Feeding Infants and Young Children During and After Illness

The Vicious Cycle of Illness and Malnutrition

A child who is sick will have little or no appetite or anorexia can contribute to a vicious cycle of illness and malnutrition that can be dangerous for a child below two years.

It is seen that, during illness a child may be too weak to eat, have trouble swallowing, or find it difficult to breastfeed because of a cough or blocked nose. Inefficient absorption of nutrients, loss of energy stores, and dehydration due to vomiting or diarrhea must be overcome. Even during a short illness, child growth often falters.

Repeated bouts of common illnesses such as diarrhea, respiratory infections, malaria, or measles undermine the overall nutritional status of infants and young children, which in turn undermines their immunity.

Deficiencies in key micronutrients such as vitamin A and zinc weaken the body’s protective mechanisms against infection. In a single year the average child under 5 years old may be sick with diarrhea five times and experience acute respiratory infections (ARI) more than six times.

Appropriate feeding both during and after illness is critical.

Eighty percent of nutrition-related deaths occur among mildly or moderately underweight children.

How to break this cycle?

1.During illness

• Continue feeding and increase fluids

For a child under 6 months old: Breastfeed more frequently and longer at each feed

For a child 6–24 months old:

• Breastfeed more frequently and longer at each feed, increase fluid intake, and offer food.
• Give frequent, small feeds.
• Give nutrient-dense foods that are soft, varied, and the child’s favorite foods.
• Give mashed or soft foods if the child has trouble swallowing (do not dilute foods or milk)
• Feed the child slowly and patiently encourage the child to eat but do not force.

2. During recovery

• Increase the amount of food after illness until the child regains weight and is growing well.
• Continue to feed frequently: give an extra meal every day or snacks be responsive to the recovering child’s increased hunger.

How much to give?

• During illness continue feeding. Sick children frequently reject or eat only small quantities of food offered to them. Do not withhold foods or liquids.
• During recuperation, children often have hearty appetites and will be eager to eat more food than usual.
• Children should be encouraged to eat more at every meal, and given an extra “meal” each day (or extra snacks in between meals) for at least two weeks.
• Any breastfed child should be breastfed frequently. A child who is not exclusively breastfed should be given plenty to drink every 1–2 hours. Boiled water, coconut or rice water, yogurt drinks, and other nutritious liquids should be given rather than sodas or artificially sweetened fruit juices.
• Along with an attempt to rehydrate a child should be given a complete diet as soon as possible.Illness can facilitate a switch to exclusive breastfeeding for a child under 6 months who has been receiving mixed feeding. The mother should be advised that as her infant recovers and continues to suckle frequently, the supply of breast milk will increase and that other liquid should gradually be decreased and stopped
• The common indicator to measure optimal feeding during illness and recuperation is the relative amount of food and liquids given to the child during illness.

What to give?

• Breastmilk

It is the perfect food during and after illness and it is energy rich, nutrient rich, and hygienic.Children who are sick continue to breastfeed even when they are not taking other food or animal milk. If a breastfed baby cannot suck properly due to illness, the mother should express milk and continue to feed the child with a spoon and/or cup. If a breastfed baby is hospitalized, mother and baby should be kept together.

• Energy and nutrient -rich foods

Children, 6 months of age and older, need energy-rich and nutrient-rich foods, during and after illness, to regain strength. These foods include meat, poultry, fish, eggs, and milk when possible. This can also be achieved by adding dry milk powder to porridges or other foods or adding groundnuts, extra fat, and/or sugar or honey. A sick child cannot absorb food well and must be fed more often than usual. A key practice during illness is many small feeds.

Some tips

During illness

• Give frequent small feeds
• If a breastfeeding infant is too weak to suckle, the mother can express her milk and feed it from a spoon or cup
• Coax the older child to eat; be patient but persistent offer foods the child likes, to overcome lack of appetite.
• Hold the child on your lap or keep him or her sitting up; (Do not feed a child lying down this can cause choking).
• If a child vomits, wait for ten minutes and continue offering fluids or food.
• Do not force a child to eat.

During recuperation

• Continue to feed frequently – give an extra meal every day or extra snacks for two weeks.The child may now seem hungry be responsive. Get the help/support of siblings or grandparents who normally feed the child.
• Remember that recuperation takes time. Increased attention to feeding should continue for 2 or more weeks following illness. Feeding during recuperation is critical to help the child “catch up” from nutritional losses.
• Older infants and young children continue to need high quality food such as meat, fish,liver, eggs, milk, and oil to meet the requirements for catch-up growth. Extra food is needed until the child has regained any weight lost and is growing well again. One rule of thumb is to give a child an extra meal every day for at least 2 weeks.

The Role of Local Beliefs

• Beliefs about withholding food/liquids.
• The belief that all food including breast milk should be withheld during illness is most common for diarrhea.
• Some believe in “resting the gut” when a child has diarrhea, or in withholding milk. They may advise mothers to delay feeding, dilute foods, or avoid giving milk.
• Withholding of food or liquids of any kind is less common during acute respiratory illness, malaria, or measles than during diarrheal episodes.
• Classification of both diseases and foods as either “hot” or “cold” is common. For example, “cold” foods typically include rice, curd, yogurt, and citrus fruits. These are considered appropriate during diarrhea, which is a “hot” disease.
  They may be restricted during a cough or an illness with a rash. “Hot” foods (ginger,honey, lentils, egg, and meats) are thought appropriate during those illnesses.
• Wherever beliefs about the appropriateness of different foods during illness are common,specific recommendations about nutritious foods should emphasize those that mothers already consider acceptable.

Diet during different illnesses

6.1 Diarrheal Disease

• Children are at greatest risk between the ages of about 6 to 11 months the period when semi-solid foods are introduced. Growth curves often dip sharply during this period.
• Mothers may withhold fluids and food during diarrhea. Counseling on breastfeeding is critical for the young child with diarrhea. A child under 6 months old with diarrhea is likely not to be exclusively breastfed. For all children, continued breastfeeding during acute diarrhea significantly reduces the duration of an episode.
• The majority of deaths associated with diarrhea are due to dehydration. In general, even a child with no dehydration should receive additional fluids and continued feeding to speed recovery. A child with signs of moderate dehydration should first be rehydrated, followed by normal feeding.

6.1.1 What to feed?

Diarrhea with no dehydration

Infant under 6 months old

• If exclusively breastfed - breastfeed frequently and longer at each feed. Give additional clean water or ORS to prevent dehydration.
• If not breastfed - give the normal milk or formula at least every three hours. Give additional clean water or ORS.
• If receiving mixed feeding - breastfeed more frequently and longer at each feed. Give other liquids with a cup and spoon, not a bottle.

Child over 6 months old

• Breastfeed frequently and longer at each feed.
• Give more fluids than usual to prevent dehydration.
• When possible, give “home fluids” that normally contain salt (e.g.,soup, rice water, and yogurt drinks). Dangerous fluids to avoid during diarrhea include drinks sweetened with sugar such as commercial sodas, commercial fruit juices, and sweetened tea. Fluids with stimulant, diuretic, or purgative effects (such as coffee or some medicinal teas) should also be avoided.
• Continue to give normal food. Do not dilute usual foods. Continued feeding speeds recovery of intestinal function and the ability to digest and absorb nutrients. If the child is not yet being given semi-solid foods, the mother should be counseled to begin soon after the diarrhea stops.

ii. Diarrhea and moderate dehydration

A child with signs of dehydration should be rehydrated, preferably with packaged ORS according to weight and age. Use a clean spoon or cup. Rehydration may take four hours or longer.

In addition:

• For an infant under 6 months old, continue breastfeeding during rehydration whenever the child wants.
• For a non-breastfed infant under 6 months old, give 100-200 ml of clean water during rehydration; then resume full strength milk or formula.
• For an older child, continue breastfeeding whenever the child wants. Begin feeding after the initial four-hour rehydration period.

iii. Severe dehydration

• A child with severe dehydration requires intravenous treatment and should be hospitalized.
• Rehydration. The gold standard for rehydration is packaged ORS.
• Administering ORS can be challenging. It may take four or more hours to rehydrate a child, giving ORS by cup or spoon.
• Use of antidiarrheals can be harmful. WHO now recommends a newly formulated low osmolarity ORS product that does reduce stool volume and duration of illness.
• Rehydration with food-based fluids such as thin rice gruel that is “normally salty” is as effective as giving standard ORS.
• This has the advantage of providing some nutrients during the immediate period of rehydration.
• Foods during diarrhea.
• A child with diarrhea should be fed a normal diet as soon as possible.
• Foods should be well cooked and mashed or ground to make them easy to digest, but not diluted. Fermented foods are also easy to digest. Fats and oils provide energy.
• Meat, fish, or egg should be given if available. Foods rich in potassium, such as bananas, are very beneficial. The banana and pectin diets also significantly reduced the amount of stool and vomiting.

6.1.2 Three Types of Diarrhea

• Acute watery diarrhea- most common, also includes cholera. A child with watery diarrhea usually regains appetite once rehydrated.
• Dysentery (bloody diarrhea) requires antibiotics; a child with bloody diarrhea will have a poor appetite until fully recovered.
• Persistent diarrhea, or watery diarrhea that goes on for more than 2 weeks is associated with about 45 percent of deaths . Antibiotics are not effective. The family must be attentive to feeding over a period of many days. Children with persistent diarrhea are often given food that is too watery. Mothers should know the importance of giving small, energy- and nutrient rich feeds at least 6 times a day.
  A child with persistent diarrhea may have some trouble digesting lactose in animal milk.Yogurt, if available, should be given in place of any animal milk usually taken by the child. Otherwise the usual milk should be mixed with cereal. Milk should not be diluted. Breastmilk does not cause lactose tolerance, and a child with persistent diarrhea should be breastfed frequently.
  Zinc. Zinc reduces both the severity and duration of diarrhea, prevents recurrence, and restores appetite during diarrhea as well as during other illnesses.Zinc may be packaged with ORS or given separately for 10-12 days.

6.2.Acute Respiratory Infection (pneumonia)

• Even mild ARI may cause stuffy nose or cough, creating problems for breastfeeding.
• Child of any age may aspirate food while coughing
• Mother may require more time, patience, and confidence than usual for breastfeeding.
• If a breastfed child is unable to suckle properly, milk should be expressed fed with cup and spoon.
• Feed child sitting up; give small feeds slowly.

6.3 Measles

• Child may have severe diarrhea as well as respiratory problems accompanied by high fever.
• Child may have sores inside the mouth.
• Keep child hydrated.
• Give soft, mashed foods that are not spicy
• Child should given vitamin A supplement.

6.4 HIV/AIDS

i. for infants <6 months on full replacement feeding

• As part of determining what method of feeding is acceptable, feasible, affordable,sustainable, and safe (AFASS), the mother may have elected not to breastfeed her child during the first 6 months of life, or to discontinue breastmilk after 6 months. Lack of breastfeeding makes the child vulnerable to frequent illness.
• Provider should counsel on hygienic preparation of milk/formula
• During diarrhea, give yogurt-based drinks if possible. Mix animal milk with cereal do not dilute the milk.

ii.for the child who is symptomatic

• A symptomatic child may have 50–100 percent greater energy requirements.
• Child may suffer frequently from thrush, fever, diarrhea, or vomiting.
• Child’s medications may cause loss of appetite or changes in taste that make it difficult to eat.
• If child is breastfeeding, continue breastfeeding.
• Feed frequently to ensure adequate intake.
• If child has thrush, avoid spicy, salty, or sticky foods, or strong citrus fruits and juices that may irritate mouth sores.
• Avoid sugary foods; these encourage yeast
• During recuperation from an illness, give energy-dense, micronutrient-rich foods.

Source: Portal Content Development Team