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24.5 Not Growing well/Growth Faltering/Failure to Thrive

Table of Contents

Children and infants who have either:

  • Unsatisfactory weight gain (growth curve flattening or weight loss) on the Road to Health chart/ booklet.

OR

  • Low weight for age, i.e. WHZ < –2 but > –3

Note: Babies who were premature and are growing parallel to or better than the Zscore line, should not be classified as having failure to thrive or not growing well.

Not growing well may be due to:

  • Insufficient food intake due to anorexia and illness or poor availability of food.
  • Insufficient uptake of nutrients, e.g. malabsorption.
  • Insufficient use of nutrients for growth due to chronic disease.
  • Increased demand for nutrients due to illness such as TB and HIV and AIDS
  • Conduct a feeding and clinical assessment to determine the cause. Exclude anaemia.

Check for malnutrition and anaemia in all children: Plot the weight on the Road to Health chart/booklet, Look at the shape of the weight curve:

  • Is the weight curve rising parallel to the reference lines?
    OR
  • Is it flattening?
    OR
  • Is there weight loss?
    • Look for visible wasting.
    • Look and feel for oedema of both feet.
    • Look for palmar pallor.
  • Check Hb if anaemia is suspected.

General measures

  • Counseling on nutrition.
  • Nutritional supplementation should be supplied unless there is a correctable cause.
  • Assess the general condition of the child.
  • Assess the child for possible HIV and TB, and manage appropriately.
  • Assess for other long-term health conditions, and manage appropriately.
  • Assess the child’s feeding and recommend actions as outlined below.
  • Provide supplements according to a child’s age to meet specific nutritional needs.
  • Provide adequate intake of micronutrients.
  • Ensure that immunisations are up to date. Record the dose given on the RTHB.
  • Follow up monthly. If responding review the child every two months.
  • Refer for social assistance if needed.

Feeding recommendations for all children:

0–6 months of age

  • Breastfeed exclusively – feed at least 8 times in 24 hours.
  • If formula is medically indicated (refer below) or if the mother has chosen to formula-feed the child, discuss safe preparation and use with the mother.

6–12 months of age

  • Continue breastfeeding (breastfeed before giving foods).
  • Introduce complementary foods at six months of age.
  • Start by giving 2–3 teaspoons (modified family food) of iron-rich food such as mashed vegetables or cooked dried beans.

Children 6–8 months

  • Should be given two meals daily, gradually increasing the number of meals so that at 12 months the child is receiving 5 small meals.
  • For children who are not growing well, mix margarine, fat, or oil with their porridge 12 months to 2 years of age
  • Continue breastfeeding. If the child is not breastfed, give 2 cups of full cream cow’s milk every day.
  • Make starchy foods the basis of the child’s meal.
  • Give locall available protein at least once a day, and fresh fruit or vegetables twice every day.

2–5 years of age

  • Give the child his/her own serving of family foods 3 times a day. In addition, give nutritious snacks e.g. bread with peanut butter, full cream milk or fresh fruit betwee meals.

Conditions which Justify Recommending that Mothers Do Not Breastfeed

  • Infants with a small number of metabolic diseases qualify to receive specialized infant formula. These infants should be managed in tertiary centres.
  • Maternal medical condition that may justify temporary or permanent avoidance
  • Severe illness that prevents a mother from caring for her infant, for example sepsis, renal failure.
  • Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mother’s breasts and the infant’s mouth should be avoided until all active lesions have resolved.
  • Maternal medications: sedating psychotherapeutic medicines, anti-epileptic medicines and opioids (may cause drowsiness and respiratory depression in the infant), radioactive iodine-131, excessive use of topical iodine or iodophors (especially on open wounds or mucous membranes), cytotoxic chemotherapy.
  • Infants who qualify to receive infant formula as part of the supplementation scheme
  • The mother has died or infant has been abandoned.
  • Other individual circumstances deemed necessary by a multidisciplinary team.

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