The Paediatric Development Clinic: A model to improve medical, nutritional and developmental outcomes for high-risk children aged under-five in rural Rwanda

Postnatal medical, nutritional and developmental needs of infants born preterm, low birth weight (LBW), with hypoxic ischemic encephalopathy (HIE) (a brain injury following asphyxia), central nervous system (CNS) infections and other disabilities, including trisomy 21, are different from those of normal weight, full-term infants without developmental disabilities and have a higher risk of respiratory, hematologic, infectious, sensory and neurologic complications and require regular monitoring and early intervention. Optimal nutrition and growth requires monitoring growth velocity over time, including weight, length and head circumference, and adequate interpretation of z-scores to assess for malnutrition. Identifying growth failure in LBW infants is particularly challenging as this group includes a mix of preterm infants, small for gestational age (SGA) infants, and infants who are both preterm and SGA. Current World Health Organization (WHO) growth charts to assess nutritional status (weight-for-length) exclude infants <45 cm. Intergrowth 21 has recently published international growth standards based on appropriate gestational age (AGA) for preterm infants, yet detailed information on gestational age and birth weight is often lacking in low- and middle-income countries (LMICs).

Infants born preterm may also have difficulties breastfeeding due to potential for an immature suck pattern, difficulties coordinating breathing and vomiting during or after feeding, and have reduced milk intake. This requires strategies to regulate the infant, including providing Kangaroo Mother Care (KMC) for thermoregulation and bonding and strategies to improve suck and reduce vomiting. Infants born with syndromes such as trisomy 21 may have low muscle tone or exhibit “floppiness,” causing the infant to be less alert and have decreased tone and sensation in the mouth and throat, resulting in difficulty swallowing. Infants born with HIE may demonstrate high muscle tone, causing stiffness and resulting in difficulty in positioning for breastfeeding, and “tight” jaws, causing difficulty in latching.

To address these challenges, specialised feeding support by trained personnel is needed to ensure adequate breastfeeding and therefore appropriate growth. In addition, higher risk of developmental delay in these newborns requires early stimulation and developmental monitoring over time.