Feeding a child through illness, and the fortnight afterwards
Keep offering food and keep breastfeeding through the illness, in smaller amounts and much more often than usual, and accept that the child will eat less than you would like. The bigger opportunity is the fortnight after the fever breaks, when her appetite comes back stronger and the household can deliberately add a meal a day. Weight lost during illness is either regained in those two weeks or it is not regained at all.
- A child eats less when ill and needs more, not less. Both things are true at once, which is what makes this hard.
- Offer small amounts every couple of hours rather than fighting over a full plate three times a day.
- Never stop breastfeeding because a child is ill. Feed more often and for shorter spells.
- The two weeks after recovery, with one extra feed a day, are what decide whether the weight comes back.
- A child who will not drink at all, or is too weak to feed, is not a feeding problem. That is an emergency.
General information, not medical advice. If you are worried about a mother or a child, go to your nearest health facility or speak to your village health team.
Why a week of illness costs more than a week
During an illness a child eats less, and at the same time her body is using more. She loses weight over a few days, which is expected and is not in itself alarming.
What decides the outcome is what happens afterwards. If the household adds food during recovery, she makes it back within a fortnight and the card shows a dip and then a climb. If everything simply returns to normal, she does not, and the line resumes from a lower point than it left.
Do that three or four times in a year, with malaria in one month and a chest illness in another, and a child who was growing normally ends up faltering without anybody having done anything wrong. This is one of the commonest ways a child arrives at malnutrition.
What do you offer when she will not eat anything?
Change the size and the timing before you change the food. A sick child will refuse a full plate and then accept four spoons offered an hour later. Aim for something small every couple of hours through the day, and count the total across the day rather than judging each attempt.
Make it softer and wetter than usual, and serve it warm rather than hot. Porridge with groundnut paste stirred in, mashed pawpaw, mashed sweet potato, soft beans, thin soup with something in it. This is not the week to insist on the ideal plate. Food she will actually swallow beats better food she refuses.
Sit with her and feed her yourself, patiently, letting her take her own time. Do not force food into a child who is turning her head away, since that usually ends with vomiting and a child who refuses next time too. Stop, wait twenty minutes, offer again.
How do you feed a breastfeeding child through illness?
Keep going, and feed more often. Illness is the wrong time to stop or to cut down. Breastmilk is fluid and food together, and it is frequently the only thing a very unwell small child will still take.
Expect shorter feeds. A child who is breathing hard, or blocked up, cannot manage a long feed, so let her come off, rest, and go back on. Ten short feeds add up to more than two she abandoned halfway.
If she is too weak to suck properly, that is not a feeding problem to solve at home. Go to a health facility.
Fever, a blocked nose and a sore mouth are feeding problems too
A blocked nose is one of the commonest reasons a baby stops feeding, and it is easily missed. She cannot breathe and suck at the same time, so she takes a mouthful and pulls away crying, and everybody concludes she has lost her appetite. Wipe the nose clear with a soft damp cloth before each feed and try again.
Sores or ulcers in the mouth make a child refuse food that has nothing wrong with it. Look inside her mouth if she is turning away from food she normally likes. Give cool, soft, plain food while it lasts, and avoid salty or sour things such as heavy tomato sauce or citrus, which will sting. Mention the sores at the health facility, because they usually need looking at.
With fever, push fluids first and keep the food small and frequent. Appetite usually returns within hours of the fever coming down, so keep offering rather than deciding she is not eating today.
Feeding through vomiting and diarrhoea
Do not stop food. The old advice to rest the stomach costs children weight they cannot afford, and it does not shorten the illness. Feed small and often, and keep the fluids going alongside.
With vomiting, go slower rather than stopping. Small amounts, spaced out, and if she brings something back, wait a short while and start again more slowly. A child who vomits everything repeatedly needs a health facility.
With diarrhoea, keep feeding and use oral rehydration salts for the fluid. Softer, blander versions of the food she normally eats are easier to keep down, and there is no need to withhold any of her usual foods unless a health worker has told you to.
The extra meal afterwards, which is the part households skip
This is the most useful thing in this guide. For at least two weeks after the illness has passed, add one extra feed a day beyond what the child normally has, and make each feed carry more than usual.
Her appetite will be strong in that period, sometimes stronger than before she was ill, and that is the body making up ground. Use it. What to add to a pot that is already cooking is set out in the guide on spotting a child who has stopped gaining, and the recovery fortnight is the two weeks when it repays the trouble most.
The extra feed holds better if it is given a fixed time and a fixed person. Pick the hour, late afternoon before the evening food is usually the one that survives a busy day, and decide who is actually in the compound at that hour to give it, because a mother at the garden or the market is not. Serve the child before the others and give her her own bowl.
Then have her weighed at the end of the fortnight so there is a dot on the card after the illness rather than a gap. If the weight has not come back, take her to be checked instead of waiting for the next weighing. A child who does not recover the weight after one illness is a child to watch closely before the next one arrives.
When not eating is itself the emergency
Most of this guide is about patience. These signs are not for patience. They mean a health facility now.
If somebody measures her arm while she is ill, a red reading is on the list below and means the same day. Yellow is not on the list, and it is not a wait-and-see either. A child who reads yellow in the middle of an illness has less in reserve than she looks to have, so tell the village health team member the reading now, and have the arm measured again as soon as the illness has passed.
- She will not drink at all, or is too weak to suck or swallow.
- She is floppy, unusually quiet, hard to wake, or has had a fit.
- She vomits everything, repeatedly, and nothing stays down.
- Both feet are swollen, and a finger pressed on the top of a foot leaves a dent that stays.
- A MUAC reading in the red, or a child who has visibly lost flesh over days rather than weeks.
- She has been refusing food for more than a day or two with no sign of improving.
What to say to the people at home who say stop feeding
In most households somebody will say that food makes diarrhoea worse, or that a child with fever should be given only water or thin tea until it passes. The advice is nearly always given out of care, by somebody who has raised more children than you have, and arguing with it directly rarely goes well.
What tends to work better is agreeing on the goal and being specific about the method. Nobody in the room wants the child to lose weight. So say that the health worker asked for small amounts often rather than big meals, that you are keeping the food soft and light, and that you will stop if the child cannot manage it.
It also helps to bring the grandmother into the plan rather than around it, since she is often the person actually feeding the child during the day. If she is the one holding the bowl and offering it every two hours, the plan holds. If she has been told nothing, it does not.
This guide describes what generally happens, not what will happen at your facility or your school. Costs, timetables and rules differ between districts and they change. Check anything that matters with your health worker, the head teacher, or your district office. If something here is wrong or out of date, tell us and we will correct it.
Questions people ask
- She has refused everything all day. Should I force her?
- No. Forcing usually ends in vomiting and in a child who fights the next attempt too. Keep offering small amounts every hour or two, and keep fluids going, particularly breastmilk. But a full day of refusing everything, in a small child, is a reason to have her seen rather than to keep trying at home.
- Is it true that milk should be stopped when a child has diarrhoea?
- Breastfeeding should never be stopped, and should be given more often than usual. For other milk, follow what the health worker treating the child tells you, because it depends on the child and on what is causing the diarrhoea. Do not stop feeding generally, since that does more harm than the diarrhoea.
- How long should the extra feeding go on for?
- At least two weeks after she is well, and longer if the weight has not come back. The way to tell is the card. Have her weighed at the end of the fortnight and compare it with the last weight before the illness. If she is short of it, keep the extra feed going and have her checked.
- She only wants sweet things and refuses real food.
- During the illness itself, taking something is better than taking nothing, so do not fight it too hard. But try to put the sweetness into food that carries something: porridge with mashed ripe banana or pawpaw in it, or sweet potato mashed with groundnut paste. Then bring the ordinary food back as her appetite returns during the recovery fortnight.
- We only have posho and tea in the house this week. What can we do?
- Tonight, take out her share of the posho and soften it with a little hot water, mashing until she can swallow it without chewing. Stop while it will still sit on a tipped spoon. If it runs off the spoon it has turned into water, and a small stomach fills with water before it fills with food. Give it to her five or six times in small amounts rather than twice, and keep breastfeeding, more often than usual, if she is still at the breast. If there is milk for the tea, put it in her food instead of in the cups. Sweet tea is not a meal and it will take her appetite before the posho does any good. Then ask the nearest household for a handful of greens today and say what it is for, because most people give. And tell the village health team member that the store is empty. She is the person who can get help to you, and she cannot do it if nobody tells her.