family members, showing respect for their ideas, and helping them to understand advice on optimal feeding. In addition, they can share information and create awareness about the importance of appropriate infant and young child feeding through other channels, for example, by involving school children or extension workers from other sectors. This multi-pronged approach to promoting and supporting infant and young child feeding has been shown to be effective in many settings (3).

Box 9 summarizes key points of contact that mothers might have with a health worker who is knowledgeable and skilled to support her in practising appropriate infant and young child feeding. Mothers who are not breastfeeding also need help with infant feeding at these times, and many of the skills needed by health workers to support them are similar.

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BOX 9

Key points of contact to support optimal feeding practices. During antenatal care At the time of childbirth and in the immediate postpartum period

5.2. Infant and young child feeding counselling

Infant and young child feeding counselling is the process by which a health worker can support mothers and babies to implement good feeding practices and help them overcome difficulties. Details of infant and young child feeding counselling depend on the child's age and the mother's circumstances. Generally, a health worker should:

Use good communication and support skills:

  • Listen and learn
  • Build confidence and give support.

Assess the situation:

  • Assess the child's growth
  • Take a feeding history
  • Observe a breastfeed
  • Assess the health of the child and the mother.

Manage problems and reinforce good practices:

  • Refer the mother and child if needed
  • Help the mother with feeding difficulties or poor practices
  • Support good feeding practices
  • Counsel the mother on her own health, nutrition and family planning.

Follow-up

5.3. Using good communication and support skills

If a health care worker is to effectively counsel a mother or other caregiver, he or she should have good communication skills. The same skills are useful in many situations, for example for family planning, and also in ordinary life. They may be described in slightly different ways and with different details in different publications, but the principles are the same. The tools described here include the basic skills useful in relation to infant and young child feeding. There are a number of similar tools that can be used for the same purpose.

The sections that follow provide concrete guidance on infant and complementary feeding counselling. They are written in a direct style and often address the reader with ‘you’ to make it more interesting and easier to absorb the content.

There are two groups of skills (see Box 10):

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BOX 10

Communication and support skills. Use helpful non-verbal communication. Ask open questions.

  • listening and learning skills help you to encourage a mother to talk about her situation and how she feels in her own way, and they help you to pay attention to what she is saying;
  • building confidence and giving support skills help you to give a mother information and suggest what she might do in her situation, so that she can decide for herself what to do. Supporting a mother is more useful than giving direct advice which she may not be able to follow, and which may even make her unwilling to talk to you again.

Listening and learning skills

Using helpful non-verbal communication. Non-verbal communication means how you communicate other than by speaking. Helpful non-verbal communication shows that the health worker respects the mother and is interested in her. It includes: keeping your head about level with the mother's, and not towering over her; making eye contact, nodding and smiling; making sure that there are no barriers, such as a table or conspicuous papers, between you and the mother; making sure that you do not seem to be in a hurry; touching her or the baby in a culturally appropriate way.

Asking open questions. “Open questions” often start with “how”, “when”, “who”, “what”, “why”. To answer them it is necessary to give some information, so they encourage a person to talk, and conversation becomes easier. The opposite are “closed questions”, which usually start with “Do you?”, “Are you”, “Is he?”, “Has she?”. A person can answer them with a “yes” or “no”, thus giving little information. Open questions can also be more general, for example “Tell me more about…”.

Using responses and gestures that show interest. Such responses include “Oh dear”, “Really?”, “Go on…” or “Eeeeh”. Gestures such as nodding and smiling are also responses that show interest. Showing interest encourages a mother to say more.

Reflecting back what the mother says. Reflecting is a very helpful way to show that you are listening and to encourage a mother to say more. It is best to reflect back using slightly different words from the mother, not to repeat exactly what she has said. You may only need to use one or two of the important words that she used to show that you have heard her.

Empathizing. Showing that you understand how she feels lets the woman know that you understand her feelings from her point of view, using phrases such as “you are worried”, “you were very upset” or “that is hard for you”. You can also empathize with good feelings, for example, “you must feel pleased”.

Avoiding words that sound judging. These are words such as “right”, “wrong”, “good”, “well”, “badly”, “properly”, “enough”. For example, the care provider should not say “Are you feeding your baby properly? Do you have enough milk?” This can make a mother feel doubtful, and that she may be doing something wrong. It is better to ask “How are you feeding your baby? How about your breast milk?” Sometimes asking “why” may sound judging, for example “Why did you give a bottle last night?” It is better to ask “What made you give a bottle?”

Confidence and support skills

Accepting what a mother thinks and feels. Accepting means not disagreeing with a mother or caregiver, but at the same time not agreeing with an incorrect idea. Disagreeing with someone can make her feel criticised, and reduce her confidence and willingness to communicate with you. Accepting involves responding in a neutral way. Later, you can give the correct information.

Recognizing and praising what a mother and baby are doing right. Health workers are trained to look for problems and may only see what is wrong and then try to correct it. Recognizing and praising a mother's good practices helps to reinforce them and build her confidence. You can also praise what a baby does, such as growing and developing well.

Giving practical help. Helping a mother or caregiver in other ways than talking, often quite simply, such as giving her a drink of water, making her comfortable in bed or helping her to wash are examples of practical help. When a mother has had a great deal of advice or has been struggling with her baby, this kind of practical help may be the best way to show that you understand, and she may be more receptive to new information and suggestions. Helping with her breastfeeding technique is also practical help, but of a different kind as it involves giving her information too. She may not be ready for that at first.

Giving a little relevant information. After you have listened to a mother or caregiver, think about her situation and decide what information is most relevant and useful at the time. You should avoid telling her too much, because she may become confused and forget what is most important. Sometimes the most useful information is a clear explanation of what she has noticed, for example the baby's behaviour, or changes in her breasts; or what to expect, for example how breast milk “comes in”, or when and why the infant needs foods in addition to breast milk. Helping her to understand the process is better than immediately telling her what to do.

Using simple language. It is important to give information in a way that is easy for a person to understand, using simple, everyday words.

Making suggestions, not commands. If you tell a mother what to do, she may not be able to do it, but it can be difficult for her to disagree with you. She may just say “yes” and not come back. Giving a suggestion allows her to discuss whether or not she can follow it. You can make other suggestions, encourage her to think of more practical alternatives and help her to decide what to do. This is particularly important in the case of infant and young child feeding, when there often are different options.

5.4. Assessing the situation

5.4.1. Assessing the child's growth

Assessing a child's growth provides important information on the adequacy of the child's nutritional status and health. There are several measures to assess growth, including weight-for-age, weight-for-height, and height-for-age. In the past, many countries used weight-for-age to assess both children's growth and their present nutritional status. National growth curves were based on weight-for-age. With the availability of the WHO growth standards (4), countries may revisit their growth charts and introduce weight-for-height as the standard for measuring nutritional status, and provide training for health workers. It is recommended to use separate standards for boys and girls.

When counselling on infant and young child feeding, it is important to understand growth charts. If growth is not recorded correctly, and charts are not interpreted accurately, incorrect information can be given to a mother, leading to worry or loss of confidence. The following sections explain briefly the different measures.

Weight-for-age

Weight-for-age reflects body weight relative to the child's age on a given day. A series of weights can tell you whether or not a child's weight is increasing over time, so it is a useful indicator of growth. This indicator is used to assess whether a child is underweight or severely underweight, but it is not used to classify a child as overweight or obese. Because weight is relatively easily measured, this indicator is commonly used, but it cannot be relied upon in situations where the child's age cannot be accurately determined. Also, it cannot distinguish between acute malnutrition and chronic low energy and nutrient intake. Examples of weight-for-age charts for boys and girls are included in Annex 2.

NOTE: If a child has oedema of both feet, fluid retention increases the child's weight, masking what may actually be very low weight. The growth chart should be marked to show that the child has oedema. A child with oedema is automatically considered severely undernourished and should be referred for specialized care.

Weight-for-length/height1

Weight-for-length/height reflects body weight in proportion to attained growth in length or height. This indicator is especially useful in situations where children's ages are unknown (e.g. refugee settlements). Weight-for-length/height charts help identify children with low weight-for-height who may be wasted or severely wasted. These charts also help identify children with high weight-for-length/height who may be at risk of becoming overweight or obese. However, assessing weight-for-height requires two measurements – of weight and height – and this may not be feasible in all settings.

Length/height-for-age

Length/height-for-age reflects attained growth in length or height at the child's age at a given visit. This indicator can help identify children who are stunted (or short) due to prolonged undernutrition or repeated illness. Children who are tall for their age can also be identified, but tallness is rarely a problem unless it is excessive and may reflect uncommon endocrine disorders. Acute malnutrition does not affect height.

Mid-upper arm circumference

Another useful way to assess a child's present nutritional status is to measure the mid-upper arm circumference (MUAC) (5). MUAC below 115 mm is an accurate indicator of severe malnutrition in children 6–59 months of age (6). MUAC should be measured in all children who have a very low weight-for-age (see Figure 14). MUAC can also be used for rapidly screening all children in a community for severe malnutrition. Management of severe malnutrition is discussed in Session 6.

FIGURE 14. Measuring mid-upper arm circumference.

FIGURE 14

Measuring mid-upper arm circumference.

Deciding whether a child is growing adequately or not

The curved lines printed on the growth charts will help you interpret the plotted points that represent a child's growth status. The line labelled “0” on each chart represents the median, which is, generally speaking, the average. The other curved lines are z-score lines,2 which indicate distance from the average.

Z-score lines on the growth charts are numbered positively (1, 2, 3) or negatively (−1, −2, −3). In general, a plotted point that is far from the median in either direction (for example, close to the 3 or −3 z-score line) may represent a growth problem, although other factors must be considered, such as the growth trend, the health condition of the child and the height of the parents.

Identifying growth problems from plotted points

Growth problems can be identified by interpreting the plotted points in the child's Growth Record. Read plotted points as follows:

  • A point between the z-score lines −2 and −3 is “below −2.”
  • A point between the z-score lines 2 and 3 is “above 2.”

Table 4 below provides a summary of definitions of growth problems according to z-scores. Notice that the child falls into a category if his or her growth indicator is plotted above or below a particular z-score line. If the growth indicator is plotted exactly on the z-score line, it is considered in the less severe category. For example, weight-for-age on the −3 line is considered “underweight” as opposed to “severely underweight.” Measurements in the shaded boxes are in the normal range.

TABLE 4. Identifying growth problems from plotted points.

TABLE 4

Identifying growth problems from plotted points.

Low weight-for-age

If a child has been weighed only once, the information does not say much about the child's growth, but only about the child's body weight relative to the standard for his or her age. Some infants are constitutionally small, and others are born with low birth weight due to prematurity or intrauterine growth restriction. These children may have low weight-for-age, but they may grow satisfactorily following the lowest standard curve. There is a need for full assessment and appropriate counselling. When the child is followed up and weighed again, the situation may become clearer.

However, low weight-for-age can also be a sign of poor feeding or illness. If weight-for-age is below the -2 z score line the child is underweight; if the weight-for-age is below the -3 z-score line (the lowest standard curve) the child is severely underweight. A child who is severely underweight is at risk of severe malnutrition, and needs special attention urgently.

Growth faltering

If a child's weight is not increasing, or if it is increasing more slowly than the standard curve for more than 1 month in babies less than 4 months of age, or 2 months in older children, then the child has growth faltering. Growth faltering is common in the first 2 years of life, and may be the first sign of inadequate feeding in an otherwise healthy child. The child may be less active than others of the same age. Sometimes growth faltering is due to illness or abnormality. When a child is ill, the weight may decrease. Following a period of growth faltering, a recovering child should gain weight more rapidly than the standard curves until he or she returns to his or her original growth trend.

Loss of weight

If a child's growth curve is falling, the child may be ill with an infection, for example, tuberculosis or AIDS. Children who are losing weight need a full assessment according to the Integrated Management of Childhood Illness (IMCI) guidelines and should be referred if they have any serious illness or danger sign. If acute malnutrition due to a shortage of food in the household is the likely reason for the weight loss, and there are no other complications, the child can be managed in the community (see Session 6.2). Close follow-up is needed to ensure that weight gain is achieved within two weeks.

Rapid rise in the growth curve

Any sharp increase in a child's growth requires attention. If a child has been ill or undernourished, a rapid rise is expected during the re-feeding period as the child experiences “catch-up” growth. Otherwise, a sharp increase may indicate inappropriate feeding practices that can lead to overweight.

If a child has gained weight rapidly, it is important to look also at height. If only the weight increased, this is a problem. If weight and height increased proportionately, this is probably catch-up growth from previous undernutrition. In this situation, the weight-for-age and height-for-age curves should both rise, but the weight-for-height growth curve follows along the standard curves.

Even if a child is overweight and trying to lose weight, he or she should not have a sharp decrease in the growth curve, as losing too much weight rapidly is undesirable. The overweight child should instead maintain his weight while increasing in height, i.e. the child should “grow into his weight.”

5.4.2. Taking a feeding history

During any contact with a mother and child, it is important to ask how feeding is progressing. Simple open questions can generate a great deal of information.

Taking a feeding history in infants 0–6 months of age

When a child is not growing well or the mother has a feeding difficulty, it is useful to conduct a detailed feeding history. The Feeding History Job Aid for infants 0–6 months in Box 11 summarizes key topics to cover in a counselling session with a mother with an infant less than 6 months of age. The form is not a questionnaire, and it may not be necessary to cover all topics in a conversation with the mother. Concentrate on those that are relevant according to the child's age and situation. Ask the mother about the child and how he or she is fed, about herself, the family and their social situation using listening and learning skills.

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BOX 11

Feeding History Job Aid, infants 0–6 months. Age of child Particular concerns about feeding of child

Taking a feeding history in children 6–23 months of age

To learn more details about how a child over the age of 6 months is fed, you need to follow the history for younger infants (Box 11), and in addition ask relevant questions listed in Box 12. Again, this is not a questionnaire, but a reminder about the important things to learn which will help you to counsel and guide the mother to feed her child adequately.

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BOX 12

Feeding History Job Aid, children 6–23 months. Is the child still breastfed? How many times per day? Day and night?

These questions are combined into the Food Intake Reference Tool (see Session 5.6), which you can use to help you decide on the information and messages that a mother needs when you counsel her.

5.4.3. Observing a breastfeed

At all contacts with lactating mothers of infants under 2 months of age, observe a breastfeed. After the age of 2 months, include an observation if a mother has any feeding difficulty or if the infant has growth faltering or low weight-for-age.

The Breastfeed Observation Job Aid in Box 13 is a tool to assist in observing a breastfeed. If the baby has just breastfed or is fast asleep, it may take some time before he or she is ready to breastfeed again. To initiate an observation:

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BOX 13

Breastfeed Observation Job Aid.

  • Ask the mother whether she could offer her baby the breast and to breastfeed in her usual way.
  • Try to observe a complete feed, to see how long the baby suckles for, and if he or she releases the breast by him- or herself.

If the mother has obvious difficulties, it may be appropriate to interrupt the feed in order to help her to improve positioning and attachment while the baby is still hungry (see Session 4.5).

The signs of good positioning and attachment are explained in more detail in Session 2.8.

While observing a feed, make a tick in the small box beside any sign observed. If a sign is not seen, simply leave the box empty.

Signs down the left side of the form show that breastfeeding is going well. Signs down the right side of the form show that there may be a difficulty. If there are some ticks down the right side, then the mother needs help, even if there are also ticks down the left side.

5.4.4. Assessing the health of the child and the mother

Assessing the health of the child

During feeding counselling it is important to assess the health status of the child using the systematic approach described in the IMCI guidelines (7,8), and manage the child accordingly.

Decide if the child has:

  • cough or difficult breathing
  • diarrhoea fever
  • ear problems
  • malnutrition or anaemia.

Recognize if the child has any signs of severe illness that require immediate referral:

  • unconscious or lethargic
  • severely malnourished
  • not able to eat or drink
  • not able to breastfeed even after help with attachment
  • copious vomiting after all feeds.

Also check for conditions that can interfere with breastfeeding:

  • blocked nose (makes suckling and breathing difficult)
  • jaundice (baby may be sleepy and suckle less)
  • thrush (Candida) (baby may take short feeds only, or may refuse to feed)
  • cleft lip or palate (makes attachment difficult and baby may have low milk intake)
  • tongue tie (makes attachment difficult, may cause sore nipples and low milk intake).

Assessing the health of the mother

During feeding counselling it is also important to enquire about the mother's own health status, her mental health, her social situation and her employment. These are all factors that will affect her ability to care for her young child. Important topics to address are listed in the Feeding History Job Aid (Box 11), and include:

  • Observe the state of her nutrition, general health and breast health as part of the observation of a breastfeed.
  • Try to learn her ideas about another pregnancy, and if she is adequately informed about family planning and has access to appropriate counselling.
  • If a mother seems to have serious clinical or mental health problems or if she is taking regular medication, make an additional physical examination and refer as necessary for specialized treatment (see Session 8).
  • If not recorded on medical records, ask the mother if she has been tested for HIV. If not, encourage her to do so (depending on current national guidance).

5.5. Managing problems and supporting good feeding practices

The results of the assessment are used to classify the mother and baby according to their situation and to decide on management. Figure 15 summarizes three categories of actions that may be required, namely: Refer urgently; Help with difficulties and poor practices and refer, if necessary; Support for good feeding practices.

FIGURE 15. Assessing and classifying infant and young child feeding.

FIGURE 15

Assessing and classifying infant and young child feeding.

5.5.1. Refer urgently

Refer the infant or young child urgently to hospital if he or she:

  • is unconscious or lethargic, and thus may be very ill;
  • is severely malnourished;
  • is not able to drink or eat anything;
  • is not able to breastfeed even after help with attachment;
  • vomits copiously, which may be both a sign of serious illness and of danger because he or she will not be able to take medications or fluids for rehydration.

There may be a need to give one or more treatments in the clinic before the infant or child leaves for hospital:

  • Oral or intramuscular antibiotic for possible severe infection;
  • Rectal or intramuscular antimalarial for severe malaria;
  • If a child is still able to breastfeed, particularly if malnourished, ask the mother to continue offering the breast while being referred. Otherwise give sugar water to prevent low blood sugar (hypoglycaemia) by mixing 2 teaspoons (10 g) of sugar with half a glass (100 ml) of water;
  • Ensure warmth, especially for newborn babies and malnourished children.

5.5.2. Help with difficulties and poor practices

Breastfeeding

Most feeding difficulties and poor practices can be managed with outpatient care or care in the community.

You may be concerned about poor practices, even though the mother is not aware of particular difficulties. You may need to help a mother to position and attach her baby at the breast to establish optimal and effective breastfeeding (see Session 4.5) and discuss with her how to improve her breastfeeding pattern.

A mother may ask for help with a difficulty that she herself has become aware of. Session 7 describes the most common feeding difficulties and summarizes key steps in their management.

Non-urgent referral may be necessary if more specialized help is needed than is available at your level. Refer children with:

  • poor growth that continues despite health centre or community care;
  • breastfeeding difficulties that do not respond to the usual management;
  • abnormalities including cleft lip and palate, tongue tie, Down syndrome, cerebral palsy.

Complementary feeding

Sometimes a child over 6 months of age may be malnourished or growing poorly, or may not be eating well. Mothers and other caregivers may not complain of difficulties with complementary feeding, but their practices are not optimal. In either situation, you should recognise the need to counsel them about improving the way in which they feed the child.

Use the Food Intake Reference Tool (Table 5) to find out if the child is fed according to recommendations. Decide what information the mother needs, and what she is able to do to improve the child's feeding.

TABLE 5. Food Intake Reference Tool, children 6–23 months.

TABLE 5

Food Intake Reference Tool, children 6–23 months.

The first column contains questions about what the child has eaten in the previous 24 hours, to help you learn how the child is fed. The second column shows the ideal practice and the third column suggests a key message to help you decide what information to give the mother about what she should do.

Sometimes a child may be gaining weight too fast compared to height and the child is at risk of becoming overweight. Using the Food Intake Reference Tool is still helpful to assess the child's diet, although it may be necessary to add some specific questions related to the consumption of energy-rich, centrally processed foods.

Mother's health

Mothers may need help to adopt better practices, or to overcome difficulties with their own health, nutrition, or family planning. Session 8 discusses important issues that a health worker should address with mothers in an infant and young child feeding counselling contact.

Non-urgent referral may be necessary to obtain more specialized help than is available at health centre level. Refer mothers if they:

  • have a breast condition that does not respond to the usual management, or that requires medication or other treatment that is not available at the health facility;
  • are on medication that may affect breastfeeding (see Session 8);
  • have tested positive for HIV, and infant feeding counselling for this situation is not available at the health facility (see Session 6.5).

Child's health

Assessing the child according to the IMCI guidelines will help you decide whether the child needs urgent referral or treatment for a common childhood condition, such as diarrhoea, pneumonia or malaria. It will also help you decide whether a child needs vaccination or a micronutrient supplement, such as vitamin A.

5.5.3. Support good feeding practices

An important part of counselling a mother is active support and reinforcement of good feeding practices. Mothers may not be aware how important and valuable it is to continue them. Support and reinforcement are equally important if all her practices are already good, or if you are encouraging her to improve some which are not optimal. Praise helps to build her confidence.

Box 14 summarises the main points for supporting good practices.

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BOX 14

Supporting good feeding practices. If the infant is less than 6 months old: If the baby is growing well, point this out to the mother and praise her and the baby.

5.5.4. Counsel the mother on her own health, nutrition and fertility

Feeding counselling also provides a unique opportunity to counsel mothers about their own nutrition and to ensure that they are fully informed and able to access family planning. If the mother is taking medication, there is only rarely a reason to advise her to stop breastfeeding. Session 8 provides some more details on these issues and can be used for reference.

5.6. Follow-up

Follow-up and continuing care of all children is important, whether they have feeding difficulties or not, in order to support good practices, prevent difficulties and manage difficulties if they arise. Follow-up may take place at a health facility or on a home visit.

Follow-up of the infant or young child with feeding difficulties

Infants up to 6 months of age

  • For a newborn with feeding difficulties, reassess after 1–2 days.
  • For an infant older than one month with feeding difficulty: reassess after 2–5 days, depending on the severity of the infant's condition and convenience of the mother.

Reassessment includes:

  • a general enquiry on progress;
  • an enquiry about the mother's experience trying suggestions discussed at a previous contact;
  • weighing the child and assessing growth;
  • observation of a breastfeed;
  • examination of the mother's breasts;
  • assessment of the infant's health;
  • if the mother has been expressing breast milk, checking whether she is managing to do this effectively and that her technique is satisfactory.

Continuing management:

  • If the infant is not gaining weight or has persistent feeding difficulties, offer additional help and follow up again after 2–5 days, or consider referral. A child who has not gained weight on two consecutive visits or within 1 month needs to be referred.
  • If the infant has gained weight and feeding difficulties are resolved, he or she should return for further follow-up after 2–4 weeks, and thereafter at the same time as children with no difficulties.

Children 6–23 months of age

Follow up after 5–7 days an infant or young child over 6 months of age with feeding difficulties. This reassessment should include:

  • a general enquiry on progress, including breastfeeding and complementary feeding;
  • an enquiry about the mother's experience trying suggestions discussed at previous contact;
  • weighing the child and monitoring growth;
  • general assessment of the infant's condition.

Continuing management:

  • If the child is not gaining weight or has persistent feeding difficulties, offer additional help with new suggestions and follow-up again after 1–2 weeks.
  • Make a home follow-up visit if possible and if not already made.
  • If the child is still not gaining weight after 2 months, consider referral.
  • If the infant or young child has gained weight and feeding difficulties are resolved, he or she should continue follow-up at the same frequency as children with no difficulties.
  • A child with overweight should not have a sharp decline in weight as losing too much weight is undesirable. An overweight child should instead maintain weight while increasing height, i.e. the child should ‘grow into his or her weight’.

Follow-up of children with no feeding difficulty

Infants and young children without any feeding difficulties also need follow-up at regular intervals for growth assessment and infant and young child feeding counselling, as described in the introduction to this Session.

Suggested intervals for feeding counselling and growth assessment for healthy full-term babies are:

  • within 6 hours of delivery, and again within 2–3 days: birth weight, feeding counselling (position and attachment, colostrum and how milk “comes in”, exclusive breastfeeding and optimal feeding pattern, expressing milk);3
  • around day 7: feeding counselling and weighing (positioning and attachment, exclusive breastfeeding and optimal feeding pattern, avoidance of supplements);
  • around 4 weeks: feeding counselling and assessing growth (positioning and attachment, exclusive breastfeeding and feeding pattern, sustaining confidence in breast-milk supply, avoiding supplements despite growth spurt);
  • at 6 weeks: feeding counselling and assessing growth, postpartum care for the mother (family planning including the lactational amenorrhoea method (LAM, see Session 8.4)), immunization;
  • At 3 and 4 months of age: continue assessing growth, continue to support exclusive breastfeeding and help with any difficulties, advise on immunization;
  • At 5–6 months of age: continue assessing growth, provide guidance on starting complementary feeding;
  • At 8–9 months, and 11–12 months: continue assessing growth, counselling on progress of complementary feeding and continued breastfeeding, advise on immunization.
  • Every 2–3 months after these other contacts have stopped, up to at least 2 years of age.
  • At other contacts with health care workers, for example, immunization or because the child is sick.

References

1.
Aidam B, Perez-Escamilla R, Lartey A. Lactation counselling increases exclusive breastfeeding rates in Ghana. Journal of Nutrition. 2005;135:1691–1695. [PubMed: 15987851]
2.
Haider R, et al. Effect of community-based peer counsellors on exclusive breastfeeding practices in Dhaka, Bangladesh: a randomized controlled trial. Lancet. 2000;356:1643–1647. [PubMed: 11089824]
3.
WHO. Community-based strategies for breastfeeding promotion and support in developing countries. Geneva: World Health Organization; 2003.
4.
WHO. Child growth standards: child catalogue. Geneva: World Health Organization; 2005. [27 August 2008]. (http://www​.who.int/childgrowth​/standards​/chart_cat-alogue/en/index.html.
5.
WHO/UNICEF/WFP/UNSCN. Community-based management of severe acute malnutrition. WHO; Geneva: 2007.
6.
WHO/UNICEF Joint Statement. The use of the WHO child growth standards for the identifica-tion of severe acute malnutrition in 6–60 month old infants and children. Geneva: World Health Organization; (in press)
7.
WHO. Integrated management of childhood illness: chartbook and training modules. Geneva: World Health Organization; 1997. (WHO/CHD/97.3 A–K)
8.
WHO. Integrated management of childhood illness: model chapter for textbooks. Geneva: World Health Organization; 2001.

Footnotes

1

Length of children less than 2 years of age is measured lying down, while standing height is measured for children 2 years of age or older.

2

Z-scores are also known as standard deviations (SD).

3

Low-birth-weight babies may require additional support, in particular in the first weeks of their life (see Session 6 for further guidance).

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All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK148966
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