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IMCI · Age: 0 - 2 months

Feeding Problem or Low Weight for Age (Infant)

Classification for a breastfed young infant presenting with feeding difficulties (not well attached, not suckling effectively, <8 feeds/24h), receiving other foods/drinks, having thrush, OR having low weight for age (WFZ between -3 and -2). Requires specific feeding assessment and counselling.

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Care priority and warning signs

Care priority

Feeding Counselling / Treat Thrush / Follow-up

Red flags

  • Weight loss or failure to gain weight.
  • Signs of dehydration.
  • Development of signs of PSBI/VSD.
  • Refusal to feed.
  • Severe thrush interfering with feeding.

Assessment

  • Assess Breastfeeding:
  • Ask: Is infant breastfed? How many times in 24 hours? (< 8 times?)
  • Ask: Does infant receive any other foods or drinks?
  • Observe a breastfeed (if not fed in last hour):
  • Is infant well attached? (Look for: More areola above than below, mouth wide open, lower lip turned out, chin touching breast). Not well attached?
  • Is infant suckling effectively? (Look for: Slow, deep sucks, sometimes pausing). Not suckling effectively?
  • Assess Weight for Age:
  • Look/Feel: Determine Weight-for-Age Z-score. Is it between -3 and -2?
  • Check for Thrush:
  • Look: Look for ulcers or white patches in the mouth (thrush).

Classification

  • Any ONE of the following signs:
  • Not well attached to breast
  • Not suckling effectively
  • Less than 8 breastfeeds in 24 hours
  • Receives other foods or drinks
  • Low weight for age (WFZ between -3 and -2)
  • Thrush (ulcers or white patches in mouth)
  • -> FEEDING PROBLEM OR LOW WEIGHT FOR AGE

Key features

  • Presence of ANY of the following: Not well attached OR Not suckling effectively OR Less than 8 breastfeeds in 24 hours OR Receives other foods/drinks OR Thrush OR Low weight for age (WFZ -3 to -2).
  • Excludes Very Low Weight infants and those with severe feeding problems classified under PSBI.
  • Requires practical breastfeeding support, management of thrush if present, and follow-up.

Management

Non-pharmacological management

  • Breastfeeding Counselling:
  • If not well attached or not suckling effectively: Teach correct positioning and attachment (Show mother: infant's head/body in line, infant close, body supported, infant approaches breast nose-to-nipple; touch lip, wait for wide mouth, aim lower lip below nipple). Help mother practice.
  • If not able to attach well immediately: Teach mother to express breastmilk and feed by cup (See page 45 for expression/cup feeding).
  • If < 8 feeds/24h: Advise to increase frequency, feed day and night, whenever infant cues.
  • If receiving other foods/drinks: Counsel mother to breastfeed more, reduce/stop other foods/drinks, use cup for any supplements.
  • If not breastfeeding at all: Refer for breastfeeding counselling and possible relactation. Advise on correct preparation/cup feeding of substitutes if needed.
  • General Care:
  • Advise mother how to keep low weight infant warm at home (Page 46).
  • Advise mother on general home care (hygiene etc. - Page 46).

Pharmacological treatment

  • If Thrush present: Teach mother how to treat thrush at home. Use Nystatin suspension (100,000 U/ml), instill 1ml into mouth 4 times daily for 7 days. Wet clean cloth with salt water, wipe mouth gently before Nystatin. Avoid feeding for 20 mins after dose. Check mother's breasts for thrush, treat mother if present (e.g., miconazole cream). Advise cup feeding if bottle used.
  • Check for TB (Page 37).

Follow-up

  • Follow up for FEEDING PROBLEM or THRUSH on day 3 (Page 48).
  • Follow up for LOW WEIGHT FOR AGE on day 14 (or day 7 if receiving no breastmilk) (Page 48).
  • At Feeding/Thrush Follow-up (Day 3): Reassess feeding (attachment, suckling, frequency). Check for thrush. If thrush worse or attachment/suckling issues persist -> Refer. If improving, continue advice/treatment.
  • At Low Weight Follow-up (Day 7/14): Weigh infant. Reassess feeding. If still low weight and feeding problem exists, counsel and ask to return in 14 days (or at next immunization). Continue seeing regularly until feeding well/gaining weight. If feeding well but still low weight, praise and monitor at routine visits. If feeding will not improve or weight lost -> Refer.

Counselling points

  • Explain the specific feeding issue identified.
  • Provide practical demonstration and support for positioning/attachment.
  • If needed, teach EBM expression and cup feeding.
  • Counsel on feeding frequency and exclusivity.
  • If thrush present, teach how to give Nystatin and do mouth care.
  • Advise on keeping infant warm.
  • Advise WHEN TO RETURN IMMEDIATELY (Danger signs).
  • Explain the schedule for follow-up visits (Day 3 for feeding/thrush, Day 7/14 for low weight).

Differential diagnosis

  • PSBI/Very Severe Disease (if feeding problem is severe)
  • Very Low Weight
  • No Feeding Problem
  • Ankyloglossia (tongue-tie) affecting latch/suckling
  • Cleft lip/palate
  • Neurological impairment affecting suck/swallow

Complications

  • Failure to thrive / Malnutrition
  • Dehydration (if intake poor)
  • Increased risk of infection
  • Early cessation of breastfeeding
  • Complications related to low weight (hypothermia, hypoglycemia)

Prevention

  • Early initiation of breastfeeding.
  • Support for correct positioning and attachment.
  • Exclusive breastfeeding on demand.
  • Avoiding unnecessary supplements.
  • Good maternal nutrition.

References

IMCI Chart Booklet - Page 38, Page 37 (TB check), Page 44 (Thrush Treatment), Page 45 (Positioning/Attachment, EBM, Cup Feed), Page 46 (Warmth, Home Care), Page 48 (Follow-up Feeding/Low Weight/Thrush)

For learning and professional reference. Use current local guidance and clinical judgement.

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