Susanne; The very same measurements that you would use in 6 mo children apply to younger children to determine malnutrition. Length, weight and MUAC all give a measure of nutritional status and growth. There are data to support that MUAC < 11 cm is severe malnutrition. WHO charts start at 45 cm, is the child shorter than 45 cm? These charts are at the following website http://www.who.int/childgrowth/standards/weight_for_length/en/ The child could well be critically ill if the child has not received adequate food for a month. In terms of management this is a little simplier, here is a young child with nothing to eat. Find a wet nurse, if none available, give the child diluted f-100 or infant formula ad lib. No other menu of complementary foods can be safely substituted.

From Jay Berkley: Hi There is good information on the Australian Breastfeeding Association website: https://www.breastfeeding.asn.au/bf-info/common-concerns%E2%80%93mum/blocked-ducts Basically, the key thing is to keep feeding and try to keep emptying the breast, if necessary by pump or manually expressing. They suggest cold packs to help with pain/inflammation. On assessment, the current recommendation is to use weight for length z score or poor feeding or VSW. We are doing quite a bit of research on this at the moment and WFLZ doesn’t seem to be a very good measure, but we have to wait for that to be formally recognised. Best wishes Jay

Weight monitoring To decide if the baby is malnourished is difficult at this age. Find out which twin was bigger at birth and compare this baby to her twin. I usually admit these babies (especially to look for underlying illness) and monitor their weights. You can calculate how much weight gain they have over a period of time once you are sure she is having enough milk. If the only problem is milk intake, she should start gaining weight pretty quickly (calculate in grams per kilogram per day). You can use these growth charts too to see if weight gain progresses along the centile: http://www.rcpch.ac.uk/system/files/protected/page/A4%20Girls%200-4yrs%20WHO%20(4th%20Jan%202013).pdf (for girls) http://www.rcpch.ac.uk/system/files/protected/page/A4%20Boys%200-4YRS%20(4th%20Jan%202013).pdf (for boys) Background Find out how the other twin has been feeding. Is the mother exclusively breastfeeding or does she give them something else? It may be that the mother preferentially gives her milk to the boy rather than the girl, which I have certainly seen happening in South Sudan. What are the issues with the mother? Does she have good technique for breastfeeding? What is her nutritional status? Does she have family support? Is she unwell? The mother may need additional food (higher nutritional needs), multivitamins and lots of clean water. She may need extra psychological support. Feeding the infant For re-feeding the child, I usually take a graded approach, depending on how the child is. If there is diarrhoea / vomiting then I usually establish the feeds more slowly, starting at 120ml/kg/d in divided feeds. The risk of re-feeding is difficult to quantify in this age group. If the child is well, I would start at around 135-150ml/kg/d. Ask the mother to express her milk into a clean container and then you can measure how much the child is being given. Top up with formula or diluted F100. Milk-wise, the choices would be in this order: - Breast milk (from the mother) - Donor breast milk - Formula - Diluted F100 (1.5L rather than 1L to make it up. See page 212 of this manual for the recipe on how to make it up http://www.who.int/maternal_child_adolescent/documents/child_hospital_care/en/ ) Method of re-lactation is nicely described in this WHO manual, page 58: http://www.who.int/nutrition/publications/infantfeeding/9789241597494/en/. The same book covers dealing with breast problems including mastitis and sore nipples. The essence is to keep getting the milk out of the breast (by expressing it) on page 65 onwards. If the nipples are cracked, put some EBM on them. Do not introduce any solids yet, although the mother may have been giving them. The practise of using animal milk in neonates is very common in South Sudan, and unfortunately amongst many of the tribes wet nursing is often not seen as acceptable. The use of animal milk will predispose the baby to multiple illnesses. Comorbidities It is odd that one twin is malnourished if the other is in a good healthy condition, since they have been exposed to the same factors. Consider illnesses that may be present – congenital (cardiac, poor sucking, abnormal neurology) and infection. Brucellosis / TB/ HIV / bacterial infection are all fairly common. Discharge Also prior to discharge find out what the mother plans on doing at home. Something needs to change otherwise the baby will just fall back into malnutrition. Check technique for how she has been making up the formula at home (if you are unable to re-establish lactation) and check the right ratios of water to powder are used. Check that the water is boiled, that the container is clean and that no teats are used (difficult to clean, high risk of infection).