A child who is not growing
A thin child is never only a feeding problem until you have asked why. In many places the answer includes HIV or TB, and finding them changes the child's life, and the mother's.
- Setting: Health centre in an area with high HIV prevalence and no malaria; the HIV and TB clinic is at the district hospital
- For nurses, clinical officers, doctors and community health workers trained in IMCI
- Reviewed October 2026
The presentation
Zainab, 26 months old, is brought by her mother, Halima, because she 'does not grow and does not want to eat'. She has had a cough on and off for a month and hot nights. Her grandfather, who lives with them, started TB treatment 3 weeks ago. Halima did not attend antenatal care and has never had an HIV test. Zainab weighs 9.2 kg.
| Sign | Value |
|---|---|
| Axillary temperature | 37.9 °C |
| Breathing rate | 38 per minute |
| Pulse | 130 per minute |
| Conscious level (AVPU) | Alert, quiet |
| Weight | 9.2 kg |
Tests at hand: Mid-upper arm circumference (MUAC) · HIV rapid test · Haemoglobin (Hb) · Blood glucose (finger-prick) · Sputum sample sent for a rapid molecular TB test
- Severe acute malnutrition Must not missStill possible
- HIV infection Must not missStill possible
- Tuberculosis Must not missStill possible
- Inadequate feeding (diet, frequency)Still possible
- Persistent diarrhoea or wormsStill possible
- PneumoniaStill possible
- AnaemiaStill possible
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
Start as for every sick child. Is there a general danger sign or a sign of severe pneumonia?
Model answer
General danger signs: not able to drink or breastfeed, vomits everything, convulsions, lethargic or unconscious. Zainab drinks from a cup, has not vomited or fitted, and is alert though quiet. None.
Cough: breathing 38 per minute, counted for a full minute (fast is 40 or more at 12 months to 5 years). No chest indrawing, no stridor, no wheeze. This is not pneumonia by IMCI signs today, but a cough for a month is not a cold either.
Differential now- Severe acute malnutrition Must not missStill possible
- HIV infection Must not missStill possible
- Tuberculosis Must not missStill possible
- Inadequate feeding (diet, frequency)Still possible
- Persistent diarrhoea or wormsStill possible
- AnaemiaStill possible
- PneumoniaLess likely (moved down)
- Step 2 of 7 · Ask
What do you ask to find out why she is not growing?
Model answer
- Feeding: still breastfed? How many meals a day, what food, who feeds her, has she lost her appetite?
- Diarrhoea: how long? 14 days or more is persistent diarrhoea.
- Cough and fever: how long? Night sweats? Is she less playful?
- TB contact: who, how close, when did they start treatment?
- HIV: has the mother or child ever been tested? Was she breastfed, and is she still breastfeeding?
- Past illnesses, hospital admissions, mouth sores, ear discharge; immunisations.
She stopped breastfeeding at 18 months. Two small meals a day; she refuses most food. Loose stools on and off, not for more than a week at a time. Cough for 4 weeks, fever most nights. She shares a room with her grandfather. Neither Halima nor Zainab has been tested. Zainab had ear discharge twice this year and white patches in her mouth 'that keep coming back'.
Differential now- HIV infection Must not missLeading (moved up)
- Tuberculosis Must not missLeading (moved up)
- Severe acute malnutrition Must not missStill possible
- Inadequate feeding (diet, frequency)Still possible
- AnaemiaStill possible
- Persistent diarrhoea or wormsLess likely (moved down)
- PneumoniaLess likely
- Step 3 of 7 · Look
Examine her. What do you measure and what do you look for?
Model answer
- MUAC (all children 6 months or older), weight-for-height if you can, and oedema of both feet (press gently on the top of both feet).
- Visible wasting: ribs, shoulders, buttocks.
- Mouth: thrush outside the newborn period is a sign of HIV disease.
- Lymph nodes in neck, armpits and groin; swelling in front of the ears (parotid); liver and spleen.
- Skin, ears, palms for pallor; chest.
MUAC 112 mm (red). No oedema. Ribs and shoulder blades are prominent. White plaques on the tongue and cheeks (oral thrush). Enlarged painless lymph nodes in the neck and armpits, both parotids slightly swollen. Some palmar pallor. Chest: a few crackles on the right.
Differential now- Severe acute malnutrition Must not missLeading (moved up)
- HIV infection Must not missLeading
- Tuberculosis Must not missLeading
- AnaemiaLeading (moved up)
- Inadequate feeding (diet, frequency)Less likely (moved down)
- Persistent diarrhoea or wormsLess likely
- PneumoniaLess likely
- Step 4 of 7 · Test
Which tests do you do, and in which order?
Model answer
- Appetite test with RUTF, because MUAC is below 115 mm: she must eat at least one-third of a 92 g packet in 30 minutes. Failing it, or any complication, means inpatient care.
- HIV: mother and child status unknown, so IMCI tests the mother first. If she is positive, test the child. Zainab is over 18 months and no longer breastfed, so a positive antibody test in her means HIV infection (confirm by the national algorithm).
- TB: collect a sample (sputum if she can produce it, otherwise stool, gastric or nasopharyngeal aspirate) for a rapid molecular test.
- Haemoglobin, because she is pale. Glucose if she becomes drowsy or will not eat.
She eats half a packet in 25 minutes: passes. Halima's rapid test is positive; Zainab's rapid test is positive, and the confirmatory test is positive. A stool sample is sent for the molecular test. Hb 92 g/L (9.2 g/dL).
Differential now- Severe acute malnutrition Must not missLeading
- HIV infection Must not missLeading
- Tuberculosis Must not missLeading
- AnaemiaLeading
- Inadequate feeding (diet, frequency)Less likely
- Persistent diarrhoea or wormsLess likely
- PneumoniaLess likely
- Step 5 of 7 · Do
List her classifications. How unwell is she, by the HIV and TB guidance?
Model answer
Findings Classification MUAC below 115 mm, no oedema, passes appetite test, no danger sign or complication Uncomplicated severe acute malnutrition Positive serological test, child 18 months or older, confirmed Confirmed HIV infection Household TB contact, cough and fever for 4 weeks, poor weight gain Presumptive TB Some palmar pallor; Hb 92 g/L Anaemia Every child under 5 with HIV is regarded as having advanced HIV disease. Zainab is also unwell, with presumptive TB. She needs ART started quickly and a TB diagnosis by a clinician who can treat children with TB and HIV: the same day if the clinic can see her.
Differential now- Severe acute malnutrition Must not missLeading
- HIV infection Must not missLeading
- Tuberculosis Must not missLeading
- AnaemiaLeading
- Inadequate feeding (diet, frequency)Less likely
- Persistent diarrhoea or wormsSet aside for now (moved down)
- PneumoniaSet aside for now (moved down)
- Step 6 of 7 · Do
What do you start at the health centre before she goes?
Model answer
- RUTF for uncomplicated severe acute malnutrition, about 150 to 185 kcal/kg a day: at 8.5 to 9.4 kg, 3.5 packets a day (or your national table). Small amounts often, with plenty of clean water.
- An oral antibiotic such as amoxicillin, as part of outpatient treatment of severe acute malnutrition (dose per national formulary).
- Cotrimoxazole prophylaxis for the HIV infection (dose by weight, per your national chart).
- No iron: RUTF already contains enough. Treat the thrush (nystatin) as on the IMCI chart.
- Halima needs her own HIV care and ART: link her today, with Zainab.
- Step 7 of 7 · Ask
What else needs to happen for this family?
Model answer
- Tell Halima the results privately, with time for questions. Offer testing to her partner and her other children.
- Screen everyone in the household for TB; child contacts who do not have TB are offered preventive treatment per your national TB programme.
- Make sure the grandfather's TB treatment is supervised and continuing.
- See Zainab every 7 days for weight, MUAC, appetite and RUTF, alongside the HIV and TB clinic.
- Return at once if she will not eat, has a fit, cannot drink, becomes drowsy or breathes fast.
Zainab's tests show HIV, and she may also have caught TB from her grandfather. Both can be treated, and treatment works best when it starts early. The clinic at the hospital will see you both today. This food is her medicine too: give it a little at a time, many times a day.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Complicated severe acute malnutrition | MUAC below 115 mm or oedema with any danger sign, medical complication, severe oedema (+++) or a failed appetite test. | First dose of antibiotic, prevent low blood sugar, keep warm; refer urgently for inpatient care. |
| HIV infection | Thrush outside the newborn period, swollen lymph nodes or parotids, recurrent ear discharge, wasting not responding to treatment; mother untested or positive. | Test mother and child; cotrimoxazole; link both to ART care quickly. |
| Tuberculosis | Household contact, cough or fever for 2 weeks or more, poor weight gain, lethargy. | Sample for a rapid molecular test; refer to a clinician who can diagnose and treat TB in children; screen the household. |
| Severe pneumonia (including in HIV) | Danger sign, chest indrawing in an HIV-infected child, SpO2 below 90%. | First dose of antibiotic and urgent referral. |
| Severe anaemia | Severe palmar pallor, Hb below 70 g/L. | Refer urgently. |
Decision at first-level care
Zainab has uncomplicated severe acute malnutrition, confirmed HIV infection, presumptive TB from a household contact, and anaemia. She is not an emergency transfer, but as a child under 5 with HIV who is unwell she should reach the HIV and TB clinic the same day. RUTF, an oral antibiotic and cotrimoxazole are started before she leaves, and her mother is linked to her own HIV care.
Source: WHO IMCI chart booklet (2014); WHO wasting guideline (2023); WHO TB Module 2 (2021); WHO consolidated HIV guidelines (2021).
- Uncomplicated severe acute malnutrition with no other serious problem: RUTF, oral antibiotic, review every 7 days.
- Moderate acute malnutrition: feeding counselling, treat illness, review in 30 days.
- Borderline MUAC or unsure appetite: repeat the appetite test in a quiet place.
- HIV test result awaiting confirmation in a well child: start care and confirm within days.
- Any danger sign, complication, severe oedema or failed appetite test: urgently.
- Child under 5 with HIV who is unwell, or presumptive TB with HIV: the same day.
- Not gaining weight on RUTF, or losing weight.
- Infant under 6 months with wasting, oedema or weight loss.
Key learning points
- Measure MUAC and look for oedema of both feet in every sick child 6 months or older.
- MUAC below 115 mm with a good appetite and no complication can be treated at home with RUTF; a failed appetite test or any complication cannot.
- In a thin child, look for HIV signs (thrush, lymph nodes, parotids) and ask about TB at home.
- When neither mother nor child has been tested, test the mother first; over 18 months and not breastfed, a positive antibody test in the child means infection.
- Every child under 5 with HIV is treated as advanced HIV disease: link to ART quickly.
Sources
- World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. Malnutrition classification by MUAC and oedema; appetite test (one-third of a 92 g packet in 30 minutes); RUTF packets by weight; HIV testing order (mother first), serological test at 18 months or older; cotrimoxazole; WHO paediatric clinical staging (oral thrush, lymphadenopathy, parotid enlargement, recurrent ear infections); no iron with RUTF; nystatin for thrush; when to return.
- World Health Organization. WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. 2023. Outpatient care of uncomplicated severe wasting; RUTF energy 150 to 185 kcal/kg a day; oral antibiotic; admission criteria.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 2: screening – systematic screening for tuberculosis disease. 2021. Screening of child contacts: cough, fever or poor weight gain.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 3: diagnosis – rapid diagnostics for tuberculosis detection, third edition. 2024. Rapid molecular test as the first test; stool and other samples in children.
- World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring. 2021. All children under 5 with HIV regarded as having advanced HIV disease; rapid ART start.