A newborn who is not feeding well
'Not feeding well' is one of the seven signs of possible serious bacterial infection in a young infant. It is also what many mothers say when breastfeeding is not going well. Watching the baby at the breast for four minutes usually tells you which it is.
- Setting: Rural health centre; the district hospital is 2 hours away by bus
- For nurses, midwives, clinical officers, doctors and community health workers trained in IMCI
- Reviewed October 2026
The presentation
Rehema is 3 weeks old. She was born at term at the health centre and weighed 3.2 kg. Her mother, Neema, 19, says she 'is not feeding well': she cries a lot, comes off the breast after a few minutes and wants to feed again soon. Neema's nipples are sore. Rehema weighs 3.0 kg today.
| Sign | Value |
|---|---|
| Axillary temperature | 36.9 °C |
| Breathing rate | 48 per minute (counted for a full minute) |
| Heart rate | 150 per minute |
| Movement | Moving arms and legs, crying |
| Weight | 3.0 kg (birth weight 3.2 kg) |
Tests at hand: Blood glucose (finger-prick) · HIV rapid test
- Possible serious bacterial infection (sepsis, pneumonia, meningitis) Must not missStill possible
- Breastfeeding problem (attachment, frequency, other drinks)Still possible
- Oral thrushStill possible
- Severe or prolonged jaundice Must not missStill possible
- Local bacterial infection (umbilicus, skin)Still possible
- Low body temperature Must not missStill possible
- HIV exposureLess likely
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
Check Rehema for the signs of serious illness in a young infant. Which seven signs, and what do you find?
Model answer
- Not feeding well, or not able to feed at all.
- Convulsions (now or since birth).
- Fast breathing: 60 or more per minute, counted for a full minute and repeated if high.
- Severe chest indrawing.
- Temperature 38 °C or above.
- Temperature below 35.5 °C.
- Movement only when stimulated, or no movement at all.
Breathing 48 (not fast), no chest indrawing, temperature 36.9 °C, no fits, moving on her own and crying vigorously. Six of the seven signs are absent. The question is the first one: is she really not feeding well, or is it a breastfeeding problem? You will answer it by watching her feed.
Critical signsNot able to feed at all, no movement at all, or convulsions is critical illness: first-dose antibiotics, prevent low blood sugar, keep warm, refer urgently.Differential now- Possible serious bacterial infection (sepsis, pneumonia, meningitis) Must not missStill possible
- Breastfeeding problem (attachment, frequency, other drinks)Still possible
- Oral thrushStill possible
- Severe or prolonged jaundice Must not missStill possible
- Local bacterial infection (umbilicus, skin)Still possible
- HIV exposureLess likely
- Low body temperature Must not missSet aside for now (moved down)
- Step 2 of 7 · Ask
What do you ask Neema about feeding and the baby's health?
Model answer
- How many breastfeeds in 24 hours, including at night?
- Does the baby get any other food or drink? What is it given with?
- Is she passing urine and stool normally?
- Has she had fever, felt cold, had a fit, vomited everything or become floppy?
- When did any yellow colour of the eyes or skin start?
- Neema's HIV test in pregnancy, and her own health and mood.
About six feeds a day, fewer at night because Rehema 'sleeps'. Since last week a neighbour advised water and some sugar water from a bottle 'because the milk is not enough'. Wet nappies about four times a day. No fever, no fits, no vomiting. No yellow colour. Neema tested HIV negative at her first antenatal visit. She is tired and sore but says her mood is fine.
Differential now- Breastfeeding problem (attachment, frequency, other drinks)Leading (moved up)
- Oral thrushStill possible
- Local bacterial infection (umbilicus, skin)Still possible
- Possible serious bacterial infection (sepsis, pneumonia, meningitis) Must not missLess likely (moved down)
- Severe or prolonged jaundice Must not missLess likely (moved down)
- HIV exposureLess likely
- Low body temperature Must not missSet aside for now
- Step 3 of 7 · Look
Rehema has not fed in the last hour. What do you do now, and what do you look for?
Model answer
Ask Neema to put her to the breast and observe for 4 minutes.
- Attachment, all four signs: chin touching the breast; mouth wide open; lower lip turned outwards; more areola visible above the mouth than below.
- Suckling: slow, deep sucks with some pauses means effective suckling.
- Then look in the mouth for ulcers or white patches (thrush), and at the umbilicus and skin (redness, pus, pustules).
- Look for jaundice: eyes, skin, palms and soles.
- Plot the weight on the weight-for-age chart.
Rehema roots and sucks eagerly but takes only the nipple: her chin is away from the breast, her mouth is not wide open and more areola shows below the mouth. Quick shallow sucks. She is not well attached and not suckling effectively. There are white patches on her tongue and inside the cheeks that do not wipe off. Umbilicus clean, skin clear, no jaundice. Her weight is below the -2 line on the chart: low weight for age.
Differential now- Breastfeeding problem (attachment, frequency, other drinks)Leading
- Oral thrushLeading (moved up)
- HIV exposureLess likely
- Possible serious bacterial infection (sepsis, pneumonia, meningitis) Must not missSet aside for now (moved down)
- Severe or prolonged jaundice Must not missSet aside for now (moved down)
- Local bacterial infection (umbilicus, skin)Set aside for now (moved down)
- Low body temperature Must not missSet aside for now
- Step 4 of 7 · Test
Do you need a test?
Model answer
- Glucose: not needed. She is active, warm and feeding eagerly. Check it in a young infant who is lethargic, floppy, cold or not able to feed.
- HIV: Neema tested negative early in pregnancy. Offer her a retest now if your national policy recommends retesting during pregnancy and breastfeeding; a new infection now would put the baby at risk through breast milk.
Neema accepts a retest: negative.
Differential now- Breastfeeding problem (attachment, frequency, other drinks)Leading
- Oral thrushLeading
- Possible serious bacterial infection (sepsis, pneumonia, meningitis) Must not missSet aside for now
- Severe or prolonged jaundice Must not missSet aside for now
- Local bacterial infection (umbilicus, skin)Set aside for now
- Low body temperature Must not missSet aside for now
- HIV exposureSet aside for now (moved down)
- Step 5 of 7 · Do
How do you classify Rehema on the young infant chart?
Model answer
Findings Classification None of the seven danger signs; feeds eagerly when put to the breast Severe disease or local infection unlikely No jaundice No jaundice Not well attached, not suckling effectively, fewer than 8 feeds in 24 hours, other drinks, thrush, low weight for age Feeding problem or low weight She is hungry, not ill. The problem is how she feeds, how often, the extra drinks and the thrush. This is managed at home with counselling, and a close follow-up.
Differential now- Breastfeeding problem (attachment, frequency, other drinks)Leading
- Oral thrushLeading
- Possible serious bacterial infection (sepsis, pneumonia, meningitis) Must not missSet aside for now
- Severe or prolonged jaundice Must not missSet aside for now
- Local bacterial infection (umbilicus, skin)Set aside for now
- Low body temperature Must not missSet aside for now
- HIV exposureSet aside for now
- Step 6 of 7 · Do
What do you do to help, before they leave?
Model answer
- Teach positioning and attachment with Neema now, until Rehema is well attached and suckling slowly and deeply. Sore nipples usually improve when attachment is good.
- Breastfeed as often and as long as the baby wants, day and night, at least 8 times in 24 hours. Wake her at night if she sleeps long.
- Stop the water and sugar water and the bottle. Breast milk is all she needs.
- Thrush: paint the mouth with half-strength gentian violet (0.25%), and show Neema how to do it at home. Look at Neema's nipples for thrush too.
- Low weight: keep her warm, skin to skin, with a hat.
- Step 7 of 7 · Ask
When do you see Rehema again, and when must Neema bring her back at once?
Model answer
- Follow-up in 2 days for the feeding problem and thrush: watch a feed again.
- Follow-up in 14 days for the low weight: weigh her on the same scale.
- Return at once if she breastfeeds poorly, moves less, becomes sicker, develops a fever, feels unusually cold, breathes fast or with difficulty, or her palms and soles turn yellow.
Your baby is hungry, not sick. Let us get her mouth wide open and deep on the breast so she gets more milk and you hurt less. Feed her whenever she wants, day and night, and give no water or bottles. Come back in two days, or straight away if she stops feeding, feels hot or cold, or breathes fast.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Possible serious bacterial infection | Any of the seven signs: not feeding well or not able to feed at all, convulsions, breathing 60 or more, severe chest indrawing, temperature 38 °C or more or below 35.5 °C, moving only when stimulated or not at all. | First-dose IM ampicillin and gentamicin, prevent low blood sugar, keep warm; refer urgently. If referral is not possible, follow the WHO outpatient regimen. |
| Severe jaundice | Any jaundice in the first 24 hours, or yellow palms and soles at any age; jaundice still present after 14 days needs hospital assessment. | Prevent low blood sugar, keep warm; refer urgently (or for assessment if prolonged and mild). |
| Low body temperature | Below 35.5 °C; cold feet and hands; low birthweight. | Warm skin to skin; treat as a danger sign and refer. |
| HIV exposure | Mother HIV positive or untested, or a new infection during breastfeeding. | Test, start or continue infant prophylaxis and maternal ART per national guidance. |
Decision at first-level care
Rehema has none of the seven danger signs: she feeds eagerly when put to the breast but is poorly attached, feeds fewer than 8 times a day, is given water by bottle, has thrush and low weight for age. She is classified as feeding problem or low weight and managed at home with attachment teaching, frequent exclusive breastfeeding, gentian violet, follow-up in 2 days and again at 14 days.
Source: WHO IMCI chart booklet (2014); WHO recommendations for management of serious bacterial infections in infants aged 0–59 days (2024).
- No danger sign; feeding problem, thrush or low weight: counselling and home care, follow-up in 2 days (14 days for low weight).
- Fast breathing as the only sign at 7 to 59 days: oral amoxicillin at home for 7 days.
- A borderline breathing count in an upset baby: settle her and count again for a full minute.
- Unsure whether she can feed: watch a full breastfeed before deciding.
- Any of the seven danger signs (critical illness or clinical severe infection).
- Jaundice in the first 24 hours, yellow palms and soles, or jaundice after 14 days.
- Fast breathing in the first week of life.
- Not able to attach or feed, or still losing weight after counselling.
Key learning points
- Check all seven signs of possible serious bacterial infection in every sick young infant.
- When a mother says 'not feeding well', watch a breastfeed for 4 minutes before you classify.
- Good attachment needs all four signs: chin to breast, mouth wide open, lower lip out, more areola above than below.
- At least 8 breastfeeds in 24 hours, no water or other drinks, no bottles.
- A feeding problem is seen again in 2 days; low weight in 14 days.
Sources
- World Health Organization. WHO recommendations for management of serious bacterial infections in infants aged 0–59 days. 2024 (ISBN 9789240102903). The seven clinical signs; critical illness; clinical severe infection; fast breathing as the only sign.
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. Young infant assessment: very severe disease, jaundice, feeding problem or low weight for age; assessing a breastfeed (4 minutes, four signs of attachment, effective suckling); fewer than 8 feeds; gentian violet for thrush; follow-up in 2 and 14 days; when to return immediately.
- World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring. 2021. Retesting during pregnancy and breastfeeding in line with national policy.