Spotting a child who has stopped gaining, before they look thin
Growth faltering is when a child stops putting on weight, and it shows on the weighing card weeks or months before it shows on the child. To catch it, have the child weighed on the same schedule every month and look at whether the line on the card is still climbing, not at whether the child looks thin. Two flat weighings in a row, or one that has dropped, is a reason to act even when the child seems perfectly well.
- A child can be losing ground for months and still look normal to the people who see them every day.
- The useful question is not whether the child is thin. It is whether the line on the card is still going up.
- Two flat weighings, or one that comes down, is the point to act, not the point to wait and see.
- A MUAC band and a weighing scale answer different questions. Use both.
- Keep the child health card in one place. A lost card costs you the whole history.
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 child can be in real trouble and still look fine
The person who notices a thin child first is almost always a visitor. A grandmother who dresses that child every morning and carries her on her back does not see a slow change. That is not carelessness, it is how eyes work. A child who has lost ground steadily since the start of the term looks to the household exactly the way she looked yesterday.
By the time a child looks thin to the household, the loss has usually been running for a season. The card exists for this reason. It remembers what your eyes cannot.
Growth faltering is the stage before thinness. The child is still eating, still playing, still walking to the borehole with the others. She has simply stopped adding weight at the rate she was adding it. Nothing about her announces it.
What the line on the child health card is actually telling you
Every time a child is weighed, at a health centre or at a village health team outreach, the weight should be marked on the growth chart on her card. The chart has printed curves on it. What matters is not which curve the child sits on. Children come in different sizes, and a small child who keeps climbing is usually a small child who is well.
What matters is the direction of her own line from one month to the next. A line that keeps rising, at whatever height, is a child who is growing. A line that has gone flat is a child who has stopped. A line that comes down is a child who has lost.
So when the card comes back from the weighing, look at the last three dots, not the last one. The first time, ask the health worker to point out the direction with her finger. Once somebody has shown you, you will see it yourself every month afterwards.
How often to weigh, and why the schedule slips
The first two years are when weighing matters most, and they are also the years when it quietly stops happening. The visits are frequent at the beginning because the child is changing fast. Then they thin out, and by eighteen months a household that was going every month is going when somebody remembers.
The slip is rarely a decision. It is one wet-season month when the path to the health centre III is not walkable with a child on your back, then a market day, then an outreach that did not happen because the vehicle never came. Three of those and you no longer have a line, only dots with a gap in the middle.
If months have been missed, do not start again from zero. Take the card back, have the child weighed, and ask the health worker to compare the new weight with the last one recorded, however old it is. An old dot is still information.
What to watch for between one weighing and the next
The card is the record, but you are the one in the house every day. A few changes are worth noticing on their own, because each of them tends to arrive before the flat line does.
- Clothes that fitted at the beginning of the term and now hang off the shoulders.
- A child who has stopped asking for food, or who leaves food she used to finish.
- Long stretches of sitting when the child used to be busy, and less interest in playing with the others.
- Repeated illness. A child who has had fever or diarrhoea three times in two months has been losing on and off all that time.
- A change in who feeds her: a new baby in the house, a mother travelling to trade, a move to a grandmother's home.
What a MUAC band adds, and what it cannot tell you
A MUAC band is a strip of tape you fit around the middle of a child's upper arm, and it shows a colour. It is quick, it needs no scale and no table, and a person can be taught to use one properly in ten minutes. That is why village health teams screen with it at parish level.
What it is good at is finding a child who is acutely malnourished right now and needs treatment. What it is not good at is picking up the slow flattening this guide is about. A child can be faltering for months and still read in the green.
The colour is the whole answer it gives. Green means no acute malnutrition today. Yellow means the child is thinning. Red means acute malnutrition, and a red reading means a health facility the same day, whatever the card says. The guide on reading a MUAC band sets out what should happen after each of the three.
So use both, and understand that they answer different questions. The band asks whether this child is in danger today. The card asks whether this child is still growing. Neither one replaces the other.
What to do in the first fortnight after you notice
The point of noticing early is that you have time to work with. Use it on small, specific steps rather than on worry.
- 01Have the child weighed again in two weeks, not next month. One reading is a dot, two readings are a direction.
- 02Write down what the child actually eats for three days, meal by meal, including what she refused. Most households are surprised by the total.
- 03Look for an illness that has become normal to everybody: a cough at night, loose stool twice a week, sores in the mouth.
- 04Ask who has been feeding her over the last three months, and whether that has changed.
- 05Tell the village health team member for your village. She is the one who will follow up, and she knows when the next outreach falls.
What to change first, before you try to change everything
The instinct is to overhaul the whole diet. That plan rarely survives the first week, because it usually costs money the household does not have and time the mother does not have either.
Change two things instead. Change how often the child eats, and change what goes into the food that is already being cooked. A small child cannot take a day's food out of two adult meals. Her stomach is small. She needs to eat more times, not off a bigger plate.
And the porridge or the sauce already on the fire can carry far more than it does. A spoon of groundnut paste stirred into the porridge. Silverfish pounded fine and added to the sauce. Beans mashed until they are soft enough to swallow without chewing. Dodo cooked into the sauce rather than served as a separate dish that nobody puts on a small child's plate.
When to stop watching and take the child to a health facility
Watching and adjusting is the right response while the line is only flat and the child is otherwise well. Some things end the watching straight away.
- The line has come down rather than flattened.
- A MUAC reading in the red. That is a health facility the same day, and it does not wait for the next weighing.
- A MUAC reading in the yellow. Yellow always means telling your village health team member or going to the facility, as well as feeding the child more often and more thickly at home. In a child whose line has already gone flat, do not wait for the next screening day.
- Swelling of both feet, where a finger pressed on the top of the foot leaves a dent that stays.
- A child who has gone listless, or who will not feed at all.
- Diarrhoea running on for several days, or any blood in the stool.
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
- The card has been lost. Is the history gone with it?
- Not entirely. Ask at the health facility where the child was weighed, because the weights are usually also written in a register there. Get a new card, have the child weighed the same day, and treat that weight as a fresh starting point. Keep the new card in the same place every time, wrapped in a plastic bag if the roof leaks.
- My child is small, but everybody in our family is small. Is that faltering?
- Probably not. Faltering is about a change in a child's own line, not about her size compared with other children. A small child whose line keeps climbing month after month is growing normally. It is the child whose line goes flat or drops who needs attention, whatever size she started at.
- The scale at the outreach and the one at the health centre give different weights. Which do I trust?
- Use the same scale where you can, and weigh the child in the same amount of clothing each time, because both of those cause small differences. If you cannot use the same scale, tell the health worker which scale each reading came from and look at the overall direction across several months rather than at the gap between two readings.
- Can I just weigh the child at home?
- You can, and it is better than not weighing at all. Weigh yourself, then weigh yourself holding the child, and take the difference. The trouble is that a household scale is not accurate enough to show the small monthly change that matters in a young child, so use it as a rough check between visits rather than as a replacement for the card.
- She eats well but she is still not gaining. What now?
- That combination is a reason to go to a health facility rather than to keep adding food. Something may be using up what she eats, or she may be losing it. A health worker can check her for the common causes, look at the card with you, and decide whether she needs treatment or referral.