Print this chapterPrint this chapter

Recognition and Management of Malnutrition

8. Nutritional Status of Infants 0 to 6 Months of Age

Objectives

  • Assess nutritional status and rule out feeding problems.
  • Counsel the mother on effective breastfeeding.
  • Know admission and discharge criteria for nutritional programs for children from 1-6 months of age.

Nutritional status and feeding problems

Assessing nutritional status and feeding problems during the first 6 months of life is a key aspect of health care. Detection of feeding problems and early diagnosis and treatment of infants with reduced weight gain or with weight loss may help prevent disease and death.

Causes of weight loss

A newborn can lose up to 10% of body weight during the first week of life due to edema reabsorption and fluid elimination. Weight loss is strongly conditioned by gestational age, birthweight, type and method of feeding and other factors associated with morbidity during the first days of life. Doctors Without Borders criteria for severe malnutrition indicating the need for admission to a Therapeutic Feeding Center or hospital include bilateral edema of the feet or for infants with a height less than 45 cm a confirmed weight loss of more than 10% of a prior documented weight. For infants with a height of 45-65 cm, criteria for admission is a W/H z score <-3. Severe acute malnutrition is considered complicated when there is also an identified medical complication. Medical complications include the presence of any danger sign and or a classification requiring hospitalization. Remember that infants under 2 months who present with signs of severe disease or local infection need inpatient care. In addition, there is consensus, that when infants younger than 6 months cannot feed because of breast feeding difficulties or inadequate formula feeding, they need admission regardless of their weight or presence of edema.

Detection of feeding problems and early diagnosis and treatment of infants with reduced weight gain or with weight loss may prevent disease and death.

Criteria for when to hospitalize or admit an infant to a therapeutic feeding center are found in Table 15.

Criteria for Admission into an ITFC
Nutritional status
  • Presence of bilateral pitting edema
  • OR
  • For infants ≤45 cm: Confirmed weight loss of more than 10% if a prior weight is available.
  • For infants 45 - 65 cm: W/H z score < -3
Additional criteria And/Or evidence of insufficient food intake
Criteria for Moving to an ATFC
Nutritional status
  • Satisfactory clinical status and absence of acute infection
  • And
  • Weight gain of 10-15 g/kg/day for 5 consecutive days in stage 3
Additional criteria Plus ability to sustain appropriate feeding
Criteria for Discharge from the ATFC
Nutritional status
  • WHZ >-2 on 2 consecutive visits
  • Weight is following the growth curve*
After discharge When discharged from the program, the infant is followed until the age of 6 months for growth monitoring, mother support and the provision of infant formula if needed.

Weight loss during the first months of life has several causes, but it most frequently is related to feeding problems. Infants who have had repeated illnesses lose weight because of an altered appetite, foods, and caloric losses from vomiting or diarrhea. Infants who are not receiving adequate amounts of breast milk or appropriate alternatives for their age may have severe malnutrition or other nutritional disorders.

The newborn can lose up to 10% of body weight in the first week of life due to edema reabsorption and fluid elimination. The weight loss is strongly conditioned by gestational age, birth weight, type and method of feeding, and other factors associated with morbidity during the first days of life.

It is always important to counsel the mother on the appropriate breastfeeding technique and to encourage breastfeeding (Box 7).

BOX 7. Correct technique for breastfeeding (attachment and position)

  • Check for lesions on the nipples
  • Show the mother how to hold the infant
    • With the body and head straight in one line
    • With the body of the infant close to hers (belly contact)
    • Holding the whole body of the child with her arm
  • Show the mother how to help the infant get a good attachment while suckling
    • Touch the infant’s lips with the nipple
    • Wait until the infant opens his/her mouth wide
    • Get the infant close to the breast quickly and make sure that the lower lip stays well under the nipple
  • Check for signs of good attachment and suckling. If they are not good enough, try again
  • Check that the mother is at ease
  • Give support and reinforce the mother’s role

Weight loss during the first week of life should not exceed 10% of the birth weight. If the infant has lost more than 10 % of body weight, he/she will be considered to have a severe nutritional problem and must be immediately referred to a hospital to be evaluated by a specialist.

For infants whose weight loss does not exceed 10% of birth weight during the first week of life, weight for age will be evaluated by comparison to the weights of children the same age, using standard growth charts. Identify infants whose weight for age is under the lower percentile in the growth chart. These infants have a very low weight and need special care regarding their feeding.

It is also important to evaluate for good attachment and positioning during breastfeeding.

To verify good attachment, check for the following:

  • The chin touches the breast (or very close)
  • The mouth is wide open
  • The lower lip is turned outward
  • More areola is visible above than below the mouth

To verify the correct position, check if:

  • The head and body of the infant are straight
  • The infant’s head is directed to the mothers breast, with the nose in front of the nipple
  • The infant’s body is close to the mother’s body (belly-to-belly)
  • The mother is holding firmly the entire body of the infant, not just the shoulders and neck.