Infant and young child feeding counselling: an integrated course: course handouts

Course handouts INFANT AND YOUNG CHILD FEEDING COUNSELLING: AN INTEGRATED COURSE

Course handouts INFANT AND YOUNG CHILD FEEDING COUNSELLING: AN INTEGRATED COURSE WHO/HEP/NFS/21.41 Director’s guide, second edition – Trainer’s guide, second edition (including Web Annex A. Guidelines for follow-up after training; Web Annex B. Supportive supervision/mentoring and monitoring; and Web Annex C. Toolkit for supportive supervision/mentoring and monitoring) – Participant’s manual, second edition – Counselling cards for health workers – Guidance on the use of counselling cards – Course handouts. © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Infant and young child feeding counselling: an integrated course. Course handouts. Geneva: World Health Organization; 2021 (WHO/HEP/NFS/21.41). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout: Christopher Yuen. iii Contents Acknowledgements vi Abbreviations used in this course vii 1. Introduction 1 2. Registration and evaluation 2 Course registration form 2 Summary participant list 3 Evaluation questionnaire for participants 4 Evaluation form for participants and trainers 12 Evaluation form for trainers 14 3. Job aids and checklists 16 3.1 For general use, or specifically for clinical practice sessions 16 Listening and learning skills checklist 16 Counselling skills checklist 17 How to use a Counselling card 18 Clinical practice discussion checklist 19 Competency progress form 20 3.2 Job aids and reference tools 22 Job aid: Breastfeed observation 23 Job aid: Feeding history – 0 up to 6 months 24 Job aid: Postnatal contacts 25 Job aid: Ongoing contacts 26 Job aid: Food intake – 6 up to 24 months 27 Instructions for completing the Job aid: Food intake – 6 up to 24 months 25 Reference tool: Food intake – 6 up to 24 months 29 Food consistency pictures 30 Instructions for use of the Child age calculator 31 Job aid: weighing and measuring a child 32 Growth problems chart 35 3.3 General assessment and follow-up 36 Log of skills practised 37 Difficulties experienced 37 Self-assessment in infant and young child feeding: competency practice and progress tracking form 38 iv 4. Other items of key information 41 Counselling skills 41 Helpful non-verbal communication 41 Making suggestions, not commands 42 The four key signs of good positioning 42 The four key signs of good attachment 42 Signs and sensations of an active oxytocin reflex 43 How to stimulate the oxytocin reflex 43 How to assess a breastfeed 44 How to help a mother to position her baby 44 How to take a feeding history – 0 up to 6 months 45 Summary: How to take a feeding history – 0 up to 6 months 45 Reasons why a baby may not get enough breast milk 46 Reasons why babies cry 46 Causes of refusal to breastfeed 47 Helping a mother and baby to breastfeed again 48 How to prepare a container for expressed breast milk 48 How to express breast milk by hand 49 How to store expressed breast milk 50 How to feed a baby by cup 50 Amount of milk to give to low-birth-weight babies who cannot breastfeed 51 Amount of milk to give to babies who cannot breastfeed 51 Management of flat and inverted nipples 52 Treatment of breast engorgement 53 Summary of differences between full and engorged breasts 54 Treatment of blocked duct and mastitis 54 Antibiotic treatment for infective mastitis 55 Treatment of Candida infection of the breast 55 Signs that a baby may not be getting enough breast milk 56 How to help a woman to increase her supply of breast milk 56 How to help a family with a baby who cries a lot 58 Seven+ contacts to sustain breastfeeding 59 Risks of starting complementary foods too early 60 Risks of starting complementary foods too late 60 Ways to enrich a child’s food 60 Iron absorption 61 Fluid needs of the young child 61 Amounts of food to offer 62 Responsive feeding practices 62 Responsive feeding techniques 62 Five keys to safer food 63 Feeding the child who is ill 64 Feeding during recovery 64 Key messages for complementary feeding 65 Causes of undernutrition 66 Conditions needed for safe use of replacement feeding 67 How to prepare commercial infant formula milk 68 Approximate amounts of commercial infant formula milk needed by month 69 How to heat-treat expressed breast milk 70 v5. Demonstrations and scripts for role-play 71 Session 5. Listening and learning 71 Session 8. Building confidence and giving support 76 Sessions 13 and 25. Assessing a breastfeed 1 and 2 78 Sessions 15 and 31. Taking a feeding history – 0 up to 6 months 1 and 2 79 Session 37. Counselling practice 81 Session 40. Sustaining breastfeeding 85 Session 47. Gathering information on complementary feeding practices 88 Session 48. Responsive feeding 91 Session 51. Checking understanding and arranging follow-up 92 Session 52. Food demonstration 93 Session 62. Growth assessment results and feeding counselling when the child is growing well 95 Session 63. Investigating causes of undernutrition 97 Session 64. Counselling a mother or caregiver whose child has undernutrition 100 Session 65. Investigating causes and counselling a mother or caregiver whose child is overweight 102 Session 67. Gathering information and counselling on complementary feeding practices and growth: role-plays 105 Session 76. Communication and support of infant feeding in the context of HIV 110 6. Exercises and worksheets 113 Session 3. Local infant and young child feeding situation 113 Session 4. Local nutrition situation 114 Session 43. The importance of complementary feeding 115 Session 45. Foods to fill the iron and vitamin A gaps 117 Session 52. Food demonstration 118 Session 53. Clinical practice session 5: Gathering information on complementary feeding practices 1 120 Session 68. Clinical practice session 7: Listening and learning – measuring children 121 Session 76. Communication and support of infant feeding in the context of HIV 122 Session 77. Supporting national health authority infant feeding recommendations for women living with HIV 123 7. Answer sheets 124 Session 6. Listening and learning exercises 1 124 Session 7. Listening and learning exercises 2 – breastfeeding 127 Session 9. Building confidence and giving support exercises 1 – breastfeeding 130 Session 10. Building confidence and giving support exercises 2 – complementary feeding 133 Session 13. Assessing a breastfeed 1 136 Session 26. Observing a breastfeed 138 Session 29. Breast conditions: exercise 142 Session 30. Refusal to breastfeed 145 Session 32. Taking a feeding history – 0 up to 6 months: exercise 147 Session 36. “Not enough milk” and Crying: exercise 150 Session 38. Feeding low-birth-weight and sick babies 153 Session 39. Increasing breast milk and relactation 154 Session 40. Sustaining breastfeeding 155 Session 46. Variety, frequency and quantity of feeding 157 Session 50. Feeding during illness and recovery 158 Session 56. Introducing child growth assessment 159 Session 59. Plotting points for growth indicators 163 Session 61. Interpreting trends on growth charts 168 8. Course-completion certificate 169 vi Acknowledgements Many people from numerous countries contributed their valuable time and expertise to the development and field-testing of the different counselling courses used as a basis for this course. The development of this course was led by the World Health Organization (WHO) Department of Nutrition and Food Safety. The following deserve special recognition for the roles they played in the development of this course: Ruth Bland, Consultant, Africa Centre for Health and Population Studies, who was the primary author and who also acted as Director of the course in all the field-tests for the first edition; Randa Saadeh, WHO, who oversaw development of the first edition; Peggy Henderson, Nigel Rollins and Constanza Vallenas, WHO, who contributed to the revision of the first edition; Carmen Casanovas, WHO, who contributed to the development and revision of the first edition; Juan Pablo Peña Rosas, Pura Rayco-Solon and Lisa Rogers, WHO, who led the initiation, development and production of the second edition, respectively; Mary Lungaho and Maryanne Stone-Jimenez, consultants, who contributed to the development and testing of the course materials; and Maaike Arts and France Begin, United Nations Children’s Fund (UNICEF), who reviewed the course and provided comments. Special thanks are due to Helen Armstrong, Genevieve Becker, Hilary Creed-Kanashiro and Felicity Savage King, who were the authors of the original training courses on breastfeeding counselling, complementary feeding counselling, and HIV and infant-feeding counselling; and to Adelheid W. Onyango and Mercedes de Onis who were authors of the training course on child growth assessment. Thanks are also due to Ilgi Ertem and Cutberto Garza, for their technical input, and to Patricia Whitesell Shirey and Florence C Johnson, for developing the modules for the training course on child growth assessment. The contribution of the many individuals from the countries where the course and counselling tools were field-tested, namely Eswatini, Ghana, Kenya, Zambia and Zimbabwe, and the staff of the UNICEF and WHO regional and country offices concerned, is also gratefully acknowledged. Thanks are due to the Bill & Melinda Gates Foundation and the Government of the Republic of Korea, for providing financial support for updates to this second edition. vii Abbreviations used in this course These abbreviations are mentioned throughout the course in the Director’s guide, Trainer’s guide, Participant’s manual and in accompanying material. They are listed here for ease of reference. AIDS acquired immunodeficiency syndrome ART antiretroviral therapy ARV antiretroviral ARV3 triple antiretroviral treatment (i.e. 3 doses per day) AZT azidothymidine BFHI Baby-friendly Hospital Initiative BMI body mass index CBR crude birth rate CSB++ milk-fortified corn–soy blend DTG dolutegravir EFV efavirenz FTC emtricitabine GMP growth monitoring and promotion HIV human immunodeficiency virus HMIS health management information system IgA immunoglobulin A IgG immunoglobulin G ILO International Labour Organization IMCI Integrated Management of Childhood Illness IQ intelligence quotient IUD intrauterine device IYCF infant and young child feeding LQAS lot quality assurance sampling MGRS WHO Multicentre Growth Reference Study MNP multiple micronutrient powder MTCT mother-to-child transmission of HIV NVP nevirapine ORS oral rehydration solution PIP programme impact pathway PMTCT prevention of mother-to-child transmission of HIV RDT rapid diagnostic test RUSF ready-to-use supplementary food RUTF ready-to-use therapeutic food SD standard deviation SMART specific, measurable, achievable, relevant, time-bound 3TC lamivudine TB tuberculosis TDF tenofovir UHT ultra-high temperature UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children’s Fund USA United States of America WASH water, sanitation and hygiene WHA World Health Assembly WHO World Health Organization

11. Introduction Breastfeeding and appropriate, safe and timely complementary feeding are fundamental to the health and development of children, and important for the health of their mothers. The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have long recognized the need for promotion of exclusive breastfeeding in the first 6 months of life, and sustained breastfeeding together with adequate complementary foods up to 2 years of age or beyond, to reduce child morbidity and mortality. All health workers who care for women and children during the postnatal period and beyond have a key role to play in establishing and sustaining breastfeeding and appropriate complementary feeding. Many health workers cannot fulfil this role effectively because they have not been trained to do so. Little time is assigned to counselling and support skills for breastfeeding and infant feeding, in the pre-service curricula of either doctors, nurses, midwives or other professionals. Hence, there is an urgent need to train all those involved in infant feeding counselling, in all countries, in the skills needed to support and protect breastfeeding and good complementary feeding practices. The materials in this training course are designed to make it possible for trainers, even those with limited experience on teaching the subject, to conduct up-to-date and effective training. The counselling material available from WHO/UNICEF includes modules related to: • counselling skills • breastfeeding • complementary feeding • growth assessment • HIV and infant feeding. These Course handouts have been designed for use by directors and trainers to aid in registering participants and evaluating trainers, and include job aids, answer sheets, forms, checklists and other tools for course participants to use during the training sessions. Items not supplied here in the Course handouts but that are helpful to course participants and published elsewhere include a child age calculator, girl’s growth record, boy’s growth record, local and/or WHO growth charts, photo booklet for the WHO training course on child growth assessment, Job aid: investigating causes of undernutrition and overweight, counselling cards, and Guidance on the use of counselling cards. 22. Registration and evaluation Course registration form Please print clearly Your name: Email address: Best mailing address: Name and address of health facility where you work: What is your current work position or job title? What are your current duties related to child growth assessment and/or infant and young child feeding (IYCF) counselling? What professional training in health have you previously received? What year did you complete your basic training in health? Indicate any course(s) related to IYCF, Integrated Management of Childhood Illness (IMCI) or growth assessment that you have participated in, and whether you are a trainer/facilitator. 2. Registration and evaluation 3 S um m ar y pa rt ic ip an t li st Da te s of c ou rs e: Lo ca tio n of c ou rs e: N am e of p ar tic ip an t Em ai l a dd re ss Be st m ai lin g ad dr es s N am e of p ar tic ip an t’s he al th fa ci lit y Cu rr en t p os iti on o r j ob tit le Infant and young child feeding counselling: an integrated course. Course handouts 4 Infant and young child feeding counselling: an integrated course Evaluation questionnaire for participants To enable us to improve the training for others in the future, please fill out this questionnaire. 1. Briefly describe your responsibilities in relation to mothers and babies. In what type of setting do you work (e.g. community, private practice, health centre, hospital)? 2. Did you find any aspect of the training especially difficult (try to think in terms of “knowledge” and “skills”)? 3. For each activity listed below, tick one box to show whether you thought that the time spent on the activity was too short, adequate or too long. Type of activity Time spent was Too short Adequate Too long Theory – lecture sessions Demonstration of practical skills Demonstration of counselling skills Clinical practice sessions 4. What additional support, if any, do you think you may need after this training, to enable you to improve infant feeding counselling for mothers/caregivers in your own work setting? 5. How could the content and/or management of this training course be improved for future participants? 2. Registration and evaluation 5 Ti tle o f s es si on Ve ry us ef ul Us ef ul So m ew ha t us ef ul N ot u se fu l Co m m en ts Infant and young child feeding counselling: an integrated course. Course handouts 6 Ti tle o f s es si on Ve ry us ef ul Us ef ul So m ew ha t us ef ul N ot u se fu l Co m m en ts 2. Registration and evaluation 7 Ti tle o f s es si on Ve ry us ef ul Us ef ul So m ew ha t us ef ul N ot u se fu l Co m m en ts Infant and young child feeding counselling: an integrated course. Course handouts 8 Ti tle o f s es si on Ve ry us ef ul Us ef ul So m ew ha t us ef ul N ot u se fu l Co m m en ts 2. Registration and evaluation 9 Ti tle o f s es si on Ve ry us ef ul Us ef ul So m ew ha t us ef ul N ot u se fu l Co m m en ts Infant and young child feeding counselling: an integrated course. Course handouts 10 Ti tle o f s es si on Ve ry us ef ul Us ef ul So m ew ha t us ef ul N ot u se fu l Co m m en ts 2. Registration and evaluation 11 Ti tle o f s es si on Ve ry us ef ul Us ef ul So m ew ha t us ef ul N ot u se fu l Co m m en ts Infant and young child feeding counselling: an integrated course. Course handouts 12 Infant and young child feeding counselling: an integrated course Evaluation form for participants and trainers Please rate the level of difficulty you have in applying the following knowledge and skills in the counselling of mothers about infant and young child feeding. For each question below, put a tick mark in the box that best describes the level of difficulty for you. 1 = Not at all difficult, 2 = Not difficult, 3 = Neutral (not sure), 4 = Difficult, 5 = Very difficult How difficult is it for you to… 1 2 3 4 5 1. Use the six Listening and learning skills to counsel a mother/caregiver? 2. Use the six Skills for building confidence and giving support to counsel a mother/ cartegiver? 3. Assess a breastfeed using the Job aid: Breastfeed observation? 4. Help a mother to position her baby for breastfeeding using The four key signs of good positioning? 5. Explain The four key signs of good attachment for breastfeeding? 6. Help a mother to get her baby to attach to the breast once they are well positioned? 7. Explain to a mother about demand feeding and its implications for the frequency and duration of breastfeeding? 8. Explain to a mother the steps of expressing breast milk by hand? 9. Practise with a mother how to cup-feed her baby safely? 10. Take a feeding history for an infant using the Job aid: Feeding history – 0 up to 6 months? 11. Use counselling skills to discuss the advantages of exclusive breastfeeding? 12. Help a mother to initiate skin-to-skin contact and breastfeeding immediately after delivery? 13. Describe the importance of breast milk in the second year of life? 14. Describe the common reasons why babies may have a low intake of breast milk? 15. Describe the common reasons for apparent insufficiency of milk? 16. List the two reliable signs that a baby is not getting enough milk? 17. List eight causes of frequent crying? 18. Demonstrate to a mother three positions for holding a colicky baby? 19. Recognize breast refusal and help a mother to breastfeed again? 20. Help a mother who has flat or inverted nipples? 2. Registration and evaluation 13 How difficult is it for you to… 1 2 3 4 5 21. Recognize the difference between full and engorged breasts? 22. Recognize sore and cracked nipples? 23. Explain how to treat Candida infection of the breast? 24. Describe the difference between engorgement and mastitis? 25. Explain the differences in treating mastitis in an HIV-positive and HIV-negative mother? 26. Explain why breast milk is important for a low-birth-weight baby? 27. Use the Job aid: Food intake – 6 up to 24 months to learn how a mother is feeding her young child? 28. Identify the gaps in a child's nutrient intake, using the Job aid: Food intake – 6 up to 24 months and the Reference tool: Food intake – 6 up to 24 months? 29. Teach a mother the 10 Key messages for complementary feeding? 30. Explain to a mother how to feed a child aged over 6 months who is not growing well? 31. Demonstrate to a mother how to prepare feeds hygienically? 32. Explain to a mother how to feed a child aged over 6 months during illness? 33. Plot the weights and length/height of a child and interpret the child's individual growth chart? 34. Use the Counselling cards to help a woman living with HIV to decide how to feed her baby? 35. Help a woman living with HIV to prepare the replacement milk she has chosen? 36. Recognize when the child of a woman living with HIV needs follow-up or referral? 37. Explain to a woman living with HIV how to prepare to stop breastfeeding early? Infant and young child feeding counselling: an integrated course. Course handouts 14 Infant and young child feeding counselling: training course Evaluation form for trainers Please rate the level of difficulty you have in applying the following facilitation skills for training in infant and young child feeding. For each question below, put a tick mark in the box that best describes the level of difficulty for you. 1 = Not at all difficult, 2 = Not difficult, 3 = Neutral (not sure), 4 = Difficult, 5 = Very difficult How difficult is it for you to… 1 2 3 4 5 1. Take centre stage during a classroom or clinical session? 2. Face the audience (not the board or screen) while speaking? 3. Make eye contact with people in all sections of the audience? 4. Use natural gestures and facial expressions while leading a classroom session? 5. Avoid blocking the view of the audience? 6. Speak slowly and clearly, and loud enough for everyone to hear? 7. Speak naturally and in a lively manner – varied level and tone of voice? 8. Use a microphone? 9. Interact with all participants? 10. Use participants’ names? 11. Ask the questions suggested in the text to different participants? 12. Allow time for participants to answer? 13. Respond positively to all answers to your questions (correct errors gently)? 14. Involve all participants (include quiet ones and control talkative ones)? 15. Postpone or cut short discussions that are off the point or distracting? 16. Give satisfactory answers to questions from participants? 17. When you do not know the answer, explain that you don't know the answer but will find it? 18. Make ready training aids and equipment, and arrange them in the room before the session? 19. Remove training aids and equipment from the room after use? 20. Arrange the room so that everyone can see clearly and participate in discussions? 21. Write clearly on the flipchart or writing board? 2. Registration and evaluation 15 How difficult is it for you to… 1 2 3 4 5 22. Lead sessions accurately and completely – including all important points? 23. Give local examples when needed? 24. Keep to time – not too fast and not too slow? 25. Avoid losing time between sessions? 26. Explain clearly what to do before a practical session? 27. Select appropriate mothers and children during clinical practice sessions? 28. Demonstrate appropriate counselling skills to participants? 29. Lead a discussion after a practice session in the clinic or classroom? 30. Give positive feedback to participants about their performance (i.e. praise)? 31. Give feedback to help participants overcome difficulties (i.e. constructive)? 32. Facilitate infant and young child feeding courses in your own country? 33. Follow up participants of training courses after training? 16 3. Job aids and checklists 3.1 For general use, or specifically for clinical practice sessions Listening and learning skills checklist Name of counsellor: Name of observer: Date of visit: (ü for Yes and X for No) Did the counsellor: Use Listening and learning skills: □ Keep the head level with mother/caregiver? □ Pay attention (eye contact)? □ Remove physical barriers (tables and notes)? □ Take time/allow the mother/caregiver time to talk? □ Use appropriate touch? □ Ask open questions? □ Use responses and gestures that showed interest? □ Reflect back what the mother/caregiver said? □ Empathize – showing that he or she understood how the mother/caregiver feels? □ Avoid using words that sound judging? 3. Job aids and checklists 17 Counselling skills checklist Name of counsellor: Name of observer: Date of visit: (ü for Yes and X for No) Did the counsellor: Use Listening and learning skills: □ Keep the head level with mother/parent/caregiver? □ Pay attention (eye contact)? □ Remove barriers (tables and notes)? □ Take time? Allow the mother/caregiver time to talk? □ Use appropriate touch? □ Ask open questions? □ Use responses and gestures that showed interest? □ Reflect back what the mother/caregiver said? □ Empathize – showing that he or she understood how the mother/caregiver feels? □ Avoid using words that sound judging? Use Skills for building confidence and giving support: □ Accept what the mother/caregiver thinks and feels? □ Recognize and praise what the mother/caregiver and baby are doing right? □ Give practical help? □ Give a little, relevant information? □ Use simple language? □ Make one or two suggestions, not commands? Infant and young child feeding counselling: an integrated course. Course handouts 18 How to use a counselling card Introduce yourself Take time to show the Counselling card to the caregiver and ask what they: Observe □ What do you see in this card? □ What does each image represent? □ What recommended practice(s) is/are shown? Think □ What do you think about this card? □ Is there anything you disagree with – or think would not be possible? Please explain. □ What are the advantages of adopting the recommended practice(s)? Try □ If mothers/caregivers in this community were in the same situation, would they be willing to try the recommended practice(s)? Why? Why not? □ If YOU were the mother/caregiver in the Counselling card, would YOU be willing to try the new practice(s)? □ What difficulties might you experience? □ How would you be able to overcome them? 3. Job aids and checklists 19 Clinical practice discussion checklist Practical skills are best developed by introducing and demonstrating the skills, observing participants as they practise the skills, and giving feedback to participants on how well they performed. Feedback should include praising participants for things done well, and giving gentle suggestions for how to overcome difficulties. Use the checklist below to help guide your feedback discussions. Questions to ask after each participant completes their turn practising (either in the clinic or using counselling stories) To the participant who practised: • What did you do well? • What difficulties did you have? • What would you do differently in the future? To the participants who observed: • What did the participant do well? • What difficulties did you observe? Listening and learning skills (give feedback on the use of these skills in all practical sessions)1 • Which listening and learning skills did you use? • Was the mother willing to talk? • Did the mother ask any questions? How did you respond? • Did you empathize with the mother? Give an example. Skills for building confidence and giving support (give feedback on the use of these skills during clinical practice sessions after Session 10)1 • Which Skills for building confidence and giving support were used? (check especially for praise and for two relevant suggestions) • Which skills were most difficult to use? • What was the mother’s response to your suggestions? Key messages for complementary feeding (give feedback on the use of these skills in Sessions 53 and 54 [Clinical practice sessions 5 and 6])2 • Which messages for complementary feeding did you use? (check especially for “only a few relevant messages”) • What was the mother’s response to your suggestions? General questions to ask at the end of each clinical practice session (in the clinic or using counselling stories) • What special difficulties or situations helped you to learn? • What was the most interesting thing that you learnt from this clinical practice session? 1 See list of skills in the Counselling skills checklist. 2 See list of Key messages for complementary feeding on page xiv of the Participant’s manual and page xvii of the Trainer’s guide. Infant and young child feeding counselling: an integrated course. Course handouts 20 Competency progress form After each clinical practice, put a tick in the boxes for each skill you have practised. For each mother and baby that you see, you can put a tick in one or more box. Discuss your progress with your trainer, and try to practise as many competencies as possible. Core competencies 1. Use Listening and learning skills (using list of 6 skills) 2. Use Skills for building confidence and giving support (using list of 6 skills) 3. Assess a breastfeed (using Job aid: Breastfeed observation) 4. Position a baby at the breast • sitting • lying down • reclining • after caesarian section • other 5. Help a mother to attach her baby at the breast • cradle hold • underarm • with the opposite arm • other 6. Explain to a mother the optimal pattern of breastfeeding (unrestricted or demand feeding) 7. Help a mother to express her milk by hand 8. Help a mother to cup-feed her baby 9. Plot and interpret a child’s growth chart 10. Take a breastfeeding history 11. Inform a woman about optimal infant feeding (early contact, exclusive breastfeeding for 6 months, and continued breastfeeding to 2 years) 12. Counsel a pregnant woman about breastfeeding (advantages and management) 3. Job aids and checklists 21 Compound competencies 13. Help a woman to initiate breastfeeding within an hour after delivery 14. Support exclusive breastfeeding for the first 6 months of life 15. Help a mother to continue breastfeeding up to 2 years of age or beyond 16. Help a mother with “not enough milk” 17. Help a mother with a baby who cries frequently 18. Help a mother whose baby is refusing to breastfeed 19. Help a mother who has flat or inverted nipples 20. Help a mother with engorged breasts 21. Help a mother with sore or cracked nipples 22. Help a mother with mastitis 23. Help a mother to breastfeed • a low-birth-weight baby • a sick baby • twins 24. Help a mother to increase her breast milk or to start breastfeeding again 25. Counsel a woman living with HIV antenatally about feeding choices Infant and young child feeding counselling: an integrated course. Course handouts 22 3.2 Job aids and reference tools The following items are provided as published elsewhere: • Child age calculator (https://www.who.int/tools/child-growth-standards) • Girl’s growth record (https://apps.who.int/iris/bitstream/handle/10665/43601/9789241595070_GirlsGrowth_eng.pdf) • Boy’s growth record (https://apps.who.int/iris/bitstream/handle/10665/43601/9789241595070_BoysGrowth_eng.pdf) • Blank WHO and/or local growth charts (https://www.who.int/childgrowth/standards/en/) • Training course on child growth assessment: WHO child growth standards. Photo booklet. Geneva: World Health Organization; 2008 (http://www.who.int/childgrowth/training/module_e_photo_booklet.pdf) • Job aid: Investigating causes of undernutrition and overweight (https://www.who.int/childgrowth/training/ jobaid_investigating_causes.pdf) • Counselling cards (https://apps.who.int/iris/bitstream/handle/10665/346567/WHO-HEP-NFS-21.24-eng.pdf) • Guidance on the use of counselling cards (https://apps.who.int/iris/bitstream/handle/10665/346569/9789240035560-eng.pdf) 3. Job aids and checklists 23 Job aid: Breastfeed observation Mother's name: Baby's name: Date: Baby's age: Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother: □ Mother looks healthy □ Mother relaxed and comfortable □ Signs of bonding between mother and baby Mother: □ Mother looks ill or depressed □ Mother looks tense and uncomfortable □ No mother/baby eye contact Baby: □ Baby looks healthy □ Baby calm and relaxed □ Baby reaches or roots for breast if hungry Baby: □ Baby looks sleepy or ill □ Baby is restless or crying □ Baby does not reach or root BREASTS □ Breasts look healthy □ No pain or discomfort □ Breast well supported with fingers away from nipple □ Breasts look red, swollen, or sore □ Breast or nipple painful □ Breasts held with fingers on areola BABY'S POSITION □ Baby’s head and body in line □ Baby held close to mother’s body □ Baby’s whole body supported □ Baby approaches breast, nose to nipple □ Baby’s neck and head twisted to feed □ Baby not held close □ Baby supported by head and neck only □ Baby approaches breast, lower lip/chin to nipple BABY'S ATTACHMENT □ Baby’s mouth open wide □ Lower lip turned outwards □ Baby’s chin touches breast □ More areola seen above baby’s top lip □ Baby’s mouth not open wide □ Lips pointing forward or turned in □ Baby’s chin not touching breast □ More areola seen below bottom lip SUCKLING □ Slow, deep sucks with pauses □ Cheeks round when suckling □ Baby releases breast when finished □ Mother notices signs of oxytocin reflex □ Rapid shallow sucks □ Cheeks pulled in when suckling □ Mother takes baby off the breast □ No signs of oxytocin reflex noticed Infant and young child feeding counselling: an integrated course. Course handouts 24 Job aid: Feeding history – 0 up to 6 months Mother's name: Baby's name: Date: Baby's age: Particular concerns about feeding of child: FEEDING • Milk (breast milk, formula, cow’s milk, other) • Frequency of milk feeds • Length of breastfeeds/quantity of other milks • Night feeds • Other foods in addition to milk (when started, what, frequency) • Other fluids in addition to milk (when started, what, frequency) • Use of bottles and how cleaned • Feeding difficulties (breastfeeding/other feeding) HEALTH • Growth chart (birth weight, weight now; length at birth, length now) • Urine frequency per day (6 times or more) • Stools (frequency, consistency) • Illnesses PREGNANCY, BIRTH AND EARLY FEEDS (where applicable) • Antenatal care • Feeding discussed at antenatal care • Delivery experience • Rooming-in • Prelacteal feeds • Postnatal help with feeding MOTHER’S CONDITION AND FAMILY PLANNING • Age • Health – including nutrition and medications • Breast health • Family planning PREVIOUS INFANT FEEDING EXPERIENCE • Number of previous babies • How many breastfed and for how long • If breastfed – exclusive or mixed fed • Other feeding experiences FAMILY AND SOCIAL SITUATION • Work situation • Economic situation • Family’s attitude to infant feeding practices 3. Job aids and checklists 25 Job aid: Postnatal contacts • Use counselling skills – Listening and learning skills and Skills for building confidence and giving support • Follow up on previous observations and questions Ask: • How is breastfeeding going – how many times, length of feeds, comfort, condition of breasts • Is the baby receiving other fluids or foods, bottles, dummies? • Baby’s health and behaviour • Pregnancy, delivery, early feeds • Mother’s condition and family planning • Previous infant feeding experience • Family and social situation – support at home, work Observe: • Condition of the mother • Condition of the baby • A breastfeed – including condition of the breasts • Child’s growth curve – weight and/or length/height, as appropriate Help the mother to: • Position and attach her baby if necessary • Express milk and cup-feed her baby – if necessary, if not done before Explain or recap as needed: • How milk “comes in” • Feeding pattern – demand feeding (baby with mother, respond day and night, let baby finish first breast, offer second) • Exclusive breastfeeding – supplements not needed • Signs the baby has what they need – passing urine, contented Respond to any other questions and worries: • Help (including possible referral) if needed with any difficulties: - Poor (or excessive) weight gain - Concerns about “not enough milk” - Concerns about baby’s crying - Suckling difficulties - Flat, inverted or large nipples - Sore nipples - Engorgement - Mastitis - Refusal to feed Infant and young child feeding counselling: an integrated course. Course handouts 26 Job aid: Ongoing contacts • Use counselling skills – Listening and learning skills and Skills for building confidence and giving support • Follow up on previous observations and questions Ask: • How is breastfeeding going – how many times, length of feeds, comfort, condition of breasts? • Is the baby receiving other fluids or foods, bottles, dummies? • Baby’s health and behaviour • Pregnancy, delivery, early feeds • Mother’s condition and family planning • Previous infant feeding experience • Family and social situation – support at home, work Observe: • (Condition of the mother) • Condition of the baby • (A breastfeed, including condition of the breasts, if there is any difficulty) • Growth monitoring – check baby’s weight and/or length/height, as appropriate Discuss: • The importance of exclusive breastfeeding to 6 months • Introduction of complementary foods from 6 months – AFATVRH: age-appropriate, frequency, amount, thickness, variety, responsive feeding and hygiene • Continuing to demand feed as often as the infant wants, day and night • Family support – talk to family if possible • Family planning • Preparation for returning to work • Any other questions Respond to any other questions and worries: • Help (including possible referral) if needed with any difficulties: - Poor (or excessive) weight gain - Concerns about “not enough milk” - Concerns about baby’s crying - Suckling difficulties - Flat, inverted or large nipples - Sore nipples - Engorgement - Mastitis - Refusal to feed 3. Job aids and checklists 27 Enter a ü in the Yes column if the practice is in place. Enter your initials if a message is given (see Reference tool: Food intake – 6 up to 24 months for the message). Job aid: Food intake – 6 up to 24 months Child's name: Date of birth: Age of child at visit: Feeding practice Yes / number where relevant Key message given Growth appropriate? Child received breast milk? How many meals of a thick consistency did the child eat yesterday? (use Food consistency pictures as needed) Child ate an animal-source food yesterday (meat/fish/offal/bird/eggs)? Child ate a dairy product yesterday? Child ate pulses, nuts or seeds yesterday? Child ate a dark-green or yellow vegetable or yellow fruit yesterday? Child ate sufficient number of meals and snacks yesterday, for their age? Quantity of food eaten at main meal yesterday appropriate for child’s age? Caregiver assisted the child at mealtimes? Child took any vitamin or mineral supplements? Child ill or recovering from an illness? Infant and young child feeding counselling: an integrated course. Course handouts 28 Instructions for completing the Job aid: Food intake – 6 up to 24 months 1. Greet the mother/caregiver. Explain that you want to talk about the child’s feeding. 2. Fill out the child’s name, birth date, age in completed months or years and today’s date. 3. Ask to see the growth chart and observe the pattern of the growth. 4. Start with: (Mother/caregiver name), let us talk about what (child’s name) ate yesterday. 5. Continue with: As we go through yesterday, tell me all (name) ate or drank, meals, other foods, water or breastfeeds. What was the first thing you gave (name) after he woke up yesterday? Did (child’s name) eat or drink anything else at that time or breastfeed? 6. If the caregiver mentions a preparation, such as a porridge or stew, ask them for the ingredients in the porridge or stew. 7. Then continue with: What was the next food or drink or breastfeed (child’s name) had yesterday? Did (child’s name) eat/drink anything else at that time? 8. Remember to “walk” through yesterday’s events with the caregiver, to help them remember all the food/drinks/ breastfeeds that the child had. 9. Continue to remind the caregiver you are interested in what the child ate and drank yesterday (caregivers may talk about what the child eats/drinks in general). 10. Clarify any points or ask for further information as needed. 11. Mark on the Job aid: Food intake – 6 up to 24 months the practices that are present. If appropriate, show the caregiver the pictures of thin and thick consistency (for porridge and mixed foods). Ask them which drawing is most like the food they gave the child. Was it thick, did it stay on the spoon and hold a shape on the plate, or was it thin and did it flow off the spoon and not hold its shape on the plate? 12. Praise practices you wish to encourage. Offer two or three Key messages as needed and discuss how the caregiver might use this information. 13. If the child is ill on that day and not eating, give the Key message 10: Encourage the child to drink and eat during illness, and provide extra food after illness to help them recover quickly. 14. See the child another day and use the Job aid: Food intake – 6 up to 24 months when they are eating again. 3. Job aids and checklists 29 Reference tool: Food intake – 6 up to 24 months Feeding practice Ideal feeding practice Key messages to help counsel mothers Growth appropriate? Look at the shape of the growth curve of the child: is the child growing? Child received breast milk? Yes Breastfeeding for 2 years or longer helps a child to develop and grow strong and healthy How many meals of a thick consistency did the child eat yesterday? (use Food consistency pictures as needed) 3 meals Foods that are thick enough to stay on the spoon give more energy to the child Child ate an animal-source food yesterday (meat/fish/offal/bird/eggs)? Animal-source foods should be eaten daily Animal-source foods are especially good for children, to help them grow strong and lively Child ate a dairy product yesterday? Try to give dairy products daily Animal-source foods are especially good for children, to help them grow strong and lively Child ate pulses, nuts or seeds yesterday? If meat is not eaten, pulses or nuts should be eaten daily, with an iron enhancer such as a vitamin-C-rich food Peas, beans, lentils, nuts and seeds are good for children Child ate a dark-green or yellow vegetable or yellow fruit yesterday? A dark-green or yellow vegetable or yellow fruit should be eaten daily Dark-green leaves and yellow- coloured fruits and vegetables help the child to have healthy eyes and fewer infections Child ate sufficient number of meals and snacks yesterday, for their age? Child 6–8 months: 2–3 meals plus 1–2 snacks if hungry Child 9–24 months: 3–4 meals plus 1–2 snacks if hungry A growing child needs 2–4 meals a day, plus 1–2 snacks if hungry: give a variety of foods Quantity of food eaten at main meal yesterday appropriate for child’s age? Child 6–8 months: gradually increased to approx. ½ cup at each meal Child 9–11 months: approx. ½ cup at each meal Child 12–24 months: approx. ¾–1 cup at each meal A growing child needs increasing amounts of food Caregiver assisted the child at mealtimes? Yes, assists with learning to eat A young child needs to learn to eat: encourage and give help … with lots of patience Child took any vitamin or mineral supplements? Vitamin and mineral supplements may be needed if child’s needs are not met by food intake Explain how to use vitamin and mineral supplements if they are needed Child ill or recovering from an illness? Continue to eat and drink during illness and recovery Encourage the child to drink and eat during illness, and provide extra food after illness to help them recover quickly Infant and young child feeding counselling: an integrated course. Course handouts 30 Food consistency pictures 3. Job aids and checklists 31 Instructions for use of the Child age calculator 1. Determine the child’s date of birth. This date should already be recorded in the Growth record on page 1 (Personal data). 2. Determine and note down the number of full years the child has completed, e.g. ask the mother how many birthdays have been celebrated if this is a local custom. (Note: simply subtracting the year of birth from the current year will be accurate only if the child has already had a birthday this year.) - If the child is one or more years old, you will turn the disk to calculate the number of additional months completed. - If the child is less than 1 year old, you will use the disk to count the number of weeks (in the first 3 months) or months (from 3 to 11 months) completed since birth. 3. Turn the disk until the bold arrow points to the child’s birthday (month and day) on the stationary circular calendar. 4. Locate today’s date on the stationary calendar and count on the rotating disk how many months (or weeks if less than 3 months old) the child has completed since birth or the last birthday. 5. Record the child’s age today in the Visit notes of the Growth record. Use abbreviations agreed upon for year, month and week. - If the child is more than 1 year old, record completed years and months, for example, “1 yr 6 mo”, “2 yr 3 mo”. If no months have been completed beyond the child’s birthday, record as “1 yr 0 mo”, “2 yr 0 mo”, etc. - If the child is between 3 months and 1 year old, record completed months, for example, “4 mo”, “11 mo”. - If the child is less than 3 months old, record completed weeks, for example, “9 wk”.1 Notice that 13 weeks = 3 months. - If the child was born on 29 February, place the bold arrow on 28 February. 1 If a country uses different growth charts that count months rather than weeks from birth, it will not be necessary to record weeks. Infant and young child feeding counselling: an integrated course. Course handouts 32 Job aid: Weighing and measuring a child Weighing a child using a taring scale Be sure that the scale is placed on a flat, hard, even surface. There must be enough light to operate the solar-powered scale. Explain all procedures to the mother and enlist her help. Babies should be weighed naked; wrap them in a blanket or other covering until weighing. Older children should be weighed with minimal clothing. If it is socially unacceptable to undress the child, remove as much clothing as possible. If the child is less than 2 years old, do tared weighing. To turn on the scale, cover the solar panel for a second. When the number 0.0 appears, the scale is ready. The mother will remove her shoes and step on the scale to be weighed first alone. Have someone else hold the undressed baby wrapped in a blanket. Ask the mother to stand in the middle of the scale, feet slightly apart (on the footprints, if marked), and to remain still. The mother’s clothing must not cover the display or the solar panel. Remind her to stay on the scale, even after her weight appears, until the baby has been weighed in her arms. With the mother still on the scale and her weight displayed, tare the scale by covering the solar panel for a second. The scale is tared when it displays a figure of a mother and baby and the number 0.0. Hand the undressed baby to the mother and ask her to remain still. The baby’s weight will appear on the display (shown to the nearest 0.1 kg). Record this weight. Note: If a mother is very heavy (e.g. more than 100 kg) and the baby’s weight is relatively low (e.g. less than 2.5 kg), the baby’s weight may not register on the scale. In such cases, have a lighter person hold the baby on the scale. If the child is 2 years or older and will stand still, weigh the child alone. If the child jumps on the scale or will not stand still, use the tared weighing procedure instead. Ask the mother to help the child remove shoes and outer clothing. Talk with the child about the need to stand still. • To turn on the scale, cover the solar panel for a second. When the number 0.0 appears, the scale is ready. • Ask the child to stand in the middle of the scale, feet slightly apart (on the footprints, if marked), and to remain still until the weight appears on the display. • Record the child’s weight to the nearest 0.1 kg. 3. Job aids and checklists 33 Measuring length or height Depending on a child’s age and ability to stand, measure the child’s length or height. • If a child is less than 2 years old, measure the child’s length lying down (recumbent) using a length board, which should be placed on a flat, stable surface such as a table. • If the child is aged 2 years or older, measure standing height unless the child is unable to stand. Use a height board mounted at a right angle between a level floor and against a straight, vertical surface such as a wall or pillar. Standing height is about 0.7 cm less than recumbent length. This difference was taken into account in developing the WHO child growth standards. Therefore, it is important to adjust the measurements if length is taken instead of height, and vice versa. • If a child less than 2 years old will not lie down for measurement of length, measure standing height and add 0.7cm to convert it to length. • If a child aged 2 years or older cannot stand, measure recumbent length and subtract 0.7 cm to convert it to height. Preparing to measure length or height Be prepared to measure length/height immediately after weighing, while the child’s clothes are off. Before weighing: • remove the child’s shoes and socks • undo braids and remove hair ornaments if they will interfere with the measurement of length/height. If a baby is weighed naked, a dry diaper can be put back on to avoid getting wet while measuring length. If the room is cool and there is any delay, keep the child warm in a blanket until length/height can be measured. Explain all procedures to the mother and enlist her help. Measuring length Cover the length board with a thin cloth or soft paper for hygiene and for the baby’s comfort. Explain to the mother that she will need to place the baby on the length board herself and then help to hold the baby’s head in place while you take the measurement. Show her where to stand when placing the baby down, i.e. opposite you, on the side of the length board away from the tape. Also show her where to place the baby’s head (against the fixed headboard) so that she can move quickly and surely without distressing the baby. • Ask her to lay the child on their back with their head against the fixed headboard, compressing the hair. • Quickly position the head so that an imaginary vertical line from the ear canal to the lower border of the eye socket is perpendicular to the board. (The child’s eyes should be looking straight up.) Ask the mother to move behind the headboard and hold the head in this position. Speed is important. Standing on the side of the length board where you can see the measuring tape and move the footboard: • Check that the child lies straight along the board and does not change position. The shoulders should touch the board, and the spine should not be arched. Ask the mother to inform you if the child arches the back or moves out of position. • Hold down the child’s legs with one hand and move the footboard with the other. Apply gentle pressure to the knees to straighten the legs as far as they can go without causing injury. Note: it is not possible to straighten the knees of newborn babies to the same degree as older children. Their knees are fragile and could be injured easily, so apply minimum pressure. • If a child is extremely agitated and both legs cannot be held in position, measure with one leg in position. • While holding the knees, pull the footboard against the child’s feet. The soles of the feet should be flat against the footboard, toes pointing upwards. If the child bends their toes and prevents the footboard from touching the soles, scratch the soles slightly and slide in the footboard quickly when the child straightens their toes. Fixed headboard Movable headboard Fixed headboard Movable headboard Infant and young child feeding counselling: an integrated course. Course handouts 34 • Read the measurement and record the child’s length in centimetres to the last completed 0.1 cm in the Visit notes of the Growth record. This is the last line that you can actually see (0.1 cm = 1 mm). Remember: If the child whose length you measured is 2 years old or more, subtract 0.7 cm from the length and record the result as height in the Visit notes. Measuring standing height Ensure that the height board is on level ground. Check that shoes, socks and hair ornaments have been removed. Working with the mother, and kneeling in order to get down to the level of the child: • Help the child to stand on the baseboard with their feet slightly apart. The back of the head, shoulder blades, buttocks, calves and heels should all touch the vertical board. • Ask the mother to hold the child’s knees and ankles to help keep their legs straight and feet flat, with the heels and calves touching the vertical board. Ask her to focus the child’s attention, soothe the child as needed, and inform you if the child moves out of position. • Position the child’s head so that a horizontal line from the ear canal to the lower border of the eye socket runs parallel to the base board. To keep the head in this position, hold the bridge between your thumb and forefinger over the child’s chin. • If necessary, push gently on the tummy to help the child stand to full height. • Still keeping the head in position, use your other hand to pull down the headboard to rest firmly on top of the head and compress the hair. • Read the measurement and record the child’s height in centimetres to the last completed 0.1 cm in the Visit notes of the Growth record. This is the last line that you can actually see (0.1 cm = 1 mm). Remember: If the child whose height you measured is less than 2 years old, add 0.7 cm to the height and record the result as length in the Visit notes. 3. Job aids and checklists 35 Growth problems chart Compare the points plotted on the child’s growth charts with the z-score lines, to determine whether they indicate a growth problem. Measurements in the shaded boxes are in the normal range. z-scorea Growth indicators Length/ height-for-age Weight-for- age Weight-for- length/height BMI-for-age Above 3 See note 1 See note 2 Obese Obese Above 2 Overweight Overweight Above 1 Possible risk of overweight (see note 3) Possible risk of overweight (see note 3) 0 (median) Below –1 Below –2 Stunted (see note 4) Underweight Wasted Wasted Below –3 Severely stunted (see note 4) Severely underweight (see note 5) Severely wasted Severely wasted BMI: body mass index. aThe z-score label in this column refers to a range. For example “above 2” means 2.1 to 3.0; “median” includes –1.1 to 1.0; “below –2” refers to –2.1 to –3.0, etc. Notes: 1. A child in this range is very tall. Tallness is rarely a problem, unless it is so excessive that it may indicate an endocrine disorder such as a growth-hormone-producing tumour. Refer a child in this range for assessment if you suspect an endocrine disorder (e.g. if parents of normal height have a child who is excessively tall for their age). 2. A child whose weight-for-age falls in this range may have a growth problem, but this is better assessed from weight-for- length/height or BMI-for-age. 3. A plotted point above 1 shows possible risk. A trend towards the 2 z-score line shows definite risk. 4. It is possible for a stunted or severely stunted child to become overweight. 5. This is referred to as very low weight in Integrated Management of Childhood Illness training modules; see IMCI in-service training. Geneva: World Health Organization; 1997 (WHO/CHD/97.3.K; https://www.who.int/publications/i/item/WHO- CHD-97-3-K). Infant and young child feeding counselling: an integrated course. Course handouts 36 3.3 General assessment and follow-up Log of skills practised Date Skill practised Comments 3. Job aids and checklists 37 Difficulties experienced Date Difficulty experienced Comments Infant and young child feeding counselling: an integrated course. Course handouts 38 Self-assessment in infant and young child feeding: competency practice and progress tracking form Instructions: • Track your practice by putting a ü in the first box (column) for each skill you have practised. • In the second box (column), enter a ü for competency where a peer has observed you and provided feedback. • In the third box (column), enter a ü for competency observed by a mentor-supervisor who provided feedback. Competencies Practised Peer observed and feedback Mentor- supervisor observed and feedback Core competencies 1. Use the six Listening and learning skills to counsel a mother or caregiver 2. Use the six Skills for building confidence and giving support to counsel a mother or caregiver 3. Assess a breastfeed using the Job aid: Breastfeed observation 4. Help a mother to position herself and her baby for breastfeeding • The four key signs of good positioning • Demonstrate different positions: - Cradle - Cross-cradle - Side-lying - Underarm - Cross-position for twins 5. Help a mother to attach her baby at the breast • The four key signs of good attachment • How to hold the breast • Signs of effective suckling 6. Explain how the breast makes milk 7. Explain to a mother about the optimal pattern of breastfeeding • Unrestricted or demand feeding • Day and night • Let baby finish first breast; offer the second one 8. Help a mother to express her breast milk by hand 9. Help a mother to cup-feed her baby 10. Plot and interpret a child’s growth chart 11. Take a feeding history for an infant aged from 0 up to 6 months using the Job aid: Feeding history – 0 up to 6 months 3. Job aids and checklists 39 Competencies Practised Peer observed and feedback Mentor- supervisor observed and feedback 12. Counsel a pregnant woman about breastfeeding (importance and management) 13. Inform a woman about optimal infant feeding (early skin- to-skin contact, early initiation of breastfeeding, exclusive breastfeeding for 6 months, and continued breastfeeding to 2 years) Compound competencies 1. Help a mother to initiate breastfeeding within an hour after delivery 2. Support exclusive breastfeeding for the first 6 months of life 3. Help a mother to continue breastfeeding up to 2 years of age or beyond 4. Help a mother with “not enough milk” 5. Help a mother with a baby who cries frequently 6. Help a mother whose baby is refusing to breastfeed 7. Help a mother who has flat or inverted nipples 8. Help a mother with engorged breasts 9. Help a mother with sore or cracked nipples 10. Help a mother with mastitis 11. Help a mother to breastfeed • a low birth-weight-baby • a sick baby • twins 12. Help a mother to increase her breast milk or to start breastfeeding again (relactate) 13. Help mothers who are in employment to breastfeed 14. Explain the importance of continued breastfeeding 15. Explain why there is an optimal age for children to start complementary feeding 16. List the local foods that can help fill the energy gap 17. Explain the reason for recommending using foods of a thick consistency 18. Describe ways to enrich foods 19. List the local foods that can fill the nutrient gaps for iron and vitamin A 20. Explain the importance of animal-source foods 21. Explain the importance of legumes Infant and young child feeding counselling: an integrated course. Course handouts 40 Competencies Practised Peer observed and feedback Mentor- supervisor observed and feedback 22. Describe age-appropriate frequency, amount, thickness, and variety of foods for an infant aged 6–9 months 23. Describe age-appropriate frequency, amount, thickness, and variety of foods for an infant aged 9–12 months 24. Describe age-appropriate frequency, amount, thickness, and variety of foods for an infant aged 12–24 months 25. Describe the importance of responsive feeding 26. Describe hygiene practices for the mother/caregiver/baby 27. List the recommendations for feeding a non-breastfed child aged over 6 months 28. Use the Job aid: Food intake – 6 up to 24 months or IYCF health-worker Job aid 1: IYCF assessment 29. Explain why children need to continue to eat during illness 30. Describe appropriate feeding during illness and recovery 31. Conduct a food demonstration with a mother/caregiver to help feed her child aged 6–24 months 41 4. Other items of key information Helpful non-verbal communication • Keep your head at the same level as the mother/caregiver • Pay attention • Remove physical barriers • Take time/allow the mother or caregiver time to talk • Use appropriate touch Counselling skills Listening and learning skills 1. Use helpful non-verbal communication 2. Ask open questions 3. Use responses and gestures that show interest 4. Reflect back what the mother/caregiver says 5. Empathize – show that you understand how the mother/caregiver feels 6. Avoid using words that sound judging Skills for building confidence and giving support 1. Accept what a mother/caregiver thinks and feels 2. Recognize and praise what a mother/caregiver and baby are doing right 3. Give practical help 4. Give a little, relevant information 5. Use simple language 6. Make one or two suggestions, not commands Infant and young child feeding counselling: an integrated course. Course handouts 42 Making suggestions, not commands Commands use the imperative form of verbs (give, do, bring) and words such as always, never, must, should. Suggestions include: • Have you considered…? • Would it be possible…? • What about trying… to see if it works for you? • Would you be able to? • Have you thought about…? Instead of…? • You could choose between… and…and… • It may not suit you, but some mothers… a few women… • Perhaps… might work. • Usually… Sometimes… Often… The four key signs of good positioning 1. The baby’s head and body are in line. 2. The baby is held close to the mother’s body. 3. The baby’s whole body is supported. 4. The baby approaches the breast, nose to nipple. The four key signs of good attachment 1. The baby’s mouth is wide open. 2. The baby’s lower lip is turned outwards. 3. The baby’s chin is touching the mother’s breast. 4. More areola is seen above the baby’s top lip than below the bottom lip. 4. Other items of key information 43 Signs and sensations of an active oxytocin reflex A mother may notice: • A squeezing or tingling sensation in her breasts just before she feeds her baby, or during a feed • Milk flowing from her breasts when she thinks of her baby, or hears him crying • Milk dripping from her other breast, when her baby is suckling • Milk flowing from her breasts in fine streams, if her baby comes off the breast during a feed • Pain from uterine contractions, sometimes with a rush of blood, during feeds in the first week • Slow deep sucks and swallowing by the baby, which show that breast milk is flowing into the baby’s mouth How to stimulate the oxytocin reflex • Help the mother psychologically: - Build her confidence. - Try to reduce any sources of pain or anxiety. - Help her to have good thoughts and feelings about the baby. • Help the mother practically. Help or advise her to: - Sit quietly and privately or with a supportive friend. Some mothers can express easily in a group of other mothers who are also expressing for their babies. - Hold her baby with skin-to-skin contact if possible. She can hold her baby on her lap while she expresses. If this is not possible, she can look at the baby. If this is not possible, sometimes even looking at a photograph of her baby helps. - Warm her breasts. For example, she can apply a warm compress, or warm water, or have a warm shower. Warn her that she should test the temperature to avoid burning herself. - Stimulate her nipples. She can gently pull or roll her nipples with her fingers. - Massage or stroke her breasts lightly. Some women find that it helps if they stroke the breast gently with finger tips or with a comb. Some women find that it helps to gently roll their closed fist over the breast towards the nipple. - Ask a helper to rub her back. Infant and young child feeding counselling: an integrated course. Course handouts 44 How to assess a breastfeed 1. Look at the mother herself 2. Look at how the mother holds her baby 3. Look at the baby’s condition 4. Observe how the baby responds to the breast 5. Observe how the mother holds her breast for the baby 6. Observe the baby’s attachment and suckling 7. Notice how the breastfeed finishes 8. Observe the condition of the mother’s breasts How to help a mother to position her baby • Greet the mother and ask how breastfeeding is going. • Assess a breastfeed. • Explain what might help, and ask whether she would like you to show her. • Make sure that she is comfortable and relaxed. • Sit down yourself in a comfortable, convenient position. • Explain how to hold her baby, and show her if necessary. The four key points are: - Baby’s head and body in line - Baby held close to mother’s body - Baby’s whole body supported - Baby approaches breast, nose to nipple • Show her how to support her breast: - With her fingers against her chest wall below her breast - With her first finger supporting the breast - With her thumb above - Her fingers should not be too near the nipple • Explain or show her how to help the baby to attach: - Touch her baby’s lips with her nipple - Wait until her baby’s mouth is opening wide - Move her baby quickly onto her breast, aiming the lower lip below the nipple • Notice how she responds and ask her how her baby’s suckling feels. • Look for signs of good attachment. If the attachment is not good, try again. 4. Other items of key information 45 How to take a feeding history – 0 up to 6 months • Greet the woman in a kind and friendly way. • Use the mother’s name and the baby’s name (if appropriate). • Ask her to tell you about herself and her baby in her own way, starting with the things that she feels are important. • Look at the child’s growth chart. It may tell you some important facts and save you asking some questions. • Ask the questions that will tell you the most important facts. The Job aid: Feeding history – 0 up to 6 months is a guide to the facts that you may need to learn about. Decide what you need to know from each of the six sections. • Be careful not to sound critical. • Use Skills for building confidence and giving support. • Try not to repeat your questions. If you need to repeat a question, first say: “Can I make sure that I have understood clearly?” and then, for example, “You said that (name) had both diarrhoea and pneumonia last month?” • Take time to learn about more difficult, sensitive things. For example: - What does the baby’s father say? Her mother? Her mother-in-law? - Is the mother happy about having the baby now? About the baby’s sex? Some mothers tell you these things spontaneously. Others tell you when you empathize, and show that you understand how they feel. Others take longer. If a mother does not talk easily, wait, and ask again later, or on another day, perhaps somewhere more private. Summary: How to take a feeding history – 0 up to 6 months • Greet the woman and introduce yourself • Use the mother’s and baby’s names (if appropriate) • Ask her to tell you about herself and her baby in her own way (use Listening and learning skills) • Look at the child’s growth chart • Ask the most important questions (use the Job aid: Feeding history – 0 up to 6 months) • Be careful not to sound critical (use Skills for building confidence and giving support) • Try not to repeat questions • Take time to learn about difficult, sensitive things Infant and young child feeding counselling: an integrated course. Course handouts 46 Reasons why a baby may not get enough breast milk Breastfeeding factors Mother: psychological factors Mother: physical condition Baby’s condition Delayed start Feeding at fixed times Infrequent feeds No night feeds Short feeds Poor attachment Bottles, pacifiers Other foods Other fluids (water, teas) Lack of confidence Worry, stress Dislike of breastfeeding Rejection of baby Tiredness Contraceptive pill (estrogen), diuretics Pregnancy Severe malnutrition Alcohol Smoking Retained piece of placenta (rare) Poor breast development (very rare) Illness Abnormality These are common These are not common Reasons why babies cry Discomfort Tiredness Illness or pain Hunger Mother’s food Drugs mother takes Colic “High-needs” babies (dirty, hot, cold) (too many visitors) (changed pattern of crying) (not getting enough milk, growth spurt) (any food, sometimes cow’s milk) (caffeine, cigarettes, other drugs) 4. Other items of key information 47 Causes of refusal to breastfeed Illness, pain, discomfort or sedation (especially in the first week) • Difficult delivery (e.g. brain damage) • Infection • Pain from bruise (vacuum, forceps) • Sedation (drugs given to mother) • Blocked nose • Sore mouth (thrush, teething) Difficulty with breastfeeding technique (especially in the first month) • Separation from mother after delivery • Use of bottles and pacifiers while breastfeeding • Not getting much milk (e.g. poor attachment) • Pressure on back of head when positioning • Delay “coming in”, engorgement • Mother shaking her breast • Restricting the length of feeds • Difficulty coordinating suckle Change that upsets the baby (especially aged 3–12 months) • Separation from mother (e.g. if mother returns to work) • New carer or too many carers • Change in the family routine • Mother ill • Mother has breast problem (e.g. mastitis) • Mother menstruating • Change in smell of mother Apparent refusal • Neonate – rooting • Age 4–8 months – distraction • Above 1 year – self-weaning Infant and young child feeding counselling: an integrated course. Course handouts 48 Helping a mother and baby to breastfeed again Help the mother to do these things: • Keep her baby close – no other carers - Give plenty of skin-to-skin contact at all times, not just at feeding times - Sleep with her baby - Ask other people to help in other ways • Offer her breast whenever her baby is willing to suckle - When her baby is sleepy, or after a cup feed - When she feels her ejection reflex working • Help her baby to take the breast - Express breast milk into the baby’s mouth - Position the baby so that they can attach easily to the breast – try different positions - Avoid pressing the back of the baby’s head or shaking the mother’s breast • Feed her baby by cup - Express her breast milk to keep the supply and keep her breasts healthy - Give her own expressed breast milk if possible; if necessary, give artificial feeds - Avoid using bottles, teats or pacifiers How to prepare a container for expressed breast milk • Choose a cup, glass, jug or jar with a wide mouth. • Wash the cup in soap and water (this can be done the day before). • Pour boiling water into the cup, and leave it for a few minutes. Boiling water will kill most of the germs. • When ready to express milk, pour the water out of the cup. 4. Other items of key information 49 How to express breast milk by hand Teach a mother to do this herself. Do not express her milk for her. Touch her only to show her what to do, and be gentle. Teach her to: • Prepare a clean dry wide mouthed container for the expressed milk. • Wash her hands thoroughly with soap and water every time before she expresses. • She needs to wash her breasts only once a day. Frequent washing, especially with soap, dries the sensitive skin of the areola, increasing the risk of fissures. • Sit or stand comfortably, and hold the container near her breast. • Put her thumb on her breast above the nipple and areola, and her first finger or first two fingers on the breast below the nipple and areola, opposite the thumb. She supports the breast with her other fingers. • Press her thumb and first finger or first two fingers slightly inwards towards the chest wall. She should avoid pressing too far, or she may block the milk ducts. • Press her breast behind the nipple and areola between her first finger or first two fingers and thumb. She should press on the larger ducts beneath the areola. Sometimes in a lactating breast, it is possible to feel the ducts. They are like pods, or peanuts. If she can feel them, she can press on them. • Press and release, press and release. This should not hurt – if it hurts, the technique is wrong. At first no milk may come, but after pressing a few times, milk starts to drip out. It may flow in streams if the oxytocin reflex is active. • Press the areola in the same way from the sides, to make sure that milk is expressed from all segments of the breast. • Avoid rubbing or sliding her fingers along the skin. The movement of the fingers should be more like rolling. • Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the milk. It is the same as the baby sucking only the nipple. • Express one breast for at least 3–5 minutes until the flow slows; then express the other side; and then repeat both sides. She can use either hand for either breast, and change when they tire. • Alternate between breasts 5 or 6 times. Stop expressing when the milk no longer flows. • Explain that to express breast milk adequately takes 20–30 minutes, especially in the first few days when only a little milk may be produced. It is important not to try to express in a shorter time. • If she is expressing colostrum in the first one or two days, collect it in a 2 or 5 mL syringe as it comes from the nipple. A helper can do this. This avoids wasting the milk, which can happen with a small volume of milk in a large container. • Some mothers find pushing slightly inwards towards the chest wall at the same time as compressing the breast helps to increase milk flow. Avoid the following: • Squeezing the nipple – this can block milk flow. • Sliding the fingers on the breast – friction can make the breasts sore. Infant and young child feeding counselling: an integrated course. Course handouts 50 How to store expressed breast milk • Use appropriate storage containers, such as clean plastic or glass jars with tight lids, and, if possible, a refrigerator. For long-term storage, 10 or more containers will be needed. • Put the expressed breast milk into a container, cover it, and put it in as cool a place as possible. The amount of expressed breast milk put into one container should not be more than the amount needed for one feed. • If the amounts of milk expressed are small, add more to the same container during one day, but not after that. • If no refrigerator is available, expressed breast milk can be kept at room temperature, even in a hot climate, for 6 hours. • If there is a refrigerator, store the containers of expressed breast milk in the main compartment for up to 24 hours, or in the freezing compartment for up to 3 months. • Before use, allow frozen milk to defrost in the main compartment, or at room temperature. Warm the milk by standing in a pot of water at hand temperature. • Use unfrozen milk within 2 hours (or give to an older child or throw away). How to feed a baby by cup • Wash your hands. • Wrap the baby in a cloth to hold their hands by their side, and to support their back. • Hold the baby sitting upright or semi-upright on your lap. • Put a cloth in front to protect the baby’s clothes from spilled milk. • Place the estimated amount of milk for one feed into the cup. • Hold the small cup of milk to the baby’s lips. - Tip the cup so that the milk just reaches the baby’s lips. - The cup rests lightly on the baby’s lower lip, and the edges of the cup touch the outer part of the baby’s upper lip. • The baby becomes alert, and opens their mouth and eyes. - A low-birth-weight baby starts to take the milk into their mouth with their tongue. - A full-term or older baby sucks the milk, spilling some of it. • Do not pour the milk into the baby’s mouth. Just hold the cup to their lips and let them take it themself (sipping or lapping). • When the baby has had enough, they will close their mouth and will not take any more. If the baby has not taken the calculated amount, they may take more next time, or you may need to feed them more often. • Measure the baby’s intake over 24 hours – not just at each feed. 4. Other items of key information 51 Amount of milk to give to low-birth-weight babies who cannot breastfeed What milk to give • Choice 1: expressed breast milk (if possible from the baby’s mother, or from a donor); this may be pasteurized or heat-treated according to local policy. • Choice 2: formula milk made up according to the instructions and World Health Organization (WHO) guidelines. Amount of milk to give to babies who weigh less than 2.5 kg (low birth weight) • Start with 60 mL/kg body weight per day. • Increase the total volume by 20 mL/kg per day, until the baby is taking a total of 180 mL/kg per day. • Divide the total into 8–12 feeds, to feed every 2–3 hours. • Continue until the baby weighs 1800 g or more, and is fully breastfeeding. Check the baby’s 24-hour intake. The size of individual feeds may vary. Amount of milk to give to babies who cannot breastfeed What milk to give • Choice 1: expressed breast milk (if possible from the baby’s mother, or from a donor); this may be pasteurized or heat-treated according to local policy. • Choice 2: formula milk made up according to the instructions and World Health Organization (WHO) guidelines. Amount of milk to give Babies who weigh 2.5 kg or more • 150 mL milk/kg body weight per day. • Divide the total into 8 feeds, and give 3-hourly. Babies who weigh less than 2.5 kg (low birth weight) • Start with 60 mL/kg body weight per day. • Increase the total volume by 20 mL/kg per day, until the baby is taking a total of 180–200 mL/kg per day. • Divide the total into 8–12 feeds, to feed every 2–3 hours. • Continue until the baby weighs 1800 g or more, and is fully breastfeeding. Check the baby’s 24-hour intake. The size of individual feeds may vary. Infant and young child feeding counselling: an integrated course. Course handouts 52 Management of flat and inverted nipples • Antenatal treatment - Antenatal treatment is probably not helpful. For example, stretching the nipples or wearing nipple shells does not help. - Most nipples improve around the time of delivery without any treatment. - Help is most important soon after delivery, when the baby starts breastfeeding. • Build the mother’s confidence - Explain that it may be difficult at the beginning, but with patience and persistence she can succeed. - Explain that her breasts will improve and become softer in the week or two after delivery. - Explain that a baby suckles from the breast – not from the nipple. Her baby needs to take a large mouthful of breast. - Explain also that as her baby breastfeeds, they will stretch her nipple out. - Encourage her to give plenty of skin-to-skin contact, and to let her baby explore her breasts. - Let the baby try to attach to the breast on their own, whenever they are interested. - Some babies learn best by themselves. • Help the mother to position her baby - If a baby does not attach well by themself, help the mother to position them so that they can attach better. - Give her this help early, in the first day, before her breast milk “comes in” and her breasts are full. - Sometimes, putting a baby to the breast in a different position makes it easier for them to attach. For example, some mothers find that the underarm position is helpful. - Sometimes, making the nipple stand out before a feed helps a baby to attach. - Stimulating her nipple may be all that a mother needs to do. - There is another method called the syringe method, which we will discuss in this session. - Sometimes, shaping the breast makes it easier for a baby to attach. To shape her breast, a mother supports it from underneath with her fingers, and presses the top of the breast gently with her thumb. • If a baby cannot suckle effectively in the first week or two, help the mother to feed with expressed milk - The mother should express her milk and feed it to her baby with a cup. - Expressing milk helps to keep breasts soft, so that it is easier for the baby to attach to the breast; and it helps to keep up the supply of breast milk. - She should not use a bottle, because that makes it more difficult for her baby to take her breast. - Alternatively, she could express a little milk directly into her baby’s mouth. - Some mothers find that this is helpful. The baby gets some milk straight away, so they are less frustrated. The baby may be more willing to try to suckle. - She should continue to give the baby skin-to-skin contact, and let them try to attach to her breast on their own. 4. Other items of key information 53 Treatment of breast engorgement • Do not “rest” the breast. To treat engorgement, it is essential to remove milk. If milk is not removed, mastitis may develop, an abscess may form and production of breast milk decreases. • If the baby is able to suckle, they should feed frequently. This is the best way to remove milk. Help the mother to position her baby, so that they attach well. Then the baby suckles effectively and does not damage the nipple. • If the baby is not able to suckle, help the mother to express her milk. Sometimes it is only necessary to express a little milk to make the breast soft enough for the baby to suckle. • Before feeding or expressing, stimulate the mother’s oxytocin reflex. Some things that you can do to help her, or she can do are: - put a warm compress on her breasts - massage her back and neck - massage her breast lightly - stimulate her breast and nipple skin - help her to relax. • Sometimes a warm shower or bath makes milk flow from the breasts, so that they become soft enough for the baby to suckle. • After a feed, put a cold compress on her breasts. This will help to reduce oedema. • Build the mother’s confidence. Explain that she will soon be able to breastfeed comfortably again. Summary of differences between full and engorged breasts Full breasts Hot Heavy Hard Milk flowing No fever Engorged breasts Painful Oedematous Tight, especially nipple Shiny May look red Milk NOT flowing (may drip) May be fever for 24 hours Infant and young child feeding counselling: an integrated course. Course handouts 54 Treatment of blocked duct and mastitis The most important part of treatment is to improve the drainage of milk from the affected part of the breast. Look for a cause of poor drainage, and correct it: • Look for poor attachment. • Look for pressure from clothes, usually a tight bra. • Notice what the mother does with her fingers as she breastfeeds. Does she hold the areola, and possibly block milk flow? Whether you find a cause, advise the mother to do these things: • Breastfeed frequently – the best way is to rest with her baby, so that she can respond to the baby and feed them whenever they are willing. • Gently massage the breast while her baby is suckling – show her how to massage over the blocked area, and over the duct that leads from the blocked area, right down to the nipple. This helps to remove the block from the duct. She may notice that a plug of thick material comes out with her milk. (It is safe for the baby to swallow the plug.) • Apply warm compresses to her breast between feeds Sometimes it is helpful to do these things: • Start the feed on the unaffected breast: this may help if pain seems to be preventing the oxytocin reflex. She should change to the affected breast after the reflex starts working. • Breastfeed the baby in different positions at different feeds – this helps to remove milk from different parts of the breast more equally. Show the mother how to hold her baby in the underarm position, or how to lie down to feed them, instead of holding them across the front at every feed. However, do not make her breastfeed in a position that is uncomfortable for her. Sometimes a mother is unwilling to feed her baby from the affected breast, especially if it is very painful. Sometimes a baby refuses to feed from an infected breast, possibly because the taste of the milk changes. In these situations, it is necessary to express the milk. If the milk stays in the breast, an abscess is more likely. Usually, blocked duct or mastitis improves within a day when drainage to that part of the breast improves. However, a mother needs additional treatment if there are any of the following: • severe symptoms when you first see her • a fissure, through which bacteria can enter • no improvement after 24 hours of improved drainage. Treat her, or refer her for antibiotics, analgesics (ibuprofen) and rest. 4. Other items of key information 55 Antibiotic treatment for infective mastitis The most common bacterium found in breast abscesses is Staphylococcus aureus. Therefore, it is necessary to treat breast infections with a penicillinase-resistant antibiotic such as either flucloxacillin or erythromycin. Drug Dose Instructions Flucloxacillin 250 mg orally 6-hourly for 7–10 days Take dose at least 30 minutes before food Erythromycin 250–500 mg orally 6-hourly for 7–10 days Take dose 2 hours after food Alternatives if these are not available Amoxicillin/clavulanate (Augmentin) 875 mg orally Twice daily for 7–10 days Cefalexin 250–500 mg orally 6-hourly for 7–10 days Clindamycin 300 mg orally 6-hourly for 7–10 days Dicloxacillin 500 mg 6-hourly for 7–10 days Cloxacillin 250–500 mg 6-hourly for 7–10 days Treatment of Candida infection of the breast • Gentian violet paint - To baby’s mouth: 0.25%, apply daily or alternate days for 5 days, or until 3 days after the lesions have healed - To mother’s nipples: 0.5% apply daily for 5 days • Nystatin cream 100 000 IU/g: - Apply to nipples 4 times daily after breastfeeds - Continue to apply for 7 days after lesions have healed • Nystatin suspension 100 000 IU/mL: - Apply 1 mL by dropper to child’s mouth 4 times daily after breastfeeds for 7 days, or as long as mother is being treated OR • For mother: fluconazole 150–300 mg orally once, followed by 50–100 mg twice daily for 2–3 weeks • For infant, oral Candida: fluconazole 6 mg/kg orally once, followed by 3 mg/kg per day for 14 days Stop using pacifiers, teats and nipple shields Infant and young child feeding counselling: an integrated course. Course handouts 56 Signs that a baby may not be getting enough breast milk Reliable signs • Poor weight gain (growth slower than standard curves) • Neonate loses more than 10% of birth weight or weighs less than birth weight at 2 weeks • Passing a small amount (fewer than 6 times a day) of concentrated urine – yellow and strong smelling) Possible signs • Baby not satisfied after breastfeeds • Baby cries often • Very frequent breastfeeds • Very long breastfeeds • Baby refuses to breastfeed • Baby has hard, dry or green stools • Baby has infrequent small stools • No milk comes when the mother tries to express • Breasts did not enlarge (during pregnancy) • Milk did not “come in” (after delivery) 4. Other items of key information 57 How to help a woman to increase her supply of breast milk • Try to help the mother and baby at home if possible. Sometimes, it is helpful to admit them to hospital for a week or two, especially if the mother may feel pressure to use a bottle again at home, but only if there is enough skilled help available in hospital. • Discuss with the mother the reason for her poor milk supply. • Explain what she needs to do to increase her supply. Explain that it takes patience and perseverance. • Use all the ways you have learnt to build her confidence. Help her to feel that she can produce breast milk again or increase her supply. Try to see her and talk to her every day at least once. • Make sure that she has enough to eat and drink. • If you know of a locally valued lactogogue, encourage her to take that. • Encourage her to rest more, and to try to relax when she breastfeeds. • Explain that she should keep her baby near her, give them plenty of skin-to-skin contact, and do as much as possible for them herself. Grandmothers can help if they take over other responsibilities – but they should not care for the baby at this time. Later they can do so again. • Explain that the most important thing is to let her baby suckle more often – at least 10 times in 24 hours, more if the baby is willing. - She can offer her breast every 2 hours. - She should let the baby suckle whenever they seem interested. - She should let the baby suckle longer than before at each breast. - She should keep the baby with her and breastfeed at night. - Sometimes it is easiest to get a baby to suckle when they are sleepy. • Make sure that her baby attaches well to the breast. • Discuss how to give other milk feeds, while she waits for breast milk to come. • Show her how to give the other feeds from a cup, not from a bottle. She should not use a pacifier. • If her baby refuses to suckle on an “empty” breast, help her to find a way to give the baby milk while they are suckling, for example, with a dropper or a breastfeeding supplementer (see below). • Discuss how much of the other feeds to give. To start with, she should give the full amount of artificial feed for a baby of their weight (150 mL/kg body weight per day; see box Amount of milk to give to babies who cannot breastfeed, in Session 38: Feeding low-birth-weight and sick babies) or the same amount that the baby has been having before. As soon as some breast milk comes, she can reduce the daily total by 30–60 mL each day. • Divide the total amount of milk for a day by the number of feeds (8,10 or 12), to decide how much to give for each feed, and add a small amount for spillage. • Check the baby’s weight gain and urine output, to make sure that they are getting enough milk. - If the baby is not gaining weight, do not reduce the artificial feed for a few days. - If necessary, increase the amount of artificial milk for a day or two. - Some women can decrease the amount by more than 30–60 mL each day. Infant and young child feeding counselling: an integrated course. Course handouts 58 How to help a family with a baby who cries a lot Look for a cause Listen and learn Help the mother to talk about feelings (guilt, anger) Empathize Take a history Learn about the baby’s feeding and behaviour Learn about the mother’s diet, coffee, smoking, drugs Ask about pressures from family and others Assess a breastfeed Position at the breast, length of feed Examine baby Check for illness or pain (treat or refer as appropriate) Check growth Build confidence and give support Accept Mother’s ideas about the cause of the crying Her feelings about her baby and their behaviour Praise what the mother and baby are doing right (as appropriate) Her baby is growing well, and is not sick Her breast milk provides all that her baby needs Her baby is fine, not naughty or bad Give relevant information The baby has a real need for comfort Crying will decrease when the baby is 3–4 months old Medicines for colic are not recommended Supplementary feeds are not necessary or helpful; artificially fed babies also have colic Comfort suckling at the breast is safe, bottles and pacifiers are not safe Make one or two suggestions (as appropriate) Reduce coffee and tea intake Smoke after not before or during breastfeeds Stop milk, eggs, soy, peanuts (1-week trial, if mother’s diet is adequate) Give only one breast for each feed, or block of time; give the other breast at the next feed, or block of time Feed the baby in an upright position Give practical help Make sure the baby is well attached at the breast Show the mother and others how to hold and carry baby with close contact, gentle movement and gentle abdominal pressure Offer to discuss the situation with the family 4. Other items of key information 59 Seven+ contacts to sustain breastfeeding Contact 1 – Antenatal • The health worker discusses benefits and management of breastfeeding, including about early skin-to-skin contact, to prevent surpirses. • At a second antenatal contact, the health worker discusses more details and the mother’s concerns. Contact 2 – At delivery, in a maternity facility or at home • The baby is placed on the mother’s naked chest immediately after delivery for early skin-to-skin contact, and allowed to crawl to the breast to attach and suckle. Contact 3 – Postnatal 1, within 24 hours • This may be within 6 hours in a maternity facility (by the birth attendant), or on the first day after a home delivery. • The health worker counsels the mother; helps her to position and attach the baby at the breast; and informs her about follow-up support and mothers’ groups. Contact 4 – Postnatal 2, at 2–4 days • The health worker checks the condition of the mother and baby; follows up on previous contacts; observes a breastfeed; counsels the mother about any difficulties; helps with positioning and attachment; explains the feeding pattern; and encourages exclusive breastfeeding. Contact 5 – Postnatal 3, at 5–8 days • The health worker checks the condition of the mother and baby; follows up on previous contacts; observes a breastfeed; counsels the mother about any difficulties; helps with positioning and attachment; explains the feeding pattern; and encourages exclusive breastfeeding. Contact 6 – Postnatal 4, between 14 and 28 days • The health worker checks the condition of the mother and baby; follows up on previous contacts; observes a breastfeed; counsels the mother about any difficulties; helps with positioning and attachment; explains the feeding pattern; and encourages exclusive breastfeeding. Contact 7 – Postnatal 5, between 6 and 8 weeks • This may take place at the mother’s postpartum contact (6 weeks). • The health worker checks the condition of the mother and baby; makes sure that breastfeeding is going well; counsels the mother about any difficulties; and encourages exclusive breastfeeding. Ongoing contacts – after 2 months • These should take place at all growth monitoring and Immunization contacts, or when the mother and baby are in contact for illness or family planning. • The health worker checks that breastfeeding is going well; counsels the mother about any difficulties; encourages exclusive breastfeeding up to 6 months; and, from 6 months, introduction of complementary foods with continued breastfeeding to 2 years. • Mothers who are living with HIV may need referral for further individual counselling, according to national policy. Infant and young child feeding counselling: an integrated course. Course handouts 60 Risks of starting complementary foods too early Adding complementary foods too soon (before 6 months) may: • take the place of breast milk, making it difficult to meet the child’s nutritional needs • result in a diet that is low in nutrients if thin, watery soups and porridges are used because these are easy for babies to eat • increase the risk of illness because fewer of the protective factors in breast milk are consumed • increase the risk of diarrhoea because the complementary foods may not be as clean or as easy to digest as breast milk • increase the risk of wheezing and other allergic conditions because the baby cannot yet digest and absorb non-human protein well • increase the mother’s risk of another pregnancy if breastfeeding is less frequent. Risks of starting complementary foods too late Starting complementary foods too late is also a risk because the child: • does not receive the extra food required to meet their growing needs • grows and develops more slowly • might not receive the nutrients needed to avoid malnutrition and deficiencies, such as anaemia from lack of iron. Ways to enrich a child’s food Foods can be made more energy and nutrient rich in a number of ways: • For a porridge or other staple: - Prepare with less water and make a thicker porridge. Do not make the food thin and runny. - Toast cereal grains before grinding them into flour. Toasted flour does not thicken so much, so less water is needed to make porridge. • For a soup or stew: - Take out a mixture of the solid pieces in the soup or stew, such as beans, vegetables, meat and the staple. Mash this to a thick puree and feed it to the child instead of the liquid part of the soup. • Add energy- or nutrient-rich food to the porridge, soup or stew, to enrich it. This enriching is particularly important if the soup is mostly liquid with few beans, vegetables or other foods in it. - Replace some (or all) of the cooking water with fresh or soured milk, coconut milk or cream. - Add a spoonful of milk powder after cooking. - Mix legume, pulse or bean flour with the staple flour before cooking. - Stir in a paste made from nuts or seeds, such as groundnut paste (peanut butter) or sesame seed paste (tahini/sim sim). - Add a spoonful of margarine, ghee or oil. 4. Other items of key information 61 Iron absorption The amount of iron that a child absorbs from food depends on: • the amount of iron in the food • the type of iron (iron from meat and fish is better absorbed than iron from plants and eggs) • the types of other foods present in the same meal (some increase iron absorption and others reduce absorption) • whether the child has anaemia (more iron is absorbed if the child has anaemia). Eating these foods at the same meal increases the amount of iron absorbed from eggs and plant foods such as cereals, pulses, seeds and vegetables: • foods that are rich in vitamin C, such as tomato, broccoli, guava, mango, pineapple, papaya, orange, lemon and other citrus fruits • small amounts of the flesh or organs/offal of animals, birds, fish and other sea foods. Iron absorption is decreased by: • drinking teas and coffee • foods that are high in fibre such as bran • foods that are rich in calcium.1 Fluid needs of the young child • Water is good for thirst. A variety of pure fruit juices can be used also. Too much fruit juice may cause diarrhoea and may reduce the child’s appetite for foods. • Drinks that contain a lot of sugar may actually make the child thirstier, as their body has to deal with the extra sugar. If packaged juice drinks are available in your area, find out which ones are pure juices and which ones have added sugar. Fizzy drinks (sodas) are not suitable for young children. • Teas and coffee reduce the iron that is absorbed from foods. If they are given, they should not be given at the same time as food, or within 2 hours before or after food. • Sometimes a child is thirsty during a meal. A small drink will satisfy the thirst and they may then eat more of their meal. • Drinks should not replace foods or breastfeeding. If a drink is given with a meal, give only small amounts and leave most until the end of the meal. Drinks can fill up the child’s stomach, so that they do not have room for foods. • Remember that children who are not receiving breast milk need special attention and special recommendations. A non-breastfed child aged 6 up to 24 months needs approximately 2–3 cups of water per day in a temperate climate, and 4–6 cups of water per day in a hot climate. This water can be incorporated into porridges or stews, but clean water should also be offered to the child several times a day, to ensure that the infant’s thirst is satisfied. 1 Foods that are rich in calcium such as milk and cheese inhibit iron absorption, but are needed for calcium intake. Infant and young child feeding counselling: an integrated course. Course handouts 62 Amounts of food to offer Age Texture Frequency Amount of food an average child will usually eat at each meal1 6–8 months Start with thick porridge, well-mashed foods Continue with mashed family foods 2–3 meals per day plus frequent breastfeeds Depending on the child’s appetite, 1–2 snacks may be offered Start with 2–3 tablespoonfuls per feed increasing gradually to ½ of a 250 mL cup 9–11 months Finely chopped or mashed foods, and foods that baby can pick up 3–4 meals plus breastfeeds Depending on the child’s appetite, 1–2 snacks may be offered ½ of a 250 mL cup/bowl 12–23 months Family foods, chopped or mashed if necessary 3–4 meals plus breastfeeds Depending on the child’s appetite, 1–2 snacks may be offered ¾ to one 250 mL cup/bowl If the baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day. Responsive feeding practices Assist children to eat, being sensitive to their cues or signals Feed slowly and patiently, encourage but do not force Talk to children during feeding, with eye-to-eye contact Responsive feeding techniques • Respond positively to the child, with smiles, eye contact and encouraging words • Feed the child slowly and patiently, with good humour • Try different food combinations, tastes and textures, to encourage eating • Wait when the child stops eating and then offer again • Give finger foods that the child can feed themself • Minimize distractions if the child loses interest easily • Stay with the child through the meal and be attentive 1 Adapt the chart to use a suitable local cup/bowl to show the amount. The amounts assume an energy density of 0.8–1.0 kcal/g. 4. Other items of key information 63 Five keys to safer food Keep clean • Wash your hands before handling food and often during food preparation. • Wash your hands after going to the toilet, changing the baby or contact with animals. • Wash very clean all surfaces and equipment used for food preparation or serving. • Protect kitchen areas and food from insects, pests and other animals. Separate raw and cooked foods • Separate raw meat, poultry and seafood from other foods. • Use separate equipment and utensils, such as knives and cutting boards, for handling raw foods. • Store foods in covered containers, to avoid contact between raw and prepared foods. Cook thoroughly • Cook food thoroughly, especially meat, poultry, eggs and seafood. • Bring foods such as soups and stews to boiling point. For meat and poultry, make sure juices are clear not pink. • Reheat cooked food thoroughly. Bring to the boil or heat until too hot to touch. Stir while reheating. Keep food at safe temperatures • Do not leave cooked food at room temperature for more than 2 hours. • Do not store food too long, even in a refrigerator. • Do not thaw frozen food at room temperature. • Food for infants and young children should ideally be freshly prepared and not stored at all after cooking. Use safe water and raw materials • Use safe water or treat it to make it safe. • Choose fresh and wholesome foods. • Use pasteurized milk. • Wash fruits and vegetables in safe water, especially if eaten raw. • Do not use food beyond its expiry date. Adapted from WHO Food Safety Programme. Five keys to safer food. Geneva: World Health Organization; 2001 (WHO/SDE/PHE/FOS/01.1; http://apps.who.int/iris/ bitstream/10665/66735/1/WHO_SDE_PHE_FOS_01.1.pdf). Infant and young child feeding counselling: an integrated course. Course handouts 64 Feeding the child who is ill • Encourage the child to drink and to eat – with lots of patience • Feed small amounts frequently • Give foods that the child likes • Give a variety of nutrient-rich foods • Continue to breastfeed – often ill children breastfeed more frequently Feeding during recovery • Feed an extra meal • Give an extra amount • Use extra energy- and nutrient-rich foods • Feed with extra patience and love • Give extra breastfeeds 4. Other items of key information 65 Key messages for complementary feeding 1. Breastfeeding for 2 years or longer helps a child to develop and grow strong and healthy 2. Starting other foods in addition to breast milk at 6 completed months helps a child to grow well 3. Foods that are thick enough to stay on the spoon give more energy to the child 4. Animal-source foods are especially good for children, to help them grow strong and lively 5. Peas, beans, lentils, nuts and seeds are good for children 6. Dark-green leaves and yellow-coloured fruits and vegetables help the child to have healthy eyes and fewer infections 7. A growing child needs 2–4 meals a day, plus 1–2 snacks if hungry: give a variety of foods 8. A growing child needs increasing amounts of food 9. A young child needs to learn to eat: encourage and give help … with lots of patience 10. Encourage the child to drink and eat during illness, and provide extra food after illness to help them recover quickly Infant and young child feeding counselling: an integrated course. Course handouts 66 4. Other items of key information 67 Conditions needed for safe use of replacement feeding 1. Safe water and sanitation are assured at household level and in the community. 2. The mother or other caregiver can reliably provide sufficient infant formula milk to support normal growth and development. 3. The mother or caregiver can prepare the infant formula milk cleanly and frequently enough, so that it is safe and carries a low risk of diarrhoea and malnutrition. 4. The mother or caregiver can, in the first 6 months, exclusively give infant formula milk. 5. The family is supportive of this practice. 6. The mother or caregiver can access health care that offers comprehensive child health services. Infant and young child feeding counselling: an integrated course. Course handouts 68 How to prepare commercial infant formula milk* 1. Before you begin to prepare a commercial infant formula milk, clean and disinfect the surface you are going to use. 2. Wash your hands with soap and water and dry them using a clean and dry cloth or a single-use paper napkin. 3. Only make enough commercial infant formula milk for one feed at a time. 4. Make ...... mL for each feed. Feed the baby ...... times every 24 hours. 5. Boil a sufficient volume of safe clean water: • if using an automatic kettle, wait until the kettle switches itself off • if using a pan of water, make sure the water is bubbling well before you turn the heat off • never use a microwave to boil the water because the heat may be unevenly distributed. 6. Allow the water to cool. Do not leave it longer than 30 minutes. The water should be at least 70 °C when it is used, not cooler. As mothers are not likely to have thermometers to measure the water temperature, tell them to use the waer within 30 minutes of it boiling. 7. Be careful not to scald yourself. Pour the appropriate amount of boiled water into a clean and sterilized feeding cup (or bottle). Always check to see that the water level is correct. 8. Loosely fill the spoon or measure (provided with the tin) with the milk powder and level it off, using the flat dry edge of a knife or level provided. Do not squash the powder down in the spoon. 9. Add the exact amount of formula powder to the water, as instructed on the label of the tin. Adding more or less formula powder than insructed can make the baby ill. • If using a bottle, gently shake the contents until they are thoroughly mixed. • If using a feeding cup, mix thoroughly with a sterlized spoon. 10. Immediately after preparation, quickly cool the feeds to a feeding temperature, by holding the bottle or feeding cup under a cold running tap. 11. Dry the outside of the feeding cup or bottle. 12. Check the feeding temperature of the feed. 13. Feed the baby using a cup (or bottle). 14. Discard any feed not used within 2 hours. 15. Wash the utensils. *These instructions are in the Guidance on the use of counselling cards, Counselling card 11. 4. Other items of key information 69 Approximate amounts of commercial infant formula milk needed by month Month Number of 500 g tins needed per month Number of 450 g tins needed per month Number of 400 g tins needed per month First month 4 5 5 Second month 6 6 8 Third month 7 8 9 Fourth month 7 8 9 Fifth month 8 8 10 Sixth month 8 9 10 Total for 6 months (approximately) 40 × 500 g (20 kg) 44 × 450 g (approx 20 kg) 51 × 400 g (approx 20 kg) Infant and young child feeding counselling: an integrated course. Course handouts 70 How to heat-treat expressed breast milk* 1. Before you begin to express or heat-treat your expressed breast milk, clean and disinfect the surface you are going to use. 2. Wash your hands with soap and water and dry them using a clean and dry cloth or a single-use paper napkin. 3. Before you begin to heat-treat the breast milk, wash the utensils you will use to express and heat-treat the milk. Use clean warm water and soap. 4. Boil these utensils after washing them. 5. Express enough milk for that individual feed, into a suitable container. 6. Put your expressed breast milk, between 50 mL and 150 mL, into a small heatproof jar. If you have more than 150 mL, use two jars. Do not overfill the jar. 7. Place the jar of milk into the pan of water; the water should be about two fingers’ width above the level of the milk, so that all the milk is heated. 8. Heat the water in the pan until it reaches a “rolling” boil; this is when the water has large bubbles. This takes a very short time. 9. Remove the jar from the boiling water immediately after the water comes to the boil (taking care not to burn yourself). 10. Put the jar in the container of cool water, or let it stand free to cool until it reaches room temperature. 11. Put a lid on the jar, to protect the milk. 12. Use the milk within 1 hour. *These instructions are in the Guidance on the use of counselling cards, Counselling card 10. 71 5. Demonstrations and scripts for role-play Session 5: Listening and learning Demonstration 5.B Closed questions to which the mother can answer “Yes” or “No” Health worker: Good morning, (name). I am (name), the community midwife. Is (child’s name) well? Mother: Yes, thank you. Health worker: Are you breastfeeding him? Mother: Yes. Health worker: Are you having any difficulties? Mother: No. Health worker: Is he breastfeeding very often? Mother: Yes. ¤ Ask: What did the health worker learn from this mother? Comment: The health worker got “yes” and “no” for answers and didn’t learn much. It can be difficult to know what to say next. Demonstration 5.C Open questions Health worker: Good morning, (name). I am (name), the community midwife. How is (child’s name)? Mother: She is well, and she is very hungry. Health worker: Tell me, how are you feeding her? Mother: She is breastfeeding. I just have to give her one bottle feed in the evening. Health worker: What made you decide to do that? Mother: She wants to feed too much at that time, so I thought that my milk is not enough. ¤ Ask: What did the health worker learn from this mother? Comment: The health worker asked open questions. The mother could not answer with a “yes” or a “no”, and she had to give some information. The health worker learnt much more. Demonstration 5.D Starting and continuing a conversation Health worker: Good morning, (name). How are you and (child’s name) getting on? Mother: Oh, we are both doing well, thank you. Health worker: How old is (child’s name) now? Mother: He is 2 days old today. Health worker: What are you feeding him on? Mother: He is breastfeeding, and having drinks of water. Health worker: What made you decide to give the water? Mother: There is no milk in my breasts, and he doesn’t want to suck. ¤ Ask: What did the health worker learn from this mother? Comment: The health worker asked an open question, which did not help much. Then she asked two specific questions, and then followed up with an open question. Although the mother said at first that she and the baby were well, the health worker later learnt that the mother needed help with breastfeeding. Infant and young child feeding counselling: an integrated course. Course handouts 72 Demonstration 5.E Using responses and gestures that show interest Health worker: Good morning, (name). How is (child’s name) now that she has started solids? Mother: Good morning. She’s fine, I think. Health worker: Mmm. (nods, smiles) Mother: Well, I was a bit worried the other day, because she vomited. Health worker: Oh dear! (raises eyebrows, looks interested) Mother: I wondered if it was something in the stew that I gave her. Health worker: Aha! (nods sympathetically). ¤ Ask: How did the health worker encourage the mother to talk? Comment: The health worker asked a question to start the conversation. Then she encouraged the mother to continue talking, with responses and gestures. Demonstration 5.F Continuing to ask for facts Health worker: Good morning, (name). How are you and (child’s name) today? Mother: He wants to feed too much – he is taking my breast all the time! Health worker: About how often would you say? Mother: About every half an hour. Health worker: Does he want to suck at night too? Mother: Yes. ¤ Ask: What did the health worker learn from the mother? Comment: The health worker asked factual questions, and the mother gave less and less information. Demonstration 5.G Reflecting back Health worker: Good morning, (name). How are you and (child’s name) today? Mother: She wants to feed too much – she is taking my breast all the time! Health worker: (Child’s name) is feeding very often? Mother: Yes. This week she is so hungry. I think that my milk is drying up. Health worker: She seems more hungry this week? Mother: Yes, and my sister is telling me that I should give her some bottle feeds as well. Health worker: Your sister says that she needs something more? Mother: Yes. Which formula is best? ¤ Ask: What did the health worker learn from the mother? Comment: The health worker reflected back what the mother said, so the mother gave more information. 5. Demonstrations and scripts for role-play 73 Demonstration 5.H Sympathy Health worker: Good morning, (name). How are you and (child’s name) today? Mother: (Child’s name) is not feeding well, I am worried he is ill. Health worker: I understand how you feel. When my child was ill, I was so worried. I know exactly how you feel. Mother: What was wrong with your child? ¤ Ask: Do you think the health worker showed sympathy or empathy? Comment: Here the focus moved from the mother to the health worker. This was sympathy, not empathy. Let us hear this again, with the focus on the mother and empathizing with her feelings. Demonstration 5.I Empathy Health worker: Good morning, (name). How are you and (child’s name) today? Mother: (Child’s name) is not feeding well, I am worried he is ill. Health worker: You are worried about him? Mother: Yes, some of the other children in the village are ill and I am frightened he may have the same illness. Health worker: It must be very frightening for you. ¤ Ask: Do you think the health worker showed sympathy or empathy? Comment: Here the health worker used the skill of empathy twice. She said “You are worried about him” and “It must be very frightening for you”. In this second version, the mother and her feelings are the focus of the conversation. Demonstration 5.J Sympathy Health worker: Good morning, (name). You wanted to talk to me about something? (smiles) Mother: I tested for HIV last week and am positive. I am worried about my baby. Health worker: Yes, I know how you feel. My sister has HIV. ¤ Ask: Do you think the health worker showed sympathy or empathy? Comment: Here the focus moved from the mother to the sister of the health worker. This was sympathy, not empathy. Let us hear this again, with the focus on the mother and empathizing with her feelings. Demonstration 5.K Empathy Health worker: Good morning, (name). You wanted to talk to me about something? (smiles) Mother: I tested for HIV last week and am positive. I am worried about my baby. Health worker: You’re really worried about what’s going to happen. Mother: Yes I am. I don’t know what I should do? ¤ Ask: Do you think the health worker showed sympathy or empathy? Comment: In the second version, the health worker concentrated on the mother’s concerns and worries. The health worker responded by saying “You’re really worried about what’s going to happen”. This was empathy. Infant and young child feeding counselling: an integrated course. Course handouts 74 Demonstration 5.L Asking facts Health worker: Good morning, (name). How are you and (child’s name) today? Mother: She is refusing to breastfeed since he started eating porridge and other foods last week – she just pulls away from me and doesn’t want me! Health worker: How old is (child’s name) now? Mother: She is 7 months old. Health worker: And how much porridge does she eat during a day? ¤ Ask: What did the health worker learn about the mother’s feelings? Comment: The health worker asked about facts and ignored the mother’s feelings. The information the health worker learnt did not help the health worker to assist the mother with her worry that the baby won’t breastfeed since other foods were offered. The health worker did not show empathy. Let us hear this again, with the focus on listening to the mother. Demonstration 5.M Empathy Health worker: Good morning, (name). How are you and (child’s name) today? Mother: She is refusing to breastfeed since she started eating porridge and other foods last week – she just pulls away from me and doesn’t want me! Health worker: It’s very upsetting when your baby doesn’t want to breastfeed. Mother: Yes, I feel so rejected. ¤ Ask: What did the health worker learn about the mother’s feelings this time? Comment: In this second version, the mother’s feelings were listened to at the beginning. Then the health worker was able to focus on what the mother sees as the problem. Demonstration 5.N Using judging words Health worker: Good morning. Is (name) breastfeeding normally? Mother: Well – I think so. Health worker: Do you think that you have enough breast milk for him? Mother: I don’t know … I hope so, but maybe not ... (she looks worried) Health worker: Has he gained weight well this month? Mother: I don’t know… Health worker: May I see his growth chart? ¤ Ask: What did the health worker learn about the mother’s feelings? Comment: The health worker has not learnt anything useful, but has made the mother very worried. 5. Demonstrations and scripts for role-play 75 Demonstration 5.O Avoiding judging words Health worker: Good morning. How is breastfeeding going for you and (child’s name)? Mother: It’s going very well. I haven’t needed to give her anything else. Health worker: How is her weight? Can I see her growth chart? Mother: Nurse said that she gained more than half a kilo this month. I was pleased. Health worker: She is obviously getting all the breast milk that she needs. ¤ Ask: What did the health worker learn about the mother’s feelings? Comment: This time the health worker learnt what she needed to know without making the mother worried. The health worker used open questions to avoid using judging words. Infant and young child feeding counselling: an integrated course. Course handouts 76 Session 8: Building confidence and giving support Demonstration 8.A Accepting what a mother thinks Mother: Health worker: ¤ Ask: Comment: Mother: Health worker: ¤ Ask: Comment: Mother: Health worker: ¤ Ask: Comment: My milk is thin and weak, and so I have to give bottle feeds. Oh no! Milk is never thin and weak. It just looks that way. (nods, smiles) Did the health worker agree, disagree or accept? This is an inappropriate response, because it is disagreeing. My milk is thin and weak, so I have to give bottle feeds. Yes – thin milk can be a problem. Did the health worker agree, disagree or accept? This is an inappropriate response because it is agreeing. My milk is thin and weak, so I have to give bottle feeds. I see. You are worried about your milk. Did the health worker agree, disagree or accept? This is an appropriate response because it shows acceptance. Demonstration 8.B Accepting what a mother feels Mother (in tears): Health worker: ¤ Ask: Comment: Mother (in tears): Health worker: ¤ Ask: Comment: It is terrible, (child’s name) has a cold and his nose is completely blocked and he can’t breastfeed. He just cries and I don’t know what to do. Don’t worry, your baby is doing very well. Was this an appropriate response? This is an inappropriate response. By saying things such as “don’t worry” or “don’t cry”, you make a mother feel it is wrong to be upset and this reduces her confidence. It is terrible, (child’s name) has a cold and his nose is completely blocked and he can’t breastfeed. He just cries and I don’t know what to do. You are upset about (child’s name) aren’t you? Was this an appropriate response? This is an appropriate response because it accepted how the mother felt and made her feel that it was alright to be upset. Notice how, in this example, empathizing was used to show acceptance. So this is another example of using a Listening and learning skill to show acceptance. 5. Demonstrations and scripts for role-play 77 Demonstration 8.C Using simple language Health worker: Mother: Health worker: ¤ Ask: Comment: Good morning (name). What can I do for you today? Can you tell me what foods to give my baby, now that she is 6 months old? I’m glad that you asked. Well now, the situation is this. Most children need more nutrients than breast milk alone when they are 6 months old because breast milk has less than 1 mg of absorbable iron and breast milk has about 450 calories, so less than the 700 calories that are needed. The vitamin A needs are higher than what is provided by breast milk and also the zinc and other micronutrients. However, if you add foods that aren’t prepared in a clean way, it can increase the risk of diarrhoea and if you give too many poor-quality foods the child won’t get enough calories to grow well. What did you observe? The health worker provided too much information. It was not relevant to the mother at this time. She used words that were unlikely to be familiar. Demonstration 8.D Using simple language Health worker: Mother: Health worker: ¤ Ask: Comment: Good morning (name). How can I help you? Can you tell me what foods to give my baby, now that she is 6 months old? You are wondering about what is best for your baby. I’m glad you have come to talk about it. It is usually a good idea to start with a little porridge to get him used to the taste of different foods. Just two spoons twice a day to start with. What did you observe this time? The health worker explained about starting complementary foods in a simple way. Infant and young child feeding counselling: an integrated course. Course handouts 78 Sessions 13 and 25: Assessing a breastfeed 1 and 2 Demonstrations 13.A and 25.A Assessing a breastfeed Mother A Sits comfortably and relaxed Happy and pleased with the baby Looks at the baby, talks to her Fondles and touches the baby lovingly Holds the baby close, facing her breast Supports the baby’s whole body Holds the baby calmly and securely and looks confident Mother B Uncomfortable and tense Sad and not interested in the baby Looks away from the baby, does not talk to her Does not touch the baby lovingly Holds the baby loosely, turned away, neck twisted Supports only the baby’s head and shoulders Holds the baby nervously, not looking confident May shake or prod the baby to make her suckle 5. Demonstrations and scripts for role-play 79 Sessions 15 and 31: Taking a feeding history – 0 up to 6 months 1 and 2 Demonstration 15.A and 31.A Taking a feeding history – 0 up to 6 months Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Good morning, I am Nurse Jane. May I ask your name, and your baby’s name? Good morning, nurse; I am Mrs Green and this is my daughter Lucy. She is lovely – how old is she? She is 5 months now. Yes – and she is taking an interest in what is going on, isn’t she? Tell me, what milk have you been giving her? Well, I started off breastfeeding her, but she is so hungry and I never seemed to have enough milk, so I had to give her bottle feeds as well. Oh dear, it can be very worrying when a child is always hungry. You decided to start bottle feeds? What are you giving her? Well, I put some milk in the bottle and then mix in a spoonful or two of cereal. When did she start these feeds? Oh, when she was about 2 months old. About 2 months. How many bottles do you give her each day? Oh, usually two – I mix up one in the morning and one in the evening, and then she just sucks it when she wants to – each bottle lasts quite a long time. So she just takes the bottle little by little? What kind of milk do you use? Yes – well, if I have formula, I use some of that; or else I just use cow’s milk and mix in some water, or sweetened milk, because they are cheaper. She likes the sweet milk! Formula is very expensive isn’t it? Tell me more about the breastfeeding. How often is she doing that now? Oh she breastfeeds when she wants to – quite often in the night, and about 4 or 5 times in the day – I don’t count. She likes it for comfort. She breastfeeds at night? Yes she sleeps with me. Oh that makes it easier, doesn’t it? Did you have any other difficulties with breastfeeding, apart from worrying about not having enough? No, it wasn’t difficult at all. Do you give her anything else yet? Any other foods or drinks? No – I won’t give her food for a long time yet. She is quite happy with the bottle feeds. Can you tell me how you clean the bottles? I just rinse them out with hot water. If I have soap I use that, but otherwise just water. Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: OK. Now can you tell me about how Lucy is. Has she got a growth chart? Can I see it? [mother hands over growth chart] Thank you, now let me see…. She was 3.5 kg and 51 cm when she was born, she was 5.5 kg and 59 cm when she was 2 months old, and now she is 6.0 kg and 66 cm. You can see that she gained weight fast for the first 2 months, but it is a bit slower since then. Can you tell me whether Lucy has had any illnesses? Well, she had diarrhoea twice last month, but she seemed to get better. Her stools are normal now. Can I ask about the earlier days – how was your pregnancy and delivery? They were normal. What did they tell you about feeding her when you were pregnant, and soon after she was born? Did anyone show you what to do? Nothing – they told me to breastfeed her, but that was all. The nurses were so busy, and I came home after one day. They just told you to breastfeed? Yes – but I didn’t have any milk in my breasts even then, so I gave her some glucose water until the milk started. Infant and young child feeding counselling: an integrated course. Course handouts 80 Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: It is confusing isn’t it when your breasts feel soft after delivery? You need help then, don’t you? Yes. Can I ask about you? How old are you? Sure – I am 22. And how is your health? I am fine. How are your breasts? I have had no trouble with my breasts. May I ask whether you are thinking about another pregnancy at any time? Have you thought about family planning? No – I haven’t thought about it – I thought that you can’t get pregnant when you are breastfeeding. Well, it is possible if you are also giving other feeds. We will talk about it more later if you like. Is Lucy your first baby? Yes. And I do not want another one just yet. Tell me about how things are at home – are you going out to work? No – I am a housewife now. I may try to find a job later when Lucy is older. Who else do you have at home to help you? Lucy’s father is with me. He has a job as a driver and he is very fond of Lucy, but he thinks she should not breastfeed at night – he thinks she breastfeeds too much and he wants her to sleep in another bed. But I am not sure ... He says that too much breastfeeding is what gives her diarrhoea. 15/2 15/3 5. Demonstrations and scripts for role-play 81 Session 37: Counselling practice Counselling story 1: “My milk is not good. (Baby’s name) cries too much.” Age of baby: 3 months Weight aged 2 weeks: 2.9 kg Weight today: 3.7 kg Baby’s feeding now: Exclusive breastfeeding. Baby sleeps with you at night, and breastfeeds when he can during the day – maybe 3 times. Baby’s health and behaviour: He is well. He seems to cry a lot. Your 7-year-old daughter carries him round much of the day, and he sucks on a pacifier. You have no idea how many times he urinates – you are not there to see. You wash about 3 or 4 nappies or cloths a day, but he may not get changed every time he wets. Pregnancy, delivery, early feeds: Baby born at home. Breastfed from soon after delivery. Mother’s condition: You are aged 32, and healthy. You do not smoke or drink. You are not using any family planning method. You feel tired, and think that bottle feeding might help. Previous infant feeding: 5 babies, all breastfed; 3 at present under 5 years of age. Family and social situation: You are very busy with housework and work in the fields. Your mother-in-law expects you to do everything, and it is difficult to find time to feed the baby. Counselling story 2: “I will bottle feed this next baby. I am not able to breastfeed.” Antenatal visit Mother’s condition: You are aged 28, and healthy. You are 6 months pregnant. Before you had your first baby you wanted very much to breastfeed. Your breasts and nipples are average in size. Previous infant feeding: You have 2 children already. Your first baby was born by caesarean section, after an obstructed labour. The baby was put into the nursery for 5 days, and was given some bottle feeds. You tried to breastfeed her after 5 days, but she did not want to suckle, and cried every time you put her to the breast. You could not get her to suckle properly, and the nurses advised you to continue giving bottles. You were very disappointed, and felt that you had failed. The baby was often ill with diarrhoea during the first year of life. Your second baby was born vaginally. No one talked to you about breastfeeding. You put the baby to the breast during the first day, but you had very sore nipples. You struggled on despite the pain, for 4 weeks. Then your nipples were so cracked and bleeding that you gave him a bottle for a few days to allow the nipples to heal. Then he refused to start breastfeeding again. Family and social situation: You are a nurse in a children’s ward. You will take your maternity leave, and you have saved up some more leave, so that you can stay home for 4 months after the baby is born. You live very near the hospital, and your sister stays with you and looks after the children while you work. Infant and young child feeding counselling: an integrated course. Course handouts 82 Counselling story 3: “(Baby’s name) is always crying and my breast milk is drying up.” Age of baby: 10 weeks Birth weight: 2.8 kg Weight at 1 month: 3.4 kg Weight now: 3.8 kg Baby’s feeding now: You breastfeed 4–5 times a day and sometimes once in the night. You also give two bottle feeds of formula milk each day. You put 1/2 scoops of milk powder into each bottle. You started this when the baby was 4 weeks old. He also has a pacifier to stop him crying so much. Baby’s health and behaviour: The baby cried a lot when he was small. He still cries a lot, but usually quietens when you give him a bottle. He had diarrhoea for a few days last month, but that has stopped. He suckles less at the breast now than he did before. Pregnancy, delivery, early feeds: Delivered at home. Breastfed from the first day. Mother’s condition: You are aged 23 and healthy. You had an intrauterine device (IUD) fitted at 6 weeks. Previous infant feeding: This is your first baby. Family and social situation: You are a housewife. Your mother lives nearby and helps. Your husband complains when the baby cries. He wants you to give bottle feeds to keep the baby quiet so that he can sleep at night. A friend of his at work suggested it. Counselling story 4: “(Baby’s name) is very thin and she is constipated.” Age of baby: 2 months Birth weight: 2.8 kg Weight at 1 month: 3.2 kg Weight now: 3.5 kg Baby’s feeding now: You feed the baby formula milk from a bottle. You make about 3–4 bottles a day. You put about 2 spoons of milk powder into each bottle. When you do not have any formula milk, you make a feed from cereal and water. You breastfeed the baby sometimes, for comfort, but there is only a little milk coming out. Baby’s health and behaviour: Your baby cries a lot, but she is very small and weak. She does not pass stools very often, and they are small and dry. You think she is constipated. She urinates about 3–4 times a day, sometimes only twice, and her urine is sometimes dark yellow. Pregnancy, delivery, early feeds: Normal. Baby delivered in hospital at night. You put her to the breast the next morning, after the doctor checked her. There was no milk coming out, and the baby was not very interested in suckling. So you started bottle feeds while you waited for your breast milk to come, but it did not come in properly. Mother’s condition: You are aged 19, and healthy. You do not smoke or drink. You will start on contraceptive pills when your periods start again. Previous infant feeding: This is your first baby. Family and social situation: You are a housewife. Your husband is a driver and is away from home a lot. Your mother has been helping you to bottle feed the baby. 5. Demonstrations and scripts for role-play 83 Counselling story 5: “(Baby’s name) cannot suckle properly.” Age of baby: 4 weeks Birth weight: 1.5 kg Weight aged 3 weeks: 1.80 kg Weight today: 1.95 kg Baby’s feeding now: Breastfeeding only. Baby’s health and behaviour: He suckles slowly and takes a long time, and he keeps stopping to rest in the middle of a feed. Pregnancy, delivery, early feeds: He was born preterm, very weak, at about 32 weeks, and was in the special care unit for 2 weeks. He was fed by nasogastric tube for 1 week, and then by cup. You stayed in the hospital, and expressed your milk 3-hourly for your baby. You expressed enough for him at that time. He started breastfeeding about 1 week ago. Mother’s condition: You are 27 and only became pregnant after 3 years of marriage. You think that you do not have enough breast milk – your breasts do not seem very full. You are very upset, and feel that you are failing as a mother. Previous infant feeding: This is your first baby. Family and social situation: Your husband is a farmer, and wants lots of strong children. He has not shown much interest in this sick, small baby. Counselling story 6: “My milk is drying up, and I will have to bottle feed (baby’s name). Which formula is best?” Age of baby: 2 months Birth weight: 3.5 kg Weight now: 5.3 kg Baby’s feeding: Breastfeeding only until now. Baby’s health and behaviour: Very healthy. Now sleeps in a cot. You get up to feed her about once in the night, if she cries. She passes urine at least 6 times a day. Pregnancy, delivery, early feeds: Normal pregnancy; delivered in hospital. Your baby stayed in the nursery. You did not see her for 24 hours. Then she was brought to you for 3-hourly for breastfeeding. She may have had a bottle while she was in the nursery. Mother’s condition: You are aged 18. You would not mind breastfeeding, if it is easy. But your friend bottle feeds and tells you that you are silly to bother. You are worried that if you continue to breastfeed, your breasts may sag, and your partner will lose interest in you. You want to be able to go out at night. Previous infant feeding: This is your first baby. Family and social situation: You live in town. Your baby’s father has a job as a labourer, and he gives you money, but not very regularly. Your parents live far away, and you do not see them often. Infant and young child feeding counselling: an integrated course. Course handouts 84 Counselling story 7: “(Baby’s name) often has diarrhoea – should I stop breastfeeding?” Age of baby: 11 months Weight at 2 months: 4.5 kg Weight at 6 months: 7.5 kg Weight at 8 months: 7.5 kg Weight today: 8.2 kg Baby’s feeding now: He breastfeeds on demand. He sleeps with you and breastfeeds at night. He is also taking rice and vegetables 3 times a day. Baby’s health and behaviour: Several times he has had diarrhoea, and the health worker has shown you how to make oral rehydration fluids. She has advised you to continue giving him rice and other food. The diarrhoea is better now, but you think that it is time to stop breastfeeding. Perhaps breastfeeding causes the diarrhoea. Pregnancy, delivery, and early feeds: Born at home, and started breastfeeding soon after delivery. No problems. Mother’s condition: You are aged 29 and healthy. You have Depo-Provera injections for family planning. You are not worried about being pregnant. Previous infant feeding: 4 previous children, all breastfed for about 2 years. Family and social situation: Your husband is a subsistence farmer, and you live on cereals and vegetables. You get water from a nearby stream. Counselling story 8: “My breast milk is getting less. What can I do?” Age of baby: 3 months Birth weight: 4.0 kg Weight at 1 month: 5.0 kg Weight at 2 months: 5.6 kg Weight now: 6.2 kg Baby’s feeding now: You breastfeed whenever you are at home. When you are at work, she has bottle feeds of formula milk. You started bottle feeds when you went back to work last month. Sometimes she has bottle feeds at night too. Baby’s health and behaviour: She is very well at the moment. Pregnancy, delivery, early feeds: She was born in hospital, delivered by forceps. She was kept in the nursery for about 6 hours, but then roomed-in with you. You needed help to start breastfeeding, but since then there have been no problems. Mother’s condition: You are aged 23, and healthy. You smoke about 15 cigarettes a day. You had an IUD fitted soon after delivery. You want very much to breastfeed longer. Previous infant feeding: You had one previous child now aged 5 years. You tried to continue breastfeeding while you were at work. But you had leaking of breast milk when you were on duty, and then your baby refused to suckle. You were really upset about this, and feel that you failed your baby, even though she did not get ill. Family and social situation: You returned to work in an office when your baby was 2 months old. Your sister cares for your children while you are at work. 5. Demonstrations and scripts for role-play 85 Session 40: Sustaining breastfeeding Demonstration 40.A Saying too little Read out the story: Ester has brought her baby Dan for weighing at 5 months. He is exclusively breastfed, and perfectly well. He has gained 800 g in the last month, and now weighs 7 kg. Play the health worker: Health worker: (Pretend to weigh Ester’s baby and mark his growth chart. Do not say anything while you do this. When you have finished, hand Ester the growth chart and say what follows.) Health worker: All right Ester, thank you. Make sure that you keep Dan’s growth chart carefully and come back next month. Demonstration 40.B Sustaining breastfeeding Health worker: (As you pretend to weigh the baby) How are you feeding Dan? Ester: Just breastfeeding, whenever he wants to. Health worker: Oh, that’s good. (As you fill in his growth chart) Look at Dan’s growth line now! What do you think of that? Ester: It is going up, isn’t it? Does that mean that he is gaining weight? Health worker: Yes, Dan gained quite a lot of weight last month – and that is just on your breast milk. (praise) You know, breastfeeding helps to keep a child healthy up to the age of 2 years or more. (information) Have you thought about starting some other food yet, as well as continuing to breastfeed? (suggestion) Infant and young child feeding counselling: an integrated course. Course handouts 86 Session 47: Gathering information on complementary feeding practices Demonstration 47.A Learning what a child eats WHO Child Growth Standards Weight-for-age BOYS Birth to 2 years ( z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 2 0 3 ● ● ● ● ● ● ● ● ● Health worker: (show growth chart) Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: (show Food consistency pictures) Mother: Health worker: Mother: Health worker: Mother: Thank you for coming today. (Mother’s name), your child’s weight line is going upwards, which shows that he has grown since I last saw him. Because (child’s name) lost some weight when he was ill, the line needs to rise some more. Could we talk about what (child’s name) ate yesterday? I am pleased that he has put on some weight, as (child’s name) has been ill recently and I was worried that he might have lost weight. I can see you are anxious about his weight. Yes. I was wondering whether I was feeding him the right sorts of food. Perhaps we could go through everything that (child’s name) ate or drank yesterday? Yes, I can tell you about that. What was the first thing you gave (child’s name) after he woke up yesterday? First thing, he breastfed. Then about one hour later, he had a small amount of bread with butter, and several pieces of papaya. Breastfeeding, then bread, butter and some pieces of papaya. That is a good start to the day. What was the next food or drink or breastfeed that he had yesterday? At mid-morning, he had some porridge with milk and sugar. Which of these drawings is most like the porridge you gave to (child’s name)? This one – the more runny one (points to the thin consistency). Was there anything else that (child’s name) had at midday yesterday? Oh yes, he had a small glass of fresh orange juice. That is a healthy drink to give to (child’s name). After this meal at midday, what was the next thing he ate? Let’s see, he didn’t eat anything more until we all ate our evening meal. He breastfed a few times in the afternoon. In the evening, he ate some rice, a spoonful of mashed greens and some mashed fish. 5. Demonstrations and scripts for role-play 87 Health worker: (show Food consistency pictures) Mother: Health worker: Mother: Health worker: Mother: Health worker: (show typical bowl) Mother: Health worker: Mother: Health worker: Mother: Health worker: Breastfeeding will help (child’s name) to grow and to stay healthy. It is good that you are still breastfeeding. Which of these pictures looks most like the food the baby ate in the evening? This thicker one. I mashed up the foods together and it looked like that. Did (child’s name) eat or drink anything more for the evening meal yesterday? No, nothing else. After that or during the night, what other foods or drinks did (child’s name) have? (Child’s name) breastfeeds during the night but he had no more foods. Using this bowl, can you show me about how much food (child’s name) ate at his main meal yesterday? (Points to bowl) About half of that bowl. Thank you. Who helps (child’s name) to eat, or does he eat by himself? Oh, yes. (Child’s name) needs help. Usually I help him, but sometimes if my mother or sister is there, they will help also. Is (child’s name) taking any vitamins or minerals? No, not now. Thank you for telling me so much about what (child’s name) eats. Infant and young child feeding counselling: an integrated course. Course handouts 88 Session 47: Gathering information on complementary feeding practices Stories for food-intake practice Story 1 Child is 15 months old. Healthy, growing well and eating normally. Breastfeeds frequently. • Early morning: Breastfeed, half bowlful of thick porridge, milk and small spoonful of sugar • Mid-morning: Small piece of bread with nothing on it, breastfeed • Midday: Three large spoonfuls of rice, two spoonfuls of mashed beans (¾ of a bowl), pieces of mango (¼ of a bowl), drink of water • Mid-afternoon: Breastfeed, one small biscuit/cookie • Evening: Two large spoonfuls of rice, one large spoon of mashed fish, two large spoonfuls of green vegetables (¾ of a bowl), drink of water • Bedtime: Breastfeed • During night: Breastfeed Story 2 Child is 9 months old. Not ill at present. Not difficult to feed. Not breastfeeding. • Early morning: Half cup of cow’s milk, half bowl of thin porridge, spoonful of sugar • Mid-morning: Half a mashed banana, small drink of fruit drink • Midday: Thin soup, one spoonful of rice, and one spoonful of mashed beans (half-full bowl), drink of water • Mid-afternoon: Sweet biscuit, ½ cup of cow’s milk • Evening: Two spoonfuls of rice, one spoonful of mashed meat and vegetable from family meal (half a bowl), drink of water • Bedtime: Piece of bread with no spread, ½ cup cow’s milk • During the night: Drink of water Story 3 Child is 18 months old. Not ill at present. Not difficult to feed. Breastfeeds. • Early morning: Full bowl of thick porridge with sugar, breastfeed • Mid-morning: Cup of diluted fruit drink • Midday: Three spoonfuls of rice, three spoonfuls of mashed beans and vegetables from the family meal (one full bowl), ½ cup of diluted fruit drink • Mid-afternoon: Large piece of bread with jam, breastfeed • Evening: Whole mashed banana, one sweet biscuit, cup of diluted fruit drink • Bedtime: Breastfeed • During the night: Breastfeed 5. Demonstrations and scripts for role-play 89 Story 4 Child is 12 months old. Growing very slowly. • Early morning: Breastfeed. Half a bowl of thin porridge • Mid-morning: Two small spoonfuls of mashed banana, breastfeed • Midday: Four spoonfuls of thin soup, one spoonful of mashed meat/vegetables/potato from the soup (¾ of a bowl), breastfeed • Mid-afternoon: Breastfeed, two spoonfuls of mashed mango • Evening: Two spoonfuls of mashed meat/vegetable/potato from family meal (less than ½ a bowl), breastfeed • Bedtime: Breastfeed, sweet biscuit mashed in cow’s milk (¼ of cup). • During the night: Breastfeed Story 5 Child is 6½ months old and healthy. Growing well. Easy to feed. Has recently started complementary feeds. • Early morning: Breastfeeds • Mid-morning : Three spoonfuls of thin porridge with milk, breastfeeds • Midday: breastfeeds • Mid-afternoon : breastfeeds • Evening : Three spoonfuls of mashed family meal – potato, fish, carrots. Thick consistency • Bedtime: Breastfeed • During night : Breastfeeds Story 6 Child is 8 months old. Not ill. Does not show much interest in eating. • Early morning: Breastfeed, two spoonfuls of thin porridge with milk and sugar (less than ½ a bowl) • Mid-morning: Breastfeed • Midday: One spoonful of rice, one spoonful of mashed beans, small piece of egg, one spoonful of mashed greens, from the family meal (½ a bowl). Drink of water. • Mid-afternoon: One sweet biscuit, breastfeed • Evening: One piece of bread with some butter, breastfeed • Bedtime: Breastfeed • During the night: Breastfeed Infant and young child feeding counselling: an integrated course. Course handouts 90 Weight charts for stories WHO Child Growth Standards Weight-for-age GIRLS Birth to 2 years ( z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 3 2 0 WHO Child Growth Standards Weight-for-age BOYS Birth to 2 years ( z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 2 0 3 WHO Child Growth Standards Weight-for-age GIRLS Birth to 2 years ( z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 3 2 0 WHO Child Growth Standards Weight-for-age BOYS Birth to 2 years ( z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 2 0 3 ● ● ● ● ● ● ● ● WHO Child Growth Standards Weight-for-age GIRLS Birth to 2 years ( z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 3 2 0 ● ● ● ● ● ● ● WHO Child Growth Standards Weight-for-age BOYS Birth to 2 years ( z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 2 0 3 ● ● ● ● ● ● ● Story 1 Story 3 Story 5 Story 2 Story 4 Story 6 5. Demonstrations and scripts for role-play 91 Session 48: Responsive feeding Demonstration 48.A Controlled feeding The “young child” is sitting next to the caregiver (or on the caregiver’s knees). The caregiver prevents the child from putting their hands near the bowl or the food. The caregiver spoons food into the child’s mouth. If the child struggles or turns away, they are brought back to the feeding position. The child may be slapped or forced if they do not eat. The caregiver decides when the child has eaten enough and takes the bowl away. Demonstration 48.B Leave to themselves The “young child” is on the floor sitting on a mat. The caregiver puts a bowl of food beside the child with a spoon in it. The caregiver turns away and continues with other activities (nothing too distracting for those watching). The caregiver does not make eye contact with the child or help very much with feeding. The child pushes food around the bowl, looks to the caregiver for help, eats a little, cannot manage a spoon well, tries with their hands but drops the food; the child gives up and moves away. The caregiver says, “Oh, you aren’t hungry” and takes the bowl away. Demonstration 48.C Responsive feeding The caregiver washes the child’s hands and their own hands and then sits level with the child. The caregiver keeps eye contact and smiles at the child. Using a small spoon and an individual bowl, small amounts of food are put to the child’s lips and the child opens their mouth and takes it a few times. The caregiver praises the child and makes pleasant comments – “Aren’t you a good boy”, “Here is lovely dinner”, while feeding slowly. The child stops taking food by shutting his mouth or turning away. The caregiver tries once – “Another spoonful of lovely dinner?”. The child refuses and the caregiver stops feeding. The caregiver offers a piece of food that the child can hold – bread crust, biscuit or something similar. “Would you like to feed yourself?” The child takes it, smiles and sucks/munches it. The caregiver encourages “You want to feed yourself, do you?” After a minute, the caregiver offers a bit more from the bowl. The child starts taking spoonfuls again. Infant and young child feeding counselling: an integrated course. Course handouts 92 Session 51: Checking understanding and arranging follow-up Demonstration 51.A Checking understanding Health worker: Mother: Health worker: Mother: Comment: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Comment: Now, (name), have you understood everything that I’ve told you? Yes, ma’am. You don’t have any questions? No, ma’am. What did you observe? This mother would need to be very determined to say that she had questions for this health worker. Let us hear this again, with the health worker using good checking questions. Now, (name), we talked about many things today, so let’s check everything is clear. What foods do you think you will give (name) tomorrow? I will make his porridge thick. Thick porridge helps him to grow. Are there any other foods you could give, maybe from what the family is eating? Oh yes. I could mash some of the rice and lentils we are having and I could give him some fruit, to help his body to use the iron in the food. Those are good foods to give your child to help him to grow. How many times a day will you give food to (name)? I will give him something to eat five times a day. I will give him thick porridge in the morning and evening, and in the middle of the day, I will give him the food we are having. I will give him some fruit or bread in between. You have chosen well. Children who are 1 year old need to eat often. Would you come back to see me in 2 weeks to see how the feeding is going? Yes, OK. What did you observe this time? This time the health worker checked the mother’s understanding and found that the mother knew what to do. She also asked the mother to come back for follow-up. If you get an unclear response, ask another checking question. Praise the mother for correct understanding, or clarify any information as necessary. 5. Demonstrations and scripts for role-play 93 Session 52: Food demonstration Demonstration 52.A Supportive teaching Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Good morning (mother’s name). How are you and (child’s name) today? We are well, thank you. A few days ago, we talked about feeding (child’s name) and you decided you would try to offer (child’s name) some food more often. How is that going? It is good. One time he had about a half of a banana. Another time he had a piece of bread with some butter on it. Those sound like good snacks. Now, we want to talk about how much food to give for his main meal. Yes, I’m not sure how much to give. It can be hard. What sort of bowl or cup do you feed him from? We usually use this bowl. (shows a bowl – about 250 mL size)1 How full do you fill the bowl for his meal?. Oh, about a third. (Child’s name) is growing very fast at this age, so he needs increasing amounts of food. What foods should I use? You have some of the food here from the family today. Let us see. (uncovers food) First we need to wash our hands. Yes, I have some water here. (washes hands with soap and dries them on a clean cloth) Now, what could you start with for the meal? I guess we would start with some rice. (puts in 2 large spoonfuls) Yes, the rice would almost fill half of the bowl. Animal-source foods are good for children – is there some you could add to the bowl? I kept a few pieces of fish from our meal. (puts in 1 large spoonful) Fish is a good food for (child’s name). A little animal-source food each day helps him to grow well. Does he need some vegetables too? Yes, dark-green or yellow vegetables help (child’s name) to have healthy eyes and fewer infections. What vegetables could you add? Some spinach? (puts in some) Spinach would be very nutritious. Some would fill half the bowl. Oh, that isn’t hard to do. I could do that each day. Two spoons of rice, a spoon of an animal-source food and some dark-green or yellow vegetable so the bowl is half full. Yes, you are able to do it. Now, what about his morning meal? I can give some porridge, with milk and a little sugar. That’s right. How much will you put in the bowl? Until it is at least half full. Health worker: Mother: Health worker: Mother: Yes. So, we’ve talked about his morning meal, and the main meal with the family. (Child’s name) needs three to four meals each day. So what else could you give? Well, he would have some banana or some bread like I said before. Those are healthy foods to give between meals. (Child’s name) needs at least half a bowlful of food three to four times a day as well. Oh, I don’t know what else to give him. 1 If a different size cup or bowl is used, adjust the text accordingly. If a smaller cup is used, it will need to be a full cup. If a larger cup is used, it may only need to be less than half full. Infant and young child feeding counselling: an integrated course. Course handouts 94 Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Your family has a meal in the middle of the day. What do you eat in the evening? Usually there is a pot of soup with some beans and vegetables in it. Could I give him that? Thick foods help him to grow better than thin foods such as soup. Could you take out a few spoons of the beans and vegetables and mash them for (child’s name). And maybe soak some bread in the soup? Yes, I could do that easily enough. So, how much will you put in (child’s name) bowl for each meal? I will fill it half full. Very good. And how often each day will you give him some food? I will give half a bowlful of food three to four times a day. If he is hungry, I will give some extra food between meals. Exactly. You know how to feed (child’s name) well. Will you bring (child’s name) back to the health centre in 2 weeks, so we can look at his weight? Yes, I will. With all this food, I know he will grow very well. 5. Demonstrations and scripts for role-play 95 Session 62: Growth assessment results and feeding counselling when the child is growing well Demonstration 62.A Learning what a child eats Health worker: (show growth chart) Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: Mother: Health worker: (show Food consistency pictures) Mother: Health worker: Mother: Health worker: Mother: Health worker: (show Food consistency pictures) Mother: Health worker: Mother: Thank you for coming today. (Mother’s name), the growth charts show that your child is growing well again since I last saw him when he was ill. I am pleased that he is recovering. I was worried that he might still be growing poorly from last time. I can see you are anxious about his growth. Yes. I was wondering if I was feeding him the right sorts of food. Perhaps we could go through everything that (child’s name) ate or drank yesterday? Yes, I can tell you about that. What was the first thing you gave (child’s name) after he woke up yesterday? First thing, he breastfed. Then about one hour later the baby had a small amount of bread with butter, and several pieces of papaya. Breastfeeding, then bread, butter and some pieces of papaya. That is a good start to the day. What was the next food or drink or breastfeed that he had yesterday? At mid-morning, the baby had some porridge with milk and sugar. Which of these drawings is most like the porridge you gave to (child’s name)? Like that thick one (points to the thick consistency). A thick porridge helps (child’s name) to grow well. After the porridge mid-morning, what was the next food, drink, breastfeed (child’s name) had? Let’s see, in the middle of the day, he had soup with vegetables and beans. How did the baby eat the vegetables and beans? I mashed them all together and added the liquid of the soup so he could eat it. Which picture is most like this food that you fed (child’s name) yesterday in the middle of the day? This one – the more runny one (points to the thin consistency). Was there anything else that (child’s name) had at midday yesterday? Oh yes, he had a small glass of fresh orange juice. WHO Child Growth Standards Weight-for-age BOYS Birth to 2 years (z-scores) Age (completed months and years) W ei gh t ( kg ) 2 years1 yearBirth 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11Months –2 –3 2 0 3 ● ● ● ● ● ● ● ● ● Infant and young child feeding counselling: an integrated course. Course handouts 96 Health worker: Mother: Health worker: (show Food consistency pictures) Mother: Health worker: Mother: Health worker: Mother: Health worker: (show typical bowl) Mother: Health worker: Mother: Health worker: Mother: Health worker: That is a healthy drink to give to (child’s name). After this meal at midday, what was the next thing he ate? Let’s see, he didn’t eat anything more until we all ate our evening meal. He breastfed a few times in the afternoon. In the evening, he ate some rice, a spoonful of mashed greens and some mashed fish. Breastfeeding will help (child’s name) to grow and to stay healthy. It is good that you are still breastfeeding. Which of these pictures looks most like the food the baby ate in the evening? This thicker one. I mashed up the foods together and it looked like that. Did (child’s name) eat or drink anything more for the evening meal yesterday? No, nothing else. After that or during the night, what other foods or drinks did (child’s name) have? (Child’s name) breastfeeds during the night but he had no more foods. Using this bowl, can you show me about how much food (child’s name) ate at his main meal yesterday? (Points to bowl) About half of that bowl. Thank you. Who helps (child’s name) to eat, or does he eat by himself? Oh, yes. (Child’s name) needs help. Usually I help him, but sometimes if my mother or sister is there, they will help also. Is (child’s name) taking any vitamins or minerals? No, not now. Thank you for telling me so much about what (child’s name) eats. 5. Demonstrations and scripts for role-play 97 Session 63: Investigating causes of undernutrition Demonstration 63.A Investigating causes of undernutrition Script 1: Dialogue with Nalah’s mother about the causes of undernutrition Step 1: Nalah is not currently ill and has no known chronic disease. Nurse: Mrs Parab: Nurse: Mrs Parab: Thank you for bringing Nalah back again, Mrs Parab. Now that we have measured and weighed her, let’s take a minute to talk, shall we? Of course. (Showing the Growth charts) As you can see from her length chart, Nalah was an average length at birth and she could have grown along this green line if all was going well. But we can see that she is a lot shorter than an average girl of 6 months. Her weight also is a lot lower than the average. Since her growth in both weight and length have slowed down together, she does not look too thin. But we want her to grow longer and to gain weight. What should we do? Step 2: The nurse begins at page 4 of the Job aid, since Nalah is 6 months old. Nurse: Mrs Parab: Well, since Nalah has not been ill, I think we should focus on her feeding. Do you mind if I ask you some questions so that we can better understand the reasons why her growth has slowed down? That would be fine. Step 3: Nurse: Mrs Parab: Alright then, has Nalah been breastfeeding less or eating less than usual? Maybe less, because it’s hard to breastfeed when I have to go to work. Sometimes I have to leave her with my neighbour. Infant and young child feeding counselling: an integrated course. Course handouts 98 Step 4: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: So you are still breastfeeding? Yes, when I can. That’s good. How many times is that during a day and a night? When I have Nalah with me at work, I breastfeed about four or five times from morning until night. If she stays with my neighbour, I can only breastfeed twice, once in the morning and once at night. Do you have any difficulty with breastfeeding itself? Is Nalah attaching well to the breast and emptying the breasts whenever she breastfeeds? Well, I have never thought about that. I was told that I should feed her from both breasts, so sometimes I switch to the other breast before the first is empty. That is something we can look at together in a moment. Do you give Nalah any other fluids besides breast milk? I sometimes have given her water, and I leave her some milk when she stays with my neighbour. What kind of milk? I buy it at the shop. It’s cow’s milk from a tin. Do you add any water to it? No, because it already looks thin to me. How many times does the neighbour give her the milk? Twice, I think. And how does she feed Nalah the milk? In a cup. That is good. Do you or the neighbour give Nalah any semi-solid or solid foods? My neighbour gives her some porridge if she seems hungry after the milk. How often is that? Not more than once a day. How does the neighbour feed Nalah the porridge? With a spoon. Have you offered Nalah any porridge at home? Not yet. Step 5: Nurse: Mrs Parab: Let me just ask you a few more questions about Nalah’s health and your home.Is Nalah often tired, or sick with diarrhoea, cough, or fever? Nalah does not seem strong to me. She sometimes has a runny nose, and she likes to be held. She does not move around a lot but lies still. 5. Demonstrations and scripts for role-play 99 Step 6: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Tell me about where you live. Do you have a latrine or toilet? No, we live in a poor area. There is a common latrine for many houses. Where do you get water? We get water from a tap in the yard, and once a week I buy water in large cans. Do you boil or treat your water? I boil the drinking water, but not the water for washing dishes. It is very good that you boil the water for drinking. How is water stored in your home? I just keep it in the same cans that we buy it in. How many people are living at home now? Just me, my husband, and Nalah. And how is your health? We are fine, although I am very tired, I must admit. Does Mr Parab help with Nalah? He is out looking for construction work most days, but he helps a bit. Do you have enough food to feed the family? We have enough to manage. Step 7: Nurse: Mrs Parab: Nurse: What do you think is the most important reason for Nalah’s small size and tiredness? Well, I thought she looked small but I did not know why. Maybe she needs more food. I wish that I could stay home and breastfeed more… Yes, that would be good if you can do it. From what you have said, it seems to me that Nalah may be growing slowly for a number of reasons, but most probably because she is not getting enough food. Please put her to the breast for a feed so we can see whether she attaches well, and let’s speak more about the emptying of the breasts. Infant and young child feeding counselling: an integrated course. Course handouts 100 Session 64: Counselling a mother or caregiver whose child has undernutrition Demonstration 64.A Counselling Nalah’s mother Script 2: Conclusion of counselling session with Nalah’s mother Nurse: Mrs Parab: Nurse:  Mrs Parab: Nurse:  Mrs Parab: Nurse:  Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nalah’s breast attachment is very good. Well done. Now, whenever you breastfeed, leave her to empty each breast so that she gets the hindmilk, which has more fat than the foremilk. Let’s talk now about how frequently you can feed her. You said that you would like to stay home and breastfeed more. Is there any way that you could do that? If my husband could get more work, I could stay home and breastfeed more. That would be helpful to Nalah if you can do it. Let’s talk about some more ways to help Nalah. Let’s look in the Growth record for the feeding recommendations for her age. (The nurse opens the Growth record to pages 16–17, to show the recommendations to Mrs Parab.) Since Nalah is now 6 months old, we need to follow the recommendations for infants who are 6 months to 1 year of age. You see that the first recommendation is to breastfeed as often as Nalah wants. Even if you cannot breastfeed more during the day, you could do it at night. Nalah also needs a good soft staple food now that she is 6 months old. What kind of porridge is she eating at your neighbour’s home? The porridge is made of maize meal. That is a fine staple food. You need to feed Nalah thick porridge 2–3 times each day, about 2–3 tablespoons (shows amount with her hands or a spoon); if she is already taking more than this, do not reduce the amount. Should I give her any other foods? Yes, but start just one new food at a time to be sure that she can tolerate it. For example, you can start giving some mashed fruit, such as banana. Let’s look at the list of some appropriate foods on page 15 of Nalah’s Growth record. The porridge will give Nalah energy, but she needs a variety of other foods for their nutrients to help her grow. Just remember to introduce them one at a time. But I don’t have all of these foods. Foods such as chicken and butter are too expensive. You don’t have to give those. Let’s talk about what you do have. What animal-source foods can you give her? I can get eggs, and sometimes fish or a bit of meat. That will do very well. Can you get leafy green and yellow-coloured vegetables and fruit? Yes. For vegetables I can get pumpkin and chard. And banana and papaya for fruit. And do you have oil or fat that you could add a little to her food? I have oil, but I think it causes constipation in babies. Oil should not cause constipation, but what it will do is to increase the energy in Nalah’s food. That all seems like too much food. Well, you will not give all of these foods every day. Remember, at first you will only give a small amount two or three times each day. And you will only introduce one new food every 3–4 days. Please tell me why you should introduce new foods one at a time. To be sure that the new food does not make her sick. That’s right. What about breastfeeding? How long should I breastfeed? Nurse: Mrs Parab: Nurse: Mrs Parab: Keep breastfeeding as often as Nalah wants to, day and night for 2 years or more. I hope that I can do that. I think that if you feed Nalah the way that we have discussed, she will be better nourished and more lively. The food will help her grow and develop more. Now, to review, please tell me how you will feed Nalah for the next month. I will try to breastfeed more often. 5. Demonstrations and scripts for role-play 101 Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Nurse: Mrs Parab: Good. What else? I will give her porridge. OK. That’s good. How much porridge and how often? About this much (shows with hands) two or three times a day. Very good. And what other foods will you start giving, one at a time? Mashed banana, papaya, pumpkin. What food will you give that comes from an animal? Eggs, most likely. All of these foods will help Nalah grow. If you can feed her as we have agreed for 1 month, there should be a change in her health. Do you think that you could bring Nalah back next month? Yes, I can bring her back. Good. We will weigh and measure her again. When she is getting enough food, you will see her being more active instead of lying still. We should also see her growing in length and weight. So, next month we will speak about her feeding needs at 7–8 months, and maybe also look for ways to prevent problems like the runny nose that you mentioned. Okay, I will bring her back in one month. That’s great. Let me write the date for that visit in her book. Of course, if Nalah gets sick or if you have any problems or questions, you can come sooner. I look forward to seeing you again. Thank you. Infant and young child feeding counselling: an integrated course. Course handouts 102 Session 65: Investigating causes and counselling a mother or caregiver whose child is overweight Demonstration 65.A Investigating causes of overweight Script 3: Dialogue with Toman’s mother about the causes of overweight Step 1: Toman is not currently ill and has no known chronic diseases. Nurse: Mrs Baruni: Nurse: Mrs Baruni: Let’s look together at Toman’s Growth record. Looking at his length-for-age, we see that he is a nice height, a bit taller than average for boys his age. The other charts show that Toman is quite heavy for his height. What do you think? Would you agree that Toman is overweight? I don’t know. I think that he is a big, healthy boy. I never thought he was really overweight. Is this a problem? It will be a problem if he continues gaining weight so fast. We need to slow down his weight gain until his height catches up. Do you mind if I ask you some questions about Toman’s eating and his physical activity? Then we can both understand why he seems to be gaining weight faster than expected. Alright. Step 2: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni Is Toman breastfed? No, I stopped breastfeeding him when he was 3 months old. Is he fed any milk formula or other milk? He drinks lots of milk. He loves milk. About how much milk does he drink each day? Oh, probably a litre. He has a glass in the morning, then at about 10:00, and also with snacks. I also give him a bottle to help him go to sleep without crying at night. How is the milk prepared? Is anything added to sweeten or thicken it? Usually it’s just fresh milk from a packet, but sometimes I warm it and add a bit of sugar or chocolate powder. How many meals does he eat each day? Three. OK. About how much does he eat at each meal? A small bowl full. What type of bread does Toman eat? He likes regular sliced bread, toast and sweet breads. Does he eat cakes or other sweets? Well, he eats sweets like cookies and cake when he stays with his father and his father’s mother over the weekend. My mother-in-law likes to bake and feed Toman sweets. She is a bit heavy herself. Does Toman drink soft drinks? Yes, sometimes. How often? At my mother-in-law’s house he has soft drinks with his meals. I give him juice instead. What about spreads on bread? Does Toman eat a lot of butter, margarine or sweet spreads on his bread? Oh yes, he loves chocolate and hazelnut spread. Does he eat high-energy snacks like chips? No, I don’t think so. What about fried foods, such as deep-fried breads or meats, or French fries? I don’t usually fry foods. I may add some oil when I cook, but not much. Does he eat fatty meat? He likes meat, but I don’t know whether the meat is fatty. 5. Demonstrations and scripts for role-play 103 Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni You said that Toman eats three meals each day. Does he also have snacks? Well, he eats breakfast, a snack around 10:00, lunch, a snack after his nap, then dinner, and finally his bottle of milk before bed. So I guess he eats about six times each day. Do you think that Toman eats too much at meals? No, not really. Besides the planned snacks, does Toman eat between meals? I don’t think so, but I don’t really know what happens at his grandmother’s house. Do you and Toman sit down at a table to eat? We try, but sometimes we may sit in front of the television to eat. Step 3: Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni Nurse: Mrs Baruni How many physically inactive hours does Toman spend each day, for example, watching the television? When he’s at home with the babysitter while I am at work, he watches a lot of television. How often is that? Five days each week while I am working. When he is at his father’s, what kind of meals does he have? Oh, at his father’s he is sure to have fast foods. That’s why they usually eat at his grandmother’s. Does Toman have many opportunities for active physical play? He really doesn’t. The babysitter stays indoors with him. Step 4: Nurse: Mrs Baruni Nurse: What do you think could be the main reasons that Toman is overweight? You know, I think he’s just a big boy like his father. He seems healthy to me, but maybe he needs to play outside and run around more. I agree. From what you have told me, Toman’s weight could be caused by a number of things, including lack of activity and food choices. Infant and young child feeding counselling: an integrated course. Course handouts 104 Demonstration 65.B Conselling Toman’s mother Script 4: Conclusion of counselling session with Toman’s mother Nurse:  Mrs Baruni: Nurse: Mrs Baruni: Nurse:  Mrs Baruni: Nurse:  Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: (checking question) Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Nurse: Mrs Baruni: Your idea of taking Toman outside to play more is a good one. It will help him to have more physical activity. Can you ask the babysitter to take him outside to play? Yes, I will ask her to do that. On the weekends, is it possible that Toman’s father would take him outside to a playground or to play ball? I can explain to him that Toman is getting fat and ask him to do that. But I really do not have much control over what he does or eats with his father and grandmother. If I make a suggestion to her, she resents it. I understand. Then let’s discuss first what you can do in your own home. I suggest that you stop adding sugar or sweetened chocolate to Toman’s milk. If you sweeten it, it is more fattening. Also, he is likely to drink more than he needs because it tastes so good. He will not like the milk as much if I don’t sweeten it. That is alright. He doesn’t need so much milk as you are giving him. Half a litre each day is plenty. And if he is thirsty before bed, give him milk or water in a cup, not a bottle. He will drink more than he needs from a bottle, and it is bad for his teeth to fall asleep with a bottle. I will never get him to sleep then. It’s alright to let him cry a bit as he falls asleep. He needs to be able to fall asleep without a bottle. It may help to rock him and sing to him. Besides, if he has been outside to play, he may be very tired and have no problem falling asleep. I had not thought of that. From what you have told me, there are more feeding changes that would be helpful, but for now let’s focus on getting him out to play, reducing sugar in his diet, and decreasing the amount of milk given daily. How do you feel about trying these three things? I am willing to try, but his grandmother will give him all the sweet foods he wants! I understand the difficulty. Can you discuss the situation with your husband? Maybe he can help. Not easily, but I could write a letter, or perhaps you could write a note or call him? That is a good idea. I will call him. Please give me his phone number. Yes, he may listen to you more than me. I will call him. If you make the feeding changes that we have agreed on, and if your husband and mother-in- law make some changes as well, it will be very good for Toman, especially if he also gets more physical activity. Now, just to review, let me ask you how you will reduce the amount of sugar that Toman is taking. I will stop adding the sugar and chocolate to his milk. And how will you reduce the total amount of milk that Toman drinks each day to about half a litre? I will try to stop giving him the bottle at night. And how will you increase his activity? I will instruct the babysitter to take him outside to play. That sounds great. We could weigh and measure Toman again in about 3 months to see his progress. Could you come back in 3 months? Yes, I will do that. Very well. At that time, we will speak about more ways to improve Toman’s health. Let me write the date for his next visit in his Growth record. Could you tell me what Toman’s father says after you speak with him? Of course! I will give you a call. Thank you. 5. Demonstrations and scripts for role-play 105 Session 67: Gathering information and counselling on complementary feeding practices and growth: role-plays Exercise 67.A Role-plays: Interviewing and counselling mothers Role-play situation 1: Mrs Khan and her son Veebol Mrs Khan has a son named Veebol, who is 9 months old. He is still breastfed, but he also takes formula milk in a bottle occasionally. Mrs Khan stays home to care for her son while her husband travels as a bicycle salesman. Their home is comfortable and has many conveniences, including a television. There is plenty of money for food. Veebol takes about a cup of mashed foods (such as porridge or sweet potatoes) three or four times each day. Mrs Khan appears to be overweight, and her son’s growth lines show a trend towards overweight, but Mrs Khan does not think that there is any problem. He is beginning to crawl but is carried around much of the time because his mother does not want him to get his hands dirty and put them into his mouth. Growth charts for Veebol Infant and young child feeding counselling: an integrated course. Course handouts 106 Role-play situation 2: Mrs Smith and her daughter Mary Mrs Smith has a daughter Mary who is 15 months old. Her growth charts indicate that she is growing well. Her mother says that she breastfeeds frequently (she can’t keep count of how many times in a day). The heath-care provider asks about Mary’s complementary feeding (using the 24-hour recall method). Yesterday Mary had three meals and two snacks. She had ½ cup of mixed-cereal porridge in the morning and some bread and peanut butter at mid-morning. She had bean stew and a little rice for lunch, followed by a slice of mango. She did not have any snack in the afternoon but breastfed several times. For supper she ate steamed fish and greens. The health-care provider has measured Mary and plotted all measurements in her growth charts. Growth charts for Mary 5. Demonstrations and scripts for role-play 107 Infant and young child feeding counselling: an integrated course. Course handouts 108 Role-play situation 3: Mrs Lima and her daughter Anete Mrs Lima is the mother of Anete, age 18 months, who seems happy and active. Anete is stunted but looks healthy. She is not breastfed. She does not like to eat and prefers to move around rather than sit still for meals. Although Mrs Lima tries to feed Anete three times each day, sometimes she will only take ¼ cup of food at a time. Anete’s growth charts are shown below. Mrs Lima appears to be normal height. She does not have HIV. Her home is simple, but there is enough money for food. Growth charts for Anete 5. Demonstrations and scripts for role-play 109 Infant and young child feeding counselling: an integrated course. Course handouts 110 Session 76: Communication and support of infant feeding in the context of HIV Demonstration 76.A Group talk for women at an antenatal clinic Talk 1: Breastfeeding is recommended by the national health authority Counsellor: ¤ My name is Lisa, and I would like to welcome you to this talk on feeding your new baby. ¤ It is never too early to think about how you will feed your baby and I expect some of you have already decided what you want to do, so I hope you find the information I am going to give you is useful. ¤ We recommend that you all breastfeed your babies, including mothers who are living with HIV. Our national health authority recommends that all mothers living with HIV should breastfeed. We know that HIV can be passed from a mother to her baby during breastfeeding, as well as in pregnancy and during birth. We now give mothers who test positive to HIV lifelong antiretroviral therapy, starting early in pregnancy (if the country does not have lifelong treatment add: until after the mother stops breastfeeding), this makes the chance of her baby being infected with HIV, very low. By taking the drugs for longer now, more babies survive without being infected with HIV and they remain healthier because they are breastfeeding, and do not get ill and die from diarrhoea, or chest infections or other common illnesses. We would urge you to be tested for HIV if you do not know whether you are infected. ¤ So what I am going to say to you about breastfeeding applies to all women. ¤ In the first 6 months of your baby’s life, we recommend that you exclusively breastfeed your baby. Your baby needs no other foods or drinks, not even water or honey after birth, just your breast milk. After 6 months, you should continue to breastfeed, but your baby will need to start other foods at this time as well. We recommend that you breastfeed for at least 12 months and may continue to breastfeed until your baby is at least 2 years old, and longer if you want to, because this will help keep your baby as healthy as possible, while you are being fully supported for adherence to antiretroviral therapy. ¤ Your breast milk is unique to you and your baby. Many of the substances found in your breast milk cannot be found in other milks. For example, your first milk, colostrum, which is already in your breasts at the time of birth, is very precious for your baby. Colostrum is only produced in small amounts in the first few days, maybe only a teaspoonful at each feed. This is all your baby needs at this time. Colostrum is precious, because it protects your baby from being ill, and helps your baby to develop properly, not only in the first few months but as your baby grows up as well. Babies who do not breastfeed are more likely to become ill, because other milks do not protect your baby. ¤ Has anyone any questions so far? ¤ Your baby is born with very little protection against infection, so I want to go back to what I was saying earlier about the importance of your first milk, the colostrum. Many women think they do not have any milk in the first few days, because they do not see it on their nipples when the baby finishes breastfeeding. But it is there, and to be certain that your baby receives colostrum immediately after birth, we give you your baby to hold close to your breasts, so that your baby’s skin and your skin are in contact. This keeps your baby warm. We try not to separate you and your baby for at least 1 hour. After a few minutes, your baby will start moving to your nipple and breast and will begin feeding by themself. We will be there to help you both when the time comes. ¤ Before you leave hospital, we will make sure you can correctly attach and position your baby at the breast, and we teach you how to look after your breasts, so that you have no problems in the future. We will also teach you to recognize when your baby wants to feed. ¤ In the early days and weeks of your baby’s life, this will mean breastfeeding whenever your baby wants, during the day and during the night. ¤ We also teach you to express your breast milk, so that in the event that you have to be away from your baby, for example, if you go back to work, your baby can have your own expressed breast milk. ¤ Breastfeeding, whenever your baby wants to feed, means you will make enough milk for your baby. But if you miss feeds or give your baby a bottle of formula milk, your breasts may make less milk. ¤ It is not only your baby who will be healthy as a result of breastfeeding. You, too, will benefit. Your bones will be stronger, cancer of the breast is less likely while you are young, and breastfeeding soon after birth helps to prevent you bleeding heavily at this time. 5. Demonstrations and scripts for role-play 111 ¤ Are there any questions? ¤ Cleanliness is very important, whichever way you feed. Always make sure you wash your hands before breastfeeding or expressing your breast milk. ¤ If you intend to give your baby formula milk or cow’s milk, please tell your infant feeding counsellor or health worker, so that they can help you feed your baby safely. ¤ Remember, however you feed your babies, we are here to help and support you. When you see the midwife, you can talk more about feeding your baby and particularly any personal questions that you may have about your own situation. ¤ Does anyone have any questions? ¤ Thank you for your attention. Talk 2: Replacement feeding is recommended by the national health authority Counsellor: ¤ My name is Lisa and I would like to welcome you to this talk on feeding your new baby. ¤ It is never too early to think about how you will feed your baby and I expect some of you have already decided what you want to do, so I hope you will find the information I give you, useful. ¤ Before we talk about breastfeeding, I want to tell you about recent international changes to our advice on infant feeding for women who test positive to HIV. Our national health authority has decided that women who are living with HIV should give their babies replacement feeds, so that there is no risk of the babies being infected with HIV through breast milk. To protect the baby from being infected with HIV during pregnancy and while the baby is being born, and to improve women’s health, women living with HIV will be given lifelong antiretroviral therapy (recommended) or prophylactic antiretroviral drugs. ¤ The decision to replacement feed has been made because mothers can safely make up the formula feeds in their homes. I want to reassure any mothers who are living with HIV or test positive in the future that we will fully support you to feed your baby safely, for as long as you need our support. We will discuss with you individually any questions you may have about how this decision could affect how you feed your baby. We strongly advise you to be tested for HIV if you do not know whether you are infected. ¤ For all other women, we recommend that you exclusively breastfeed your baby for the first 6 months of your baby’s life. Your baby needs no other foods or drinks, not even water or honey after birth, just your breast milk. After 6 months, you should continue to breastfeed, but your baby will need to start other foods at this time as well. We recommend that you continue to breastfeed and give other foods until your baby is at least 2 years old, and longer if you want to, because this will help keep your baby as healthy as possible. A mother who is living with HIV and decides to breastfeed is recommended to breastfeed for at least 1 year and continue breastfeeding for up to 24 months or longer (similar to mothers who are not HIV positive), while receiving antiretroviral therapy. ¤ Your breast milk is unique to you and your baby. Many of the substances found in your breast milk cannot be found in other milks. For example, your first milk, colostrum, which is already in your breasts at the time of birth, is very precious for your baby. it is only produced in small amounts in the first few days, maybe only a teaspoonful at each feed. This is all your baby needs at this time. Colostrum is precious, because it protects you baby from being ill, and helps your baby to develop properly, not only in the first few months but as your baby grows up as well. Babies who do not breastfeed are more likely to become ill because other milks do not protect your baby. ¤ Has anyone any questions so far? ¤ Your baby is born with very little protection against infection, so I want to go back to what I was saying earlier about the importance of your first milk, the colostrum. Many women think they do not have any milk in the first few days, because they do not see it on their nipples when the baby finishes breastfeeding. Your baby is born with very little protection against infection, so I want to go back to what I was saying earlier about the importance of your first milk, the colostrum. Many women think they do not have any milk in the first few days, because they do not see it on their nipples when the baby finishes breastfeeding. But it is there, and to be certain that your baby receives colostrum immediately after birth, we give you your baby to hold close to your breasts, so that your baby’s skin and your skin are in contact. This keeps your baby warm. We try not to separate you and your baby for at least 1 hour. After a few minutes, your baby will start moving to your nipple and breast and will begin feeding by themself. We will be there to help you both when the time comes. Infant and young child feeding counselling: an integrated course. Course handouts 112 ¤ Before you leave hospital, we will make sure you can correctly attach and position your baby at the breast, and teach you how to look after your breasts, so that you have no problems in the future. We will also teach you to recognize when your baby wants to feed. ¤ In the early days and weeks of your baby’s life, this will mean breastfeeding whenever your baby wants, during the day and during the night. ¤ We also teach you to express your breast milk, so that if you have to be away from your baby for example if go back to work, you can still give them your own breast milk. Breastfeeding, whenever your baby wants to feed, means you will make enough milk for your baby. ¤ It is not only your baby who will be healthy as a result of breastfeeding. You too will benefit. Your bones will be stronger, cancer of the breast is less likely while you are young, and breastfeeding soon after birth helps to prevent you bleeding heavily at this time. ¤ Are there any questions? ¤ Cleanliness is very important, however you feed. Always make sure you wash your hands before breastfeeding or expressing your breast milk. If you intend to give your baby formula or cow’s milk, please tell your infant feeding counsellor or health worker, so that they can help you feed your baby safely. ¤ Remember, however you feed your babies, we are here to help and support you. When you see the midwife, you can discuss more about feeding your baby and particularly any personal questions that you may have about your own situation. ¤ Does anyone have any questions? ¤ Thank you for your attention. 113 6. Exercises and worksheets Session 3: Local infant and young child feeding situation Few Half Most How many babies have immediate skin-to-skin contact? How many breastfeed within 1 hour after delivery? How many have other foods or drinks before they start breastfeeding? How many breastfeed exclusively for 6 months? How many have other foods or drinks before: 1 day? 1 month? 2 months? 3 months? 4 months? 6 months? How many continue to breastfeed for more than: 6 months? 12 months? 24 months? How many children start solid/semi-solid foods: Before 6 months of age? Between 6 and 8 months of age? After 8 months of age? How many children aged 6 up to 24 months: Receive an appropriate variety of foods?1 Receive an appropriate frequency of foods?2 Receive an appropriate amount of food for each meal?3 Receive an appropriate consistency of foods?4 1 Children should receive foods from 4 or more out of 7 foods groups. The 7 foods groups are: (1) grains, roots and tubers, (2) legumes and seeds, (3) dairy products (milk, yogurt, cheese), (4) flesh foods (meat, poultry, fish, liver), (5) eggs, (6) vitamin-A rich fruits and vegetables (mango, papaya, passion fruit, oranges, dark green leaves, carrots, yellow sweet potato, pumpkin), (7) other fruits and vegetables. 2 From 6 up to 9 months: 2–3 meals per day; depending on the child’s appetite, 1–2 snacks may be offered. From 9 up to 12 months: 3–4 meals per day; depending on the child’s appetite, 1–2 snacks may be offered. From 12 up to 24 months: 3–4 meals per day; depending on the child’s appetite, 1–2 snacks may be offered. 3 From 6 up to 9 months: start with 2–3 tablespoonfuls per feed, increasing gradually to ½ of a 250 mL cup. From 9 up to 12 months: ½ of a 250 mL cup/bowl. From 12 up to 24 months: ¾ to 1 250 mL cup/bowl. 4 From 6 up to 9 months: start with thick porridge, well-mashed foods, continue with mashed family foods with finger foods that baby can pick up from 8 months. From 9 up to 12 months: finely chopped or mashed foods, and finger foods. From 12 up to 24 months: family foods, chopped or mashed if necessary. Infant and young child feeding counselling: an integrated course. Course handouts 114 Session 4: Local nutrition situation Few Half Most How many children aged under 5 years have acute severe malnutrition? How many children aged under 5 years have acute moderate malnutrition? How many children aged under 5 years are overweight/obese? How many women of childbearing age are overweight/obese? How many children aged under 5 years of age have anaemia? How many women of childbearing age have anaemia? How many children start solid/semi-solid foods at 6 months of age? 6. Exercises and worksheets 115 Session 43: The importance of complementary feeding Exercise 43.A Assess your practices Does this practice occur? With all children With some children Does not occur Comments Weigh the child Measure the child’s length Look at the child’s growth chart Discuss how the child is feeding Note on the child’s chart that feeding was discussed Carry out demonstrations of young children’s food preparations and feeding techniques Make home visits to assess foods and feeding practices Other activities Infant and young child feeding counselling: an integrated course. Course handouts 116 Most-frequent activities occurring in your health facility: Least-frequent activities occurring in your health facility: 6. Exercises and worksheets 117 Session 45: Foods to fill the iron and vitamin A gaps Exercise 45.A What is in the bowl? Choose foods that are available to families in your area to form one meal for a young child, aged ____________________ What are the Key messages you could give for the foods that you have chosen? Infant and young child feeding counselling: an integrated course. Course handouts 118 Session 52: Food demonstration Exercise 52.A Preparing a young child’s meal Group: Task Achieved Comments Mixture of foods: Staple Animal-source food Bean/pulse plus vitamin C fruit or vegetable Dark-green vegetable or yellow-coloured fruit or vegetable Consistency Amount Prepared in a clean and safe manner Key messages: 1. 2. 6. Exercises and worksheets 119 Recipes for food demonstration1,2 – fill in the food and the amount needed Recipe 1 Family food for a 10-month-old child’s main course (about ½ cupful – a cup/bowl that holds 250 mL) Staple:_________________________________________________________________________________________________ Meat or fish or beans:____________________________________________________________________________________ If using beans or egg instead of meat, include a source of vitamin C to help iron absorption: ______________________ Dark-green or yellow vegetable: ___________________________________________________________________________ Milk or hot boiled water or soup water if milk is not available: 1 tablespoon (large spoon) Wash hands and use clean surface, utensils and plates. Take the cooked foods and mash them together. Add the oil or margarine and mix well. Check the consistency of the mashed food with a spoon – it should stay easily on the spoon without dripping off. Add the milk or water to the mashed foods and mix well. Only add a small amount of milk or water to make the right consistency. Recipe 2 Family food for a 15-month-old child’s main course (a full cup) Staple:_________________________________________________________________________________________________ Meat or fish or beans:____________________________________________________________________________________ If using beans or egg instead of meat, include a source of vitamin C to help iron absorption: ______________________ Dark-green or yellow vegetable: ___________________________________________________________________________ Oil or margarine: 1 teaspoon (small spoon) Wash hands and use clean surface, plates and utensils. Take the cooked foods and cut them into small pieces or slightly mash them together (depending on the child’s age). Add the oil or margarine and mix well. 1 The amounts indicated are recommended if the energy content of the meals is 0.8 to 1.0 kcal/g. These amounts should be adjusted if the foods are diluted. 2 If there is a need to increase the amounts of food for each meal, instruct the participants to make the change in their recipes. Infant and young child feeding counselling: an integrated course. Course handouts 120 Session 53: Clinical practice session 5: Gathering information on complementary feeding practices 1 Exercise 53.A Summary of groups’ Job aids: Food intake – 6 up to 24 months Job aid: Food intake – 6 up to 24 months Child's name: Date of birth: Age of child at visit: Feeding practice Yes / number where relevant Key message given Growth appropriate? Child received breast milk? How many meals of a thick consistency did the child eat yesterday? (use Food consistency pictures as needed) Child ate an animal-source food yesterday (meat/fish/offal/bird/eggs)? Child ate a dairy product yesterday? Child ate pulses, nuts or seeds yesterday? Child ate a dark-green or yellow vegetable or yellow fruit yesterday? Child ate sufficient number of meals and snacks yesterday, for their age? Quantity of food eaten at main meal yesterday appropriate for child’s age? Caregiver assisted the child at mealtimes? Child took any vitamin or mineral supplements? Child ill or recovering from an illness? Total the numbers for each box/practice. 6. Exercises and worksheets 121 Session 68: Clincal practice session 7: Listening and learning – measuring children Worksheet: Measuring weight, length and height This will be a practical exercise in a clinic setting, or in the classroom if children and measuring equipment can be brought there. The mothers should be present, if possible, to tell the children’s dates of birth and to assist with measuring and reassuring them. Your facilitator will assign you to work in pairs. Each pair should do the following steps for at least two children, one who is less than 2 years old and one who is 2–5 years old. Review records or ask the mother to determine the child’s name, sex and date of birth. Record this information in the inset box below on the left. Use the Child age calculator to determine the child’s age today. Make a visual assessment of the child (e.g. does the child appear thin, fat, active, lethargic)? • Observe the child for signs of marasmus or kwashiorkor. If there is any apparent oedema, test for oedema of both feet. • Weigh the child. • Measure the child’s length or height. • Record results on the Visit notes page below. Visit notes Date Age today (completed years/ months or weeks) Measurements (record below; then plot on charts) Reason for visit, observations, recommendations Weight (kg) Length/ height (cm) Child 1: Sex: DOB: Child 2: Sex: DOB: Child 3: Sex: DOB Child 4: Sex: DOB: Each person take a turn{ Infant and young child feeding counselling: an integrated course. Course handouts 122 Session 76: Communication and support of infant feeding in the context of HIV Exercise 76.A Reflection on group talk for women at an antenatal clinic Questions for Group 1 1. Was this talk easy or difficult to understand? Why? 2. What did you think about the length of the talk? 3. What about the language used in the talk? 4. What did you learn about HIV and infant feeding and the use of antiretroviral therapy or drugs? 5. What “key points” do you remember from this talk? 6. What might affect what you remember about the talk? Questions for Group 2 1. Do you think the counsellor was an effective communicator? 2. Which communication skills, learnt about in previous sessions, were used? 3. Can you give any examples? 4. What did you think about the balance of information given to mothers? 5. Was there anything missing in the talk? 6. What could you do to make the talk more lively? Questions for Group 3 1. This was a group talk; how involved in it did you feel? 2. Do any of you have group talks like this in your clinics? 3. Would talks like this be possible in your clinics? 4. If not, why? 5. If you were giving the talk, what would you have done differently? 6. How could you make sure pregnant women remember what you have told them in this talk? 6. Exercises and worksheets 123 Session 77: Supporting national health authority infant feeding recommendations for women living with HIV Exercise 77.A Putting infant feeding recommendations for women living with HIV into practice Question card How can you help to put the national health authority infant feeding recommendations into practice? 1. Discuss what needs to happen in your facility or area to implement the national health authority infant feeding recommendations. 2. Discuss what you can do to implement the recommendations in your place of work. 3. If applicable, include some of the following questions in your discussion: • What needs to be done at district level? • What needs to be done at community/clinical level? - Obtaining antiretroviral drugs/providing replacement milk • How to engage with local communities: - Community workers/dealing with prejudice/fears/etc. - Grandparents/religious groups • How to provide opportunities for linking with other services e.g. family planning. • What information to collect for local clinical use at monthly/other meetings with mothers. • What questions do you think mothers may have about breastfeeding/replacement feeding? 124 7. Answer sheets Session 6: Listening and learning exercises 1 Exercise 6.A Asking open questions “Closed” questions Suggested answers for “open” questions 1. Does your baby sleep with you? Where does your baby sleep? 2. Are you often away from your baby? How much time do you spend away from your baby? 3. Does Sara eat porridge? What kinds of foods does Sara eat? 4. Do you give fruit to your child often? How often does your child eat fruit? Exercise 6.B Reflecting back what a mother/caregiver says 1. Mika does not like to take thick porridge. ü a. Mika does not seem to enjoy thick foods? b. What foods have you tried? c. It is good to give Mika thick foods as he is over 6 months old. 2. He doesn’t seem to want to suckle from me. a. Has he had any bottle feeds? b. How long has he been refusing? ü c. He seems to be refusing to suckle? 3. I tried feeding her from a bottle, but she spat it out. a. Why did you try using a bottle? ü b. She refused to suck from a bottle? c. Have you tried to use a cup? 4. My husband says our baby is old enough to stop breastfeeding now. Your husband wants you to stop breastfeeding your baby? 7. Answer sheets 125 Exercise 6.C Empathizing – showing that you understand how the mother/caregiver feels 1. James has not been eating well for the past week. I am very worried about him. ü a. You are anxious because James is not eating? b. What did James eat yesterday? c. Children often have times when they do not eat well. 2. My breast milk looks so thin – I am afraid it is not good. a. That's the foremilk – it always looks rather watery. ü b. You are worried about how your breast milk looks? c. Well, how much does the baby weigh? 3. I feel there is no milk in my breasts, and my baby is a day old already. ü a. You are upset because your breast milk has not come in yet? b. Has she started suckling yet? c. It always takes a few days for breast milk to come in. 4. I am anxious that if I breastfeed I will pass HIV on to my baby. ü a. I can see you are worried about breastfeeding your baby. b. Would you like me to explain to you about how the HIV virus is passed from mothers to babies? c. What have you heard about other options for feeding your baby? 5. Angelique brings Sammy to see you. He is 9 months old. Angelique is worried. She says “Sammy is still breastfeeding and I feed him three other meals a day, but I am so upset, he still looks so thin”. What would you say to Angelique to empathize with how she feels? (Possible answers include: You are worried because Sammy looks thin to you? You are worried about Sammy?) 6. Catherine comes to the clinic. She is pregnant with her first baby and has found out she has HIV. She says: “I am frightened that my mother-in-law might find out”. What would you say to Catherine to empathize with how she feels? (Possible answers include: You are frightened about what your mother-in-law will think? You are worried about your mother-in-law finding out?) Infant and young child feeding counselling: an integrated course. Course handouts 126 Exercise 6.D Translating judging words Using and avoiding judging words English Well Normal Enough Problem Local language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Judging question Does he suckle well? Are his stools normal? Is he gaining enough weight? Do you have any problems breastfeeding? Non-judging question How is he suckling? What are his stools like? How is your baby growing? How is breastfeeding going for you? 7. Answer sheets 127 Session 7: Listening and learning exercises 2 – breastfeeding Exercise 7.A Asking open questions How to do the exercise: Questions 1–4 are “closed” and it is easy to answer “yes” or “no”. Write a new “open” question, which requires the mother to tell you more. Example: “Closed” question “Open” question Do you breastfeed your baby? How are you feeding your baby? To answer: “Closed” questions Suggested answers for “open” questions 1. Does your baby sleep with you? Where does your baby sleep? 2. Are you often away from your baby? How much time do you spend away from your baby? 3. Are your nipples sore? How do your breasts and nipples feel? 4. Optional short story exercise (To do if you have time, or need more practice) Joseph and Mabel bring 3-month-old Johnny to the clinic. They want to talk to you because he is not gaining weight. Write two open questions that you would ask Joseph and Mabel. The questions must be ones that they cannot say just “yes” or “no” to. (Possible answers include: How are you feeding Johnny? What illnesses has Johnny had? How is Johnny behaving? Tell me how Johnny is feeding?) Exercise 7.B Reflecting back what a mother/caregiver says 1. My baby is passing a lot of stools – sometimes eight in a day. ü a. He is passing many stools each day? b. What are the stools like? c. Does this happen every day, or only on some days? 2. He doesn’t seem to want to suckle from me. a. Has he had any bottle feeds? b. How long has he been refusing? ü c. He seems to be refusing to suckle? 3. I tried feeding her from a bottle, but she spat it out. a. Why did you try using a bottle? ü b. She refused to suck from a bottle? c. Have you tried to use a cup? Infant and young child feeding counselling: an integrated course. Course handouts 128 4. Sometimes he doesn’t pass a stool for 3 or 4 days. (He doesn’t pass a stool some days?) or (for 3 or 4 days?) 5. My husband says our baby is old enough to stop breastfeeding now. (Your husband wants you to stop breastfeeding your baby?) 6. Optional short story exercise (To do if you have time, or need more practice) You meet Cora in the market with her 2-month-old baby. You say how well the baby looks, and ask how she and the baby are doing. She says “Oh, we’re doing fine. But she needs a bottle feed in the evening”. What do you say, to reflect back what Cora says? (Possible answers include: She seems to need more in the evening? She seems very hungry sometimes? She needs a bottle?) Exercise 7.C Empathizing – showing that you understand how the mother/caregiver feels 1. James has not been eating well for the past week. I am very worried about him. ü a. You are anxious because James is not eating? b. What did James eat yesterday? c. Children often have times when they do not eat well. 2. My breast milk looks so thin – I am afraid it is not good. a. That's the foremilk – it always looks rather watery. ü b. You are worried about how your breast milk looks? c. Well, how much does the baby weigh? 3. I feel there is no milk in my breasts, and my baby is a day old already. ü a. You are upset because your breast milk has not come in yet? b. Has she started suckling yet? c. It always takes a few days for breast milk to come in. 4. I am anxious that if I breastfeed I will pass HIV on to my baby. ü a. I can see you are worried about breastfeeding your baby. b. Would you like me to explain to you about how the HIV virus is passed from mothers to babies? c. What have you heard about other options for feeding your baby? 5. My breasts leak milk all day at work – it is so embarrassing. (It must be embarrassing if it happens at work.) 6. I have bad pains in my stomach when he is breastfeeding. (You are really having strong pains, aren’t you?) 7. Edna brings baby Sammy to see you. She looks worried. She says “Sammy breastfeeds very often, but he still looks so thin!” What would you say to Edna to empathize with how she feels? (Possible answers include: You are worried because Sammy looks thin to you? You are worried about how Sammy looks?) 7. Answer sheets 129 8. Catherine comes to the clinic. She is pregnant with her first baby and has found out she has HIV. She says: “I am frightened that my mother-in-law might find out”. What would you say to Catherine to empathize with how she feels? (Possible answers include: You are frightened about what your mother-in-law will think? You are worried about your mother-in-law finding out?) Exercise 7.D Translating judging words Using and avoiding judging words English Well Normal Enough Problem Local language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Judging question Does he suckle well? Are his stools normal? Is he gaining enough weight? Do you have any problems breastfeeding? Non-judging question How is he suckling? What are his stools like? How is your baby growing? How is breastfeeding going for you? Infant and young child feeding counselling: an integrated course. Course handouts 130 Session 9: Building confidence and giving support: exercises 1 – breastfeeding Exercise 9.A Accepting what a mother THINKS 1. Mother of a 1-month-old baby: “I give him drinks of water, because the weather is so hot now.” Oh, that is not necessary! Breast milk contains plenty of water. Yes, babies may need extra drinks of water in this weather. You feel that he needs drinks of water sometimes. Disagrees Agrees Accepts 2. Mother of a 9-month-old baby: “I have not been able to breastfeed for 2 days, so my milk is sour.” Breast milk is not very nice after a few days. You are worried that your breast milk may be sour? But milk never goes sour in the breast! Agrees Accepts Disagrees 3. “The first milk is not good for a baby – I cannot breastfeed until it has gone.” You do not want him to have the first milk? 4. “I don’t let her suckle for more than 10 minutes, because it would make my nipples sore.” You are frightened that you might have sore nipples? 5. “I need to give him formula milk now that he is 2 months old. My breast milk is not enough for him now.” I see... 7. Answer sheets 131 Exercise 9.B Accepting what a mother FEELS Story 1 Marion is in tears. She says that her breasts have become soft again, so her milk must be less, but the baby is only 3 weeks old. a. Don’t cry – I’m sure you still have plenty of milk. ü b. You are really upset about this, I know. c. Breasts often become soft at this time – it doesn’t mean that you have less milk! Story 2 Dora is very bothered. Her baby sometimes does not pass a stool for 1 or 2 days. When she does pass a stool, she pulls up her knees and goes red in the face. The stools are soft and yellowish brown. a. You needn’t be so bothered – this is quite normal for babies. b. Some babies don’t pass a stool for 4 or 5 days. ü c. It really bothers you when she doesn’t pass a stool, doesn’t it? Exercise 9.C Praising what a mother and baby are doing right Story 3 The mother of a 3-month-old baby says that he is crying a lot in the evenings, and she thinks that her milk supply is decreasing. The baby gained weight well last month. a. Many babies cry at that time of day – it is nothing to worry about. ü b. He is growing very well – and that is on your breast milk alone. c. Just let him suckle more often – that will soon build up your milk supply. Story 4 A 4-month-old baby is completely fed on replacement feeds from a bottle. She has diarrhoea. The growth chart shows that she weighed 3.5 kg at birth, and that he has only gained 200 g in the last 2 months. The bottle smells very sour. (Possible answer: I am glad that you came to the clinic, and it is very helpful that you brought her weight chart.) Exercise 9.D Giving a little, relevant information 1. Mother returning to work a b c d (e) f a. Foremilk normally looks watery, and hindmilk is whiter 2. Mother with a 12-month-old baby a b c d e (f) b. Exclusive breastfeeding is best until a baby is 6 months old 3. Mother who thinks that her milk is too thin (a) b c d e f c. More suckling makes more milk 4. Mother who thinks that she does not have enough breast milk a b (c) d e f d. Colostrum is all that a baby needs at this time 5. Mother with a 2-month-old baby who is exclusively breastfed a (b) c d e f e. Night breastfeeds are good for a baby and help to keep up the milk supply 6. A newly delivered mother who wants to give her baby prelacteal feeds a b c (d) e f f. Breastfeeding is valuable for 2 years or more Infant and young child feeding counselling: an integrated course. Course handouts 132 Exercise 9.E Using simple language Information Using simple language 1. Exclusive breastfeeding is best up to 6 months of age. Breast milk alone is all a baby needs until he is about 6 months old. 2. To suckle effectively, a baby needs to be well attached to the breast. To get the milk, your baby needs to take a big mouthful of breast. Exercise 9.F Giving a little, relevant information Command Suggestions Do not give your baby any drinks of water or glucose water, before he is at least 6 months old! You may find that breastfeeding is all that she needs – extra water is not usually necessary. Have you thought of giving her just breastfeeds? Babies can get all the water that they need from breast milk. Feed him more often, whenever he is hungry, then your milk supply will increase! A good way to build up your milk supply is to breastfeed your baby more often. Would you be able to breastfeed him more often? That is a good way to build up your milk supply. 7. Answer sheets 133 Session 10: Building confidence and giving support: exercises 2 – complementary feeding Exercise 10.A Accepting what a mother THINKS 1. Mother of a 7-month-old baby: “My child is not eating any food that I offer, so I will have to stop breastfeeding so often. Then he will be hungry and will eat the food.” Oh, no, you must not give him less breast milk. That is a bad idea. I see… Yes, sometimes babies do get full up on breast milk. Disagrees Accepts Agrees 2. Mother of a 12-month-old child: “My baby has diarrhoea, so I must stop giving her any solids.” Yes, often foods can make the diarrhoea worse. You are worried about giving foods at the moment? But solids help a baby to grow and gain weight again – you must not stop them now. Agrees Accepts Disagrees 3. “My neighbour’s child eats more than my child and he is growing much bigger. I must not be giving my child enough food.” You feel unsure whether your child is getting enough to eat? 4. “I am worried about giving my 1-year-old child family foods in case he chokes.” Mmm. You are concerned that she might choke. Exercise 10.B Accepting what a mother FEELS Story 1 Agnes is in tears. Her baby is refusing to eat vegetables and she is worried. a. Don’t cry – many children do not eat vegetables. ü b. You are really worried about this? c. It is important that your baby eats vegetables for the vitamins he needs. Story 2 Susan is crying. Since starting complementary foods, her baby has developed a rash on her buttocks. The rash looks like a nappy rash. a. Don’t cry – it is not serious. b. Lots of babies have this rash – we can soon make it better. ü c. You are really upset about this rash, aren’t you? Infant and young child feeding counselling: an integrated course. Course handouts 134 Exercise 10.C Praising what a mother and baby are doing right Story 3 A 15-month-old child is breastfeeding and having thin porridge and sometimes tea and bread. She has not gained weight for 6 months, and is thin and miserable. It is good that you are continuing to breastfeed her at this age. Story 4 A 9-month-old baby and his mother have come to see you. Here is the growth chart of the baby. Your baby gained weight last month on the food that you are offering him. Exercise 10.D Giving a little, relevant information 1. Mother with a 7-month-old baby. a (b) c d a. Children need extra water at this age – about 4–5 cups in a hot climate. 2. Mother with a 15-month-old baby who is getting two meals per day. a b (c) d b. Children who start complementary feeding at 6 completed months of age grow well. 3. Mother with a 12-month-old baby who thinks that the baby is too old to breastfeed any longer. a b c (d) c. Growing children of this age need 3–4 meals per day, plus 1–2 snacks if hungry, in addition to milk. 4. Mother of a non-breastfed child who is 11 months old. (a) b c d d. Breastfeeding to at least 2 years of age helps a child to grow strong and healthy. 7. Answer sheets 135 Exercise 10.E Using simple language Information Using simple language 1. Breastfeeding beyond 6 months of age is good, as breast milk contains absorbable iron, calories and zinc. Breastfeeding to at least 2 years of age helps a child to grow strong and healthy. 2. Non-breastfed children aged 14 months should receive protein, zinc and iron in appropriate quantities. For children who are not breastfeeding, it is helpful to give an animal-source food each day. Exercise 10.F Making one or two suggestions, not commands Command Suggestions 1. You must use thick foods. Family foods with a thick consistency nourish and fill the child. Would you be able to use thicker foods? 2. Your child should be eating a full bowl of food by 1 year of age. Increasing amounts of food helps a child grow. Could you give your child a full bowl of food at mealtimes? Infant and young child feeding counselling: an integrated course. Course handouts 136 Session 13: Assessing a breastfeed 1 Exercise 13.A Using the job aid: Breastfeed observation Job aid: Breastfeed observation – Slide 13/8 Mother's name: Baby's name: Date: Baby's age: Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother: □ Mother looks healthy □ Mother relaxed and comfortable □ Signs of bonding between mother and baby Mother: □ Mother looks ill or depressed □ Mother looks tense and uncomfortable □ No mother/baby eye contact Baby: □ Baby looks healthy □ Baby calm and relaxed □ Baby reaches or roots for breast if hungry Baby: □ Baby looks sleepy or ill □ Baby is restless or crying □ Baby does not reach or root BREASTS □ Breasts look healthy □ No pain or discomfort □ Breast well supported with fingers away from nipple □ Breasts look red, swollen, or sore □ Breast or nipple painful □ Breasts held with fingers on areola BABY'S POSITION □ Baby’s head and body in line □ Baby held close to mother’s body □ Baby’s whole body supported □ Baby approaches breast, nose to nipple □ Baby’s neck and head twisted to feed □ Baby not held close □ Baby supported by head and neck only □ Baby approaches breast, lower lip/chin to nipple BABY'S ATTACHMENT □ Baby’s mouth open wide □ Lower lip turned outwards □ Baby’s chin touches breast □ More areola seen above baby’s top lip □ Baby’s mouth not open wide □ Lips pointing forward or turned in □ Baby’s chin not touching breast □ More areola seen below bottom lip SUCKLING □ Slow, deep sucks with pauses □ Cheeks round when suckling □ Baby releases breast when finished □ Mother notices signs of oxytocin reflex □ Rapid shallow sucks □ Cheeks pulled in when suckling □ Mother takes baby off the breast □ No signs of oxytocin reflex noticed ü ü ü ü ü ü ü ü ü 7. Answer sheets 137 Job aid: Breastfeed observation – Slide 13/9 Mother's name: Baby's name: Date: Baby's age: Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother: □ Mother looks healthy □ Mother relaxed and comfortable □ Signs of bonding between mother and baby Mother: □ Mother looks ill or depressed □ Mother looks tense and uncomfortable □ No mother/baby eye contact Baby: □ Baby looks healthy □ Baby calm and relaxed □ Baby reaches or roots for breast if hungry Baby: □ Baby looks sleepy or ill □ Baby is restless or crying □ Baby does not reach or root BREASTS □ Breasts look healthy □ No pain or discomfort □ Breast well supported with fingers away from nipple □ Breasts look red, swollen, or sore □ Breast or nipple painful □ Breasts held with fingers on areola BABY'S POSITION □ Baby’s head and body in line □ Baby held close to mother’s body □ Baby’s whole body supported □ Baby approaches breast, nose to nipple □ Baby’s neck and head twisted to feed □ Baby not held close □ Baby supported by head and neck only □ Baby approaches breast, lower lip/chin to nipple BABY'S ATTACHMENT □ Baby’s mouth open wide □ Lower lip turned outwards □ Baby’s chin touches breast □ More areola seen above baby’s top lip □ Baby’s mouth not open wide □ Lips pointing forward or turned in □ Baby’s chin not touching breast □ More areola seen below bottom lip SUCKLING □ Slow, deep sucks with pauses □ Cheeks round when suckling □ Baby releases breast when finished □ Mother notices signs of oxytocin reflex □ Rapid shallow sucks □ Cheeks pulled in when suckling □ Mother takes baby off the breast □ No signs of oxytocin reflex noticed ü ü ü ü ü ü Infant and young child feeding counselling: an integrated course. Course handouts 138 Session 26: Observing a breastfeed Exercise 26.A Using the job aid: Breastfeed observation ► Conclusions ¤ Most of the ticks are on the right side, under Signs of possible difficulty. ¤ So the baby in Slide 26/13 is poorly positioned and poorly attached. ► Participants may also notice that the mother’s fingers are over the lower part of the areola, making it difficult for the baby to attach well. Job aid: Breastfeed observation – Slide 26/13 Mother's name: Baby's name: Date: Baby's age: Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother: □ Mother looks healthy □ Mother relaxed and comfortable □ Signs of bonding between mother and baby Mother: □ Mother looks ill or depressed □ Mother looks tense and uncomfortable □ No mother/baby eye contact Baby: □ Baby looks healthy □ Baby calm and relaxed □ Baby reaches or roots for breast if hungry Baby: □ Baby looks sleepy or ill □ Baby is restless or crying □ Baby does not reach or root BREASTS □ Breasts look healthy □ No pain or discomfort □ Breast well supported with fingers away from nipple □ Breasts look red, swollen, or sore □ Breast or nipple painful □ Breasts held with fingers on areola BABY'S POSITION □ Baby’s head and body in line □ Baby held close to mother’s body □ Baby’s whole body supported □ Baby approaches breast, nose to nipple □ Baby’s neck and head twisted to feed □ Baby not held close □ Baby supported by head and neck only □ Baby approaches breast, lower lip/chin to nipple BABY'S ATTACHMENT □ Baby’s mouth open wide □ Lower lip turned outwards □ Baby’s chin touches breast □ More areola seen above baby’s top lip □ Baby’s mouth not open wide □ Lips pointing forward or turned in □ Baby’s chin not touching breast □ More areola seen below bottom lip SUCKLING □ Slow, deep sucks with pauses □ Cheeks round when suckling □ Baby releases breast when finished □ Mother notices signs of oxytocin reflex □ Rapid shallow sucks □ Cheeks pulled in when suckling □ Mother takes baby off the breast □ No signs of oxytocin reflex noticed ü ü ü ü ü ü ü ü ü ü ü ü 7. Answer sheets 139 Job aid: Breastfeed observation – Slide 26/14 Mother's name: Baby's name: Date: Baby's age: Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother: □ Mother looks healthy □ Mother relaxed and comfortable □ Signs of bonding between mother and baby Mother: □ Mother looks ill or depressed □ Mother looks tense and uncomfortable □ No mother/baby eye contact Baby: □ Baby looks healthy □ Baby calm and relaxed □ Baby reaches or roots for breast if hungry Baby: □ Baby looks sleepy or ill □ Baby is restless or crying □ Baby does not reach or root BREASTS □ Breasts look healthy □ No pain or discomfort □ Breast well supported with fingers away from nipple □ Breasts look red, swollen, or sore □ Breast or nipple painful □ Breasts held with fingers on areola BABY'S POSITION □ Baby’s head and body in line □ Baby held close to mother’s body □ Baby’s whole body supported □ Baby approaches breast, nose to nipple □ Baby’s neck and head twisted to feed □ Baby not held close □ Baby supported by head and neck only □ Baby approaches breast, lower lip/chin to nipple BABY'S ATTACHMENT □ Baby’s mouth open wide □ Lower lip turned outwards □ Baby’s chin touches breast □ More areola seen above baby’s top lip □ Baby’s mouth not open wide □ Lips pointing forward or turned in □ Baby’s chin not touching breast □ More areola seen below bottom lip SUCKLING □ Slow, deep sucks with pauses □ Cheeks round when suckling □ Baby releases breast when finished □ Mother notices signs of oxytocin reflex □ Rapid shallow sucks □ Cheeks pulled in when suckling □ Mother takes baby off the breast □ No signs of oxytocin reflex noticed ► Conclusions ¤ Most of the ticks are on the right side, under Signs of possible difficulty. ¤ So the baby in Slide 26/14 is poorly positioned and poorly attached. ü ü ü ü ü ü ü ü ü ü Infant and young child feeding counselling: an integrated course. Course handouts 140 Job aid: Breastfeed observation – Slide 26/15 Mother's name: Baby's name: Date: Baby's age: Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother: □ Mother looks healthy □ Mother relaxed and comfortable □ Signs of bonding between mother and baby Mother: □ Mother looks ill or depressed □ Mother looks tense and uncomfortable □ No mother/baby eye contact Baby: □ Baby looks healthy □ Baby calm and relaxed □ Baby reaches or roots for breast if hungry Baby: □ Baby looks sleepy or ill □ Baby is restless or crying □ Baby does not reach or root BREASTS □ Breasts look healthy □ No pain or discomfort □ Breast well supported with fingers away from nipple □ Breasts look red, swollen, or sore □ Breast or nipple painful □ Breasts held with fingers on areola BABY'S POSITION □ Baby’s head and body in line □ Baby held close to mother’s body □ Baby’s whole body supported □ Baby approaches breast, nose to nipple □ Baby’s neck and head twisted to feed □ Baby not held close □ Baby supported by head and neck only □ Baby approaches breast, lower lip/chin to nipple BABY'S ATTACHMENT □ Baby’s mouth open wide □ Lower lip turned outwards □ Baby’s chin touches breast □ More areola seen above baby’s top lip □ Baby’s mouth not open wide □ Lips pointing forward or turned in □ Baby’s chin not touching breast □ More areola seen below bottom lip SUCKLING □ Slow, deep sucks with pauses □ Cheeks round when suckling □ Baby releases breast when finished □ Mother notices signs of oxytocin reflex □ Rapid shallow sucks □ Cheeks pulled in when suckling □ Mother takes baby off the breast □ No signs of oxytocin reflex noticed ► Conclusions ¤ The baby in Slide 26/15 is the same baby as in Slide 26/14, after a health worker has helped the mother to reposition her baby. ¤ Most of the ticks are on the left side, under Signs that breastfeeding is going well. ¤ So the baby is now better positioned. He is probably well attached, though he is so close to the breast that it is difficult to see his mouth. ü ü ü ü ü ü ü ü 7. Answer sheets 141 Job aid: Breastfeed observation – Slide 26/16 Mother's name: Baby's name: Date: Baby's age: Signs that breastfeeding is going well: Signs of possible difficulty: GENERAL Mother: □ Mother looks healthy □ Mother relaxed and comfortable □ Signs of bonding between mother and baby Mother: □ Mother looks ill or depressed □ Mother looks tense and uncomfortable □ No mother/baby eye contact Baby: □ Baby looks healthy □ Baby calm and relaxed □ Baby reaches or roots for breast if hungry Baby: □ Baby looks sleepy or ill □ Baby is restless or crying □ Baby does not reach or root BREASTS □ Breasts look healthy □ No pain or discomfort □ Breast well supported with fingers away from nipple □ Breasts look red, swollen, or sore □ Breast or nipple painful □ Breasts held with fingers on areola BABY'S POSITION □ Baby’s head and body in line □ Baby held close to mother’s body □ Baby’s whole body supported □ Baby approaches breast, nose to nipple □ Baby’s neck and head twisted to feed □ Baby not held close □ Baby supported by head and neck only □ Baby approaches breast, lower lip/chin to nipple BABY'S ATTACHMENT □ Baby’s mouth open wide □ Lower lip turned outwards □ Baby’s chin touches breast □ More areola seen above baby’s top lip □ Baby’s mouth not open wide □ Lips pointing forward or turned in □ Baby’s chin not touching breast □ More areola seen below bottom lip SUCKLING □ Slow, deep sucks with pauses □ Cheeks round when suckling □ Baby releases breast when finished □ Mother notices signs of oxytocin reflex □ Rapid shallow sucks □ Cheeks pulled in when suckling □ Mother takes baby off the breast □ No signs of oxytocin reflex noticed ► Conclusions ¤ Most of the ticks are on the left side, under Signs that breastfeeding is going well. ¤ So the baby in Slide 26/16 is well positioned and almost certainly well attached. It is difficult to see the baby’s mouth, because she is so close to the mother’s breast. ü ü ü ü ü ü ü ü ü ü Infant and young child feeding counselling: an integrated course. Course handouts 142 Session 29: Breast conditions: exercise Example: Mrs A says that both her breasts are swollen and painful. She put her baby to her breast for the first time on the third day, when her milk “came in”. This is the sixth day. Her baby is suckling, but now it is rather painful, so she does not let him suck for very long. Her milk is not dripping out as fast as it did before. What is the diagnosis? (Engorged breasts) What may have caused the condition? (Delay starting to breastfeed) How can you help Mrs A? (Help her to express her milk, and help her to position her baby at her breast, so that he can attach better.) To answer: Mrs B’s baby was born yesterday. She tried to feed her soon after delivery, but she did not suckle very well. She says that her nipples are inverted, and she cannot breastfeed. You examine her breasts, and notice that her nipples look flat. You ask Mrs B to use her fingers and to stretch her nipple and areola out. She is able to stretches the nipple out a short way, showing that the nipple and areola are protractile. What could you say to accept Mrs B’s idea about her nipples? (Something such as: I see or You are worried about your nipples?) How could you build her confidence? (Praise the protractility of her breasts. Give her relevant information. For example, explain how, if her baby suckles from the breast not the nipple, she stretches the nipple out. She can get the milk if she takes a big mouthful of breast.) What practical help could you give Mrs Betty? (Offer to help her to get her baby to take more of her breast into her mouth, that is, to improve her attachment.) Mrs C has had a painful swelling in her left breast for 3 days. The skin of a large part of the breast looks red, and it is hard and extremely tender. Mrs C has a fever and feels too ill to go to work today. She is a teacher in the local primary school. Her baby sleeps with her and breastfeeds at night. By day, she expresses milk to leave for him. She has no difficulty in expressing her milk. But she is very busy, and it is difficult for her to find time to express milk, or to breastfeed her baby during the day. What is the diagnosis? (Mastitis. It is not possible to say if it is infective or non-infective.) Why do you think that Mrs C has this condition? (She is very busy, and she feeds and expresses in a hurry. There is a long time between feeds during the day.) How would you treat Mrs C? (Suggest that she takes sick leave for a few days, and breastfeeds her baby more often. Help her to get a sick-leave certificate so that she can do this. Ask her about family members and friends who could help her with some of her tasks at home. • She should rest as much as possible, in bed if she can. • Give her analgesics (ibuprofen) for a few days. • If the mastitis is not better by tomorrow, give her antibiotics.) What could you suggest to prevent the same problem occurring again? (Discuss the reasons why the condition has occurred. Help her to think of ways to breastfeed her baby more, and to take more time to express her milk, especially during the day.) 7. Answer sheets 143 Mrs D complains of nipple pain when her 6-week-old baby is suckling. You examine her breasts while her baby is asleep, and can see no fissures. When the baby wakes, you watch her feeding. Her body is twisted away from her mother’s. Her chin is away from the breast, and her mouth is not wide open. She takes rapid, shallow sucks. As she releases the breast, you notice that the nipple looks squashed. What is the cause of Mrs Dora’s nipple pain? (Her baby is poorly attached to her breast.) What could you say to build Mrs Dora’s confidence? (Possibilities include: Praise her for breastfeeding exclusively; Give relevant information, in a positive way, using simple language: If you hold your baby closer so that she can take more of the breast into her mouth, breastfeeding should soon be more comfortable.) What practical help could you give her? (Offer to help her to improve her baby’s position and attachment.) Mrs E says that her right breast has been painful since yesterday, and she can feel a lump in it, which is tender. She has no fever and feels well. She has started to wear an old bra which is tight, because she wants to prevent her breasts from sagging. Her baby is 10 weeks old and now sometimes sleeps for 6–7 hours at night without feeding. You watch him suckling. Mrs E holds him close, and his chin is touching her breast. His mouth is wide open and he takes slow, deep sucks. What could you say to empathize with Mrs Ellen’s worries about her figure? (You are worried that breastfeeding may change your figure?) What is the diagnosis? (Blocked duct) What may be the cause? (Tight clothes, and a long interval between feeds at night. The baby’s attachment to the breast is good.) What three suggestions would you give Mrs Ellen? (1. Breastfeed her baby more often for a day or two. 2. Massage the lump gently while her baby is feeding. 3. Try to find a larger bra, which supports her breasts without blocking the ducts.) Mrs F’s baby is 3 months old. She says that her nipples are sore. They have been sore on and off since an attack of mastitis several weeks ago. The mastitis cleared up after a course of antibiotics. This new pain feels like needles going deep into her breast when her baby suckles. The pain continues between feeds, and her nipples are sometimes itchy. You watch her baby breastfeeding. You can see areola above the baby’s mouth but not below. The baby’s mouth is wide open, her lower lip is turned back, and her chin is close to the breast. The baby takes some slow deep sucks and you see her swallow. What might be the cause of Mrs Flora’s sore nipples? (Candida infection. Her baby is well attached to her breast.) What treatment would you give to her and her baby? (Give gentian violet or nystatin for her nipples. Check and treat her baby’s mouth and bottom for Candida.) How would you build Mrs Flora’s confidence? (Possibilities include: Praise the way in which her baby is suckling. Give relevant information: explain the reason for the sore nipples, and explain that breastfeeding should be comfortable again after the treatment.) Infant and young child feeding counselling: an integrated course. Course handouts 144 Mrs G says that her breasts are painful. Her baby is 5 days old. Both Mrs Graces’ breasts are swollen, and the skin looks shiny. The nipples are stretched flat and there is a fissure across the tip of her right nipple. You watch her breastfeeding. Her baby is restless and makes smacking sounds as he tries to suckle. After a few sucks, he pulls away and cries. What can you say to empathize with Mrs Grace? (You are very uncomfortable, aren’t you?) What is the cause of Mrs Grace’s difficulties? (Her breasts are engorged, her nipples are stretched tight and her baby cannot attach well, and her right nipple is damaged.) What practical help can you give Mrs Grace? (Help her to express some of her milk, by hand or pump, to make the breasts softer. Then help her to attach her baby to her breast better. Suggest that she breastfeeds her as often as she is willing, so that the baby removes more of the milk. She may need to express again until the engorgement has cleared.) 7. Answer sheets 145 Session 30: Refusal to breastfeed Exercise 30.A Breast refusal How to do the exercise: • Read the stories, and write your answers to the questions in pencil in the space after each story. • When you have finished, discuss your answers with the trainer. To answer: Mrs H had her baby 3 days ago. She says that she has been trying by herself to put her baby to her breast for 2 days, but he could not attach well, and now he is refusing. She will have to bottle feed. A nurse has now come to help Mrs H to attach the baby. The nurse puts the baby to face Mrs H’s breast. The nurse then holds Mrs H’s breast with one hand, and the back of the baby’s head with her other hand. The nurse then tries to push the baby onto the breast. The baby pushes his head back and cries. Why does Mrs H’s baby refuse to breastfeed? (The baby had difficulty attaching, and Mrs H did not receive help at first. Now a nurse has come to help her, but the nurse’s technique is not good. She is pushing on the back of the baby’s head, which makes the baby want to fight back.) What could you say to praise the mother and the nurse? (The mother: It is good that you are still trying to breastfeed. The nurse: It is good that you are trying to help Mrs Haley to attach her baby.) What would you suggest that the nurse does differently? (Suggest that a different technique might help: • Try to guide the mother to position and attach her baby by herself, without touching. • Show her what to do using a doll, if you have one, or a rolled up towel. • Explain that she should support the baby by his shoulders and back, and not by pressing on his head. • If you need to help her to position the baby, put your hand over her hand to guide her – do not hold the baby yourself. See Sessions 14 and 27: Positioning a baby at the breast 1 and 2.) What three things could you suggest that Mrs H does? (Do not try to make the baby take the breast any more now. Let him enjoy skin-to-skin contact, and explore the breast with his mouth, until he is willing to try to suckle. Teach her to express her breast milk to feed him by cup until he suckles.) Mrs J has a baby who is 1 month old. The baby was born in hospital, and was given three bottle feeds before she started to breastfeed. When Mrs J went home, her baby wanted to breastfeed often, and she seemed unsatisfied. Mrs J thought that she did not have enough milk. She continued to give bottle feeds, in addition to breastfeeding, and hoped that her supply of breast milk would increase. Now her baby is refusing to breastfeed. When Mrs J tries to breastfeed, the baby cries and turns away. Mrs J wants very much to breastfeed, and she feels rejected by her baby. What could you say to empathize with Mrs J? (You are upset that she seems not to want your breast milk.) Why is Mrs J’s baby refusing to breastfeed? (She started having bottle feeds before breastfeeding was established, and did not learn to attach properly.) What two pieces of relevant information might be helpful to Mrs J? (Explain why the baby is refusing: Your baby is having difficulty getting your breast milk, so she is frustrated. She has learnt to get milk from a bottle. Reassure her that she can overcome it: She still wants you, and she can learn to enjoy breastfeeding again.) Infant and young child feeding counselling: an integrated course. Course handouts 146 What four things would you offer to help Mrs J to do, so that she and her baby can enjoy breastfeeding again? (1. Stop using the bottle – feed her by cup. 2. Keep her baby close, with skin-to-skin contact, and offer her breast whenever she is willing. 3. Express her milk, and feed it to her baby by cup. 4. Learn how to position her baby so that, when she is ready, she can attach well.) Mrs K says that her 3-month-old baby is refusing to breastfeed. He was born in hospital and roomed-in from the beginning. He breastfed without any difficulty. Mrs K returned to work 2 weeks ago. Her baby has 2–3 bottle feeds while she is at work. For the last week, he has refused to breastfeed when she comes home in the evening. She thinks that her breast milk is not good, because she works hard and feels hot all day. What could you say to accept Mrs K’s ideas about her milk? (O dear. Or: You think that getting hot harms your milk?) What might be the cause of her baby’s refusal to breastfeed? (He is separated from his mother for a large part of the day. Also, he has bottle feeds while she is away.) What praise and relevant information could you give to build Mrs K’s confidence? (Praise her for breastfeeding up till now, and for her baby’s good health. Relevant information: breast refusal is quite common when a baby’s routine changes, and can be overcome.) What could you suggest that she does to breastfeed again? (Suggest that, if possible, she takes sick leave, and cares for the baby herself, with plenty of skin-to-skin contact, offering him her breast when he is willing. She should express her milk to feed him with. She can give other feeds from a cup and not a bottle, so that her baby wants to suckle when she is with him. If she cannot take sick leave, she can try to do the same thing over a weekend, and whenever she is at home. Ask the person who cares for the baby to use a cup not a bottle to feed him.) 7. Answer sheets 147 Session 32: Taking a feeding history – 0 up to 6 months: exercise Story 1 Reason for visit: My mother told me to bring the baby (baby’s name). Everything is fine. History: 1. I give him formula, about 3 bottles a day, with 2 spoonfuls of milk powder in each bottle. He had difficulty in suckling, so I gave him bottle feeds while I tried to breastfeed. He has refused to breastfeed for 2 weeks. 2. He is 6 weeks old and weighs 2.5 kg. He was born in hospital and weighed 2.0 kg. He has 2–3 soft stools a day. They did not measure his length. 3. I didn’t go to the antenatal clinic. In hospital, he was in the nursery for 6 hours. The midwives did not talk to me or help me to breastfeed, and I was frightened to ask. They discharged me after 24 hours. I did not know what to do with the baby. My breasts got very full after 2 days and my mother told me to breastfeed. 4. I am 15 years old, and healthy. My nipples are flat and my breasts are painful. I don’t know anything about family planning. This is my first visit to a health centre. They make me feel ashamed. 5. This is my first baby. 6. I was at school before the baby came. My mother bought the tins of formula. My father wants me to find a job and a place of my own, to look after myself and the baby. Story 2 Reason for visit: My baby (baby’s name) has diarrhoea. History: 1. I breastfeed her often, and she sleeps with me at night. I give her thin cereals in a bottle, 2–3 times a day. I started this when she was about 8 weeks old. 2. She is 4 months old. She was born in hospital, and weighed 3.0 kg, her length was 50 cm. She weighed 4.5 kg at 2 months, and weighs 4.8 kg now. I am not aware of her being measured after birth. When she was about 7 weeks old, she started crying to be fed often; that is why I started cereal feeds. But now she has less appetite and is passing watery stools. 3. She started to breastfeed soon after delivery. The midwife helped me and I had no difficulties. 4. I am aged 30, and well. I rely on breastfeeding for family planning until my periods start again. 5. I had two previous children. I breastfed both without any difficulty. 6. I work on a small farm with my husband and his parents. My mother-in-law helps me very much. She advised me to start cereals, because of the crying. Story 3 Reason for visit: I have sore nipples. History: 1. I breastfeed my baby many times a day, for about 20–30 minutes each time. He also sleeps with me and feeds at night. 2. He weighed 4.0 kg when he was born. Now he is 3 weeks old and weighs 4.5 kg. He is well. I do not know his length, did not know they have to measure his length. 3. He was born by caesarean section, and was kept in the nursery and bottle fed for 2 days. Since then, I have been trying to breastfeed, but my baby had difficulty in learning to suckle. The midwives suggested bottles, but I did not want to bottle feed. I persisted with breastfeeding until now. Nobody asked me about breastfeeding at the antenatal clinic. 4. I am 26, and healthy. I am disappointed because I really want to breastfeed, but my nipples hurt so much that I will have to give up. They bleed sometimes. And he feeds so often that I think I don’t have enough milk. 5. I had one baby before. I breastfed him, but I never had enough milk and he was never satisfied. I gave up after a few weeks. 6. I am divorced, but my mother stays with me and helps me with the children. Infant and young child feeding counselling: an integrated course. Course handouts 148 Story 4 Reason for visit: I have come for my 6 weeks’ postnatal check-up. Everything is fine. History: 1. I breastfeed her quite often. I don’t give her anything else, but I have bought a pacifier, which I give her to suck when she cries. 2. I don’t know her birth weight or length. She weighs 4.9 kg today. She cries a lot, and doesn’t seem satisfied. She passes soft stools several times a day. Otherwise she is well. 3. She was born at home, and started breastfeeding soon after delivery. She had some water for the first few days. My mother helped me to breastfeed. 4. I am 18 years old, and I am worried that breastfeeding will spoil my figure. I want to bottle feed, like the advertisements. I will get some milk, when I have some money. 5. I have not had a baby before. 6. I live at home with my mother, who farms. She helps me a lot but she says that the baby cries a lot because I don’t eat enough and I probably don’t have enough milk. She thinks she may need other milk too. Story 5 Reason for visit: I have a painful swelling in my breast, and I feel feverish. History: 1. I breastfeed my baby whenever I am at home, about once in the morning, twice in the evening, and a few times in the night. He suckles for about 5 minutes each time. While I am working, my helper gives him bottle feeds of formula. This started when I went back to work about 1 month ago. Before that I just breastfed. 2. My baby is 4 months old and healthy. He weighed 3.5 kg. Now he weighs 5.9 kg. I don’t know how often he passes urine – I am not at home. 3. He was born at home, and I breastfed him straight away. The community midwife helped me. [If she works in a factory and she has a helper at home, she may be covered by social security and therefore could deliver in a social security hospital.] 4. I am 27 years old, and healthy. I had a painful swelling in the other breast soon after I went back to work. It was at the weekend, I continued breastfeeding, and it got better by itself. This time it is worse. 5. I have one older child. I breastfed him for 4 months, until my milk dried up. I started work when he was 2 months old, and bottle fed him when I was out. I was very disappointed when I had to stop breastfeeding. 6. I work in a factory, and I am away from home for about 10 hours every day. I am exhausted when I get home. I am too busy to breastfeed my baby for long. I have a helper who cares for the children. My parents live a long way away. 7. Answer sheets 149 Comments on the stories Story 1 The baby refuses to breastfeed because he has been given bottle feeds. The mother did not have early contact, or help to breastfeed in the first day. She needed help for flat nipples. This is her first baby, and the baby was small and had difficulty feeding. But this is not just a breastfeeding situation. She is an adolescent single mother, her father is unsupportive and her mother is not very helpful. The health services are unfriendly and disapproving, and give her the minimum of help. She is too ashamed to ask and just struggles on. You only learn about this serious situation when you ask about her own condition and her social situation. Story 2 The baby was hungry, probably with a growth spurt. She was growing well on her breast milk alone for the first 2 months, and there were no other difficulties with breastfeeding. She gave dilute cereal feeds because of the crying, but they were not necessary. This has caused diarrhoea and slowing of growth. You know the reason for the diarrhoea by the end of Section 1 of the Job aid: Feeding history – 0 up to 6 months. However, in Section 6, you learn that it is her mother-in-law who advises her. It is very important to know this, as explaining to the mother may not be useful unless you can also talk to her mother-in-law. Story 3 The mother did not receive the necessary help from the hospital staff to enable her to breastfeed. Her baby is probably poorly attached, which is causing sore nipples (you will find this out later by observing a breastfeed). He is growing, so he must be getting plenty of milk, but he is suckling inefficiently, and needs to suckle often and for a long time. You know what her main problem is early in the history. But it is important to know that she had also had problems breastfeeding her previous baby, so she lacks confidence and knowledge that could help her to breastfeed successfully. Story 4 The mother is very young and breastfeeding, but not very motivated. She says that everything is fine, but she is worried that it may spoil her figure. Also, she has seen advertisements about formula feeding and would like to do that (see Session 82: Commercial promotion of breast-milk substitutes). The grandmother, even though she tries to be supportive, is making her lose confidence in her milk, by suggesting that she does not have enough. You only learn about these important things quite late in the history, so it is useful to check through all the sections. Story 5 The mother has mastitis, probably because her baby is only feeding for a short time, and not often enough, so the baby is not emptying the breasts properly. It is important not to stop when you make the diagnosis of mastitis, but to continue to Section 6, so that you learn how busy and tired this mother is. That is important for the management. Note about the comments Some things are mentioned in the histories that have not been covered in the sessions – such as advertisements for family planning and formula milk. They are only mentioned in a general way, and do not require much knowledge. If necessary, the trainer should be able to explain the importance of the topic in the history. Infant and young child feeding counselling: an integrated course. Course handouts 150 Session 36: “Not enough milk” and Crying: exercise How to do the exercise: ¤ Read through the following stories about mothers who feel that they do not have enough milk, or whose babies are crying “too much”. ¤ Use a growth chart to decide whether a child is growing adequately. ¤ Write your answers to the questions in pencil in the space after each story. ¤ When you have finished, discuss your answers with the trainer. Example: Mrs M says that she does not have enough milk. Her baby is crying “all the time”. He is 3 months old, and weighs 5.5 kg. Last month he weighed 5.3 kg, and the month before 5.0 kg. Mrs M manages the family farm by herself, so she is very busy. She breastfeeds her baby about 2–3 times at night, and about twice a day, whenever she has time. She does not give her baby any other food or drink. What could you say to empathize with Mrs M? (You are very busy; it is difficult to find time to feed a baby.) Is Mrs M’s baby getting enough milk? (No he is not getting enough – he has only gained 400 g in 2 months, and his growth is not following the standard growth curves.) What do you think is the cause of Mrs M’s baby not getting enough milk? (Mrs M is not breastfeeding him often enough.) Can you suggest how Mrs M could give her baby more breast milk? (Could she take her baby with her so that she could breastfeed him more often? Could someone bring her baby to her where she is working? Could she express her breast milk to leave for her baby?) To answer: Mrs N’s baby is 6 weeks old. She says that her breast milk is not good, and her baby does not seem satisfied. She weighed 3.4 kg at birth and now weighs 5 kg. Mrs N’s baby cries and wants to feed often, after an hour, or an hour and a half. She sometimes feeds for 30 minutes or more. She cries and wants to breastfeed often at night too, and Mrs N is exhausted. She passes pale urine about 6 times a day. You assess a breastfeed and you notice that Mrs N holds the baby loosely, her chin does not touch her breast, there is more areola visible below the baby’s mouth than above it, and the baby’s lips point forward. Is Mrs N’s baby getting as much breast milk as she needs? (Yes, she is getting as much as she needs. Her growth curve is following the standard curves.) What may be the reason for her behaviour? (She is poorly attached to the breast, so she is not suckling effectively. In order to get enough breast milk, she has to feed very often and for a long time. ) What information would you give Mrs N? (Her baby is getting the breast milk that she needs, but she is not getting it easily. She could get the milk more easily and would be more content if she takes the nipple into her mouth from below, so that her chin is closer to the breast.) What practical help would you offer to Mrs N? (Offer to show her how to improve her baby’s attachment at the breast.) 7. Answer sheets 151 Mrs O says that she is exhausted, and will have to bottle feed her 2-month-old baby. The baby’s growth chart shows that he weighed 2.9 kg at birth, 3.2 kg at 1 month of age and 3.5 kg at 2 months. He goes to sleep after a breastfeed, but then wakes up very soon and wants to feed again – she cannot count how many times in a day. She thinks that she does not have enough breast milk. While she is talking to you, her baby wants a feed, and you observe him suckling. His mouth is wide open, there is more areola above than below his mouth, and his chin is close to the breast. You cannot see his lower lip as he is close to the breast. After about 2 minutes, he pauses and Mrs O quickly takes him off her breast. What could you say to show that you accept Mrs O’s ideas about her milk? (Yes, I see. You are worried about your milk?) Is Mrs O’s baby getting enough breast milk? (No. He is gaining weight slowly. His growth is not following the standard curves) What is the reason for this? (She does not let him suckle for long enough.) What can you suggest to help Mrs O? (Suggest that she lets her baby stay at the breast for longer at each feed. She should let her baby continue suckling until he releases the breast himself. If he pauses, let him just stay at the breast until he suckles again. If he stays at the breast longer at each feed, he will not need to feed so often.) Mrs P is 16 years old. Her baby was born 2 days ago and is very healthy. She has tried to breastfeed her twice, but her breasts are still soft, so she thinks that she has no milk and will not be able to breastfeed. Her young husband has offered to buy her a bottle and some formula. What could you say to accept what Mrs P says about her breast milk? (You think that there is no milk in your breasts? You are worried about your breast milk?) What is the reason why Mrs P doubts her ability to breastfeed? (She lacks confidence, and she lacks knowledge. Her milk has not “come in” yet – but this is normal.) What relevant information would you give her? (Her breasts already have some milk, a special kind called “colostrum”. This is what her baby needs just now. Explain that if her baby suckles more often, it will help more milk to come in. In a day or two, her breasts will feel full.) What practical help could you give Mrs P? (Offer to help her to put her baby to her breast. Help her when her baby shows, by restlessness or mouthing, that she is ready for a feed.) Infant and young child feeding counselling: an integrated course. Course handouts 152 Mrs Q says that her baby always cries in the evenings, and seems to be hungry. He is 6 weeks old, and weighs 5.2 kg. He weighed 3.7 kg when he was born. Mrs Q’s baby has been crying in the evenings since the age of 2 weeks. At other times he breastfeeds well and is more contented. Mrs Q’s sister told Mrs Q that she probably does not have enough milk when she is tired in the evening. Her sister suggested that Mrs Q give a bottle feed in the evening, so that she can save up her milk for the night feeds. Mrs Q drinks tea once or twice a day. She does not smoke cigarettes, and she does not drink milk or coffee. Is Mrs Q’s baby getting enough milk? (Yes – he has gained 1.5 kg in 6 weeks. His growth curve is following the standard curves.) What is the cause of Mrs Q’s baby’s crying? (This is probably colic. She drinks only a little tea, so caffeine is unlikely to be the cause.) What are Mrs Q and her baby doing right, that you could praise? (Her baby is gaining weight well. He is getting all that he needs from her breast milk.) What three pieces of information would you give to her? (1. Supplementary feeds are not necessary, and might make the breast milk decrease. 2. Medicines for colic are not recommended. 3. This colicky crying usually decreases after 3–4 months. That seems like a long time to wait, but it does improve in the end.) What could you suggest that Mrs Q might do, to help her baby meanwhile? (Discuss different ways to carry and comfort her baby more.) Mrs R says that her breasts seem to be empty and her baby is hungry. Her baby is 4 months old, and weighs 5.3 kg. She weighed 3 kg at birth, and at 2 months of age she weighed 4.9 kg. Mrs R’s baby started feeding immediately after delivery, and has demand fed since then. She breastfeeds about 6 times a day and several times in the night, for about 15–20 minutes each time. Recently, she has not seemed satisfied, and Mrs R’s breasts do not seem full even before a feed. The baby has never had any other food or drinks, and Mrs R has not had any breast problems. This is her fourth baby and she does not want another, so she has been taking family planning pills since she was 6 weeks old. You observe a breastfeed, and see more areola above than below the baby’s mouth, her mouth is wide open, her lower lip is turned out and her chin touches the breast. She continues suckling for more than 20 minutes, and then stops by herself. Is Mrs R’s baby getting enough milk? (Not during the last 2 months. For the first 2 months, she gained well, and her growth followed the standard curves. But from 2–4 months of age, her growth curve has fallen below the standard curve, so she is not getting enough milk.) What do you think may be the cause of the poor weight gain? (This may be because Mrs R is taking contraceptive pills. There does not seem to be any difficulty breastfeeding. You need to find out if the pill is one that contains estrogen, for example “combined” pills.) What information would you give Mrs R? (The low milk supply may be due to the contraceptive pill. You will try to help her to find another method, and build up her supply again.) How do you suggest that she feeds her baby meanwhile? (She should continue to breastfeed her as often as possible, including at night, and for as long as possible at each feed. If possible, she should avoid giving supplementary feeds, because this may make the baby suckle less at the breast, which could reduce her breast milk more. It would have all the risks and disadvantages of mixed feeding. Follow the baby up within a week, to check whether her weight is increasing, and whether Mrs R feels that her breasts feel full and her milk supply is increasing. If not, she may have to give the baby one or two supplementary feeds each day by cup, while continuing frequent breastfeeds, until her milk supply does increase (see Session 39: Increasing breast milk and relactation). 7. Answer sheets 153 Session 38: Feeding low-birth-weight and sick babies Exercise 38.A Feeding low-birth-weight and sick babies How to do the exercise: ¤ For Question 1 (optional), use the information in the box Amount of milk to give to babies who cannot breastfeed, to calculate how much milk the baby needs. Read the Example. ¤ For Questions 2 and 3, explain briefly how you would advise the mother about feeding her baby. Example: Mabel’s baby was born 8 weeks early, and cannot yet suckle strongly. Mabel is expressing her milk and feeding her baby 3-hourly by cup. He weighs 1.6 kg, and it is the 5th day. How much milk should Mabel give at each feed today? A low-birth-weight baby needs 60 mL/kg on the first day On the fifth day, he will need (60 + 20 + 20 + 20 + 20) mL/kg = 140 mL/kg Mabel’s baby weighs 1.6 kg, so he will need: 1.6 × 140 = 224 mL on the 5th day He feeds 3-hourly, so he has 8 feeds each day So at each feed he needs 224 ÷ 8 mL = 28 mL of expressed breast milk (Mabel should offer a little more than this if possible, for example, 30 mL. This also allows for spillage.) To answer: Question 1 (optional) Baby Anna was born at 31 weeks’ gestation and cannot yet suckle. She weighs 1.5 kg and you are tube feeding her with her mother’s expressed breast milk. This is the second day she has taken oral feeds. You are feeding her 2-hourly. How much will you give at each feed? (Baby Anna needs 1.5 × (60 + 20) mL = 120 mL/day If she has 12 feeds per day, she needs 10 mL per feed You are tube feeding, so you do not need to give extra.) Question 2 Mona has just delivered a baby 6 weeks before her expected date. He weighs 1500 g, and is being observed in the special care unit. Mona wants to breastfeed, but she is worried that her baby will not be able to. What could you say to empathize with Mona? (You are worried about your baby, aren’t you?) What could you say to build her confidence? (Possibilities include: • Many babies as small as your baby can breastfeed. • It is good that you want to breastfeed – your milk will help your baby.) Question 3 Baby Zora is 3 days old and today her eyes and skin look slightly yellow. Her mother breastfeeds her 3–4 times a day, and she also gives Zora glucose water between breastfeeds. What relevant information would you give to Zora’s mother? (Jaundice at this age is common and not usually serious. Breast milk can help jaundice to clear.) How would you advise her mother to feed Baby Zora now? (Advise her to breastfeed Zora more often. Suggest that she stops giving the feeds of glucose water, and gives extra breastfeeds instead.) Infant and young child feeding counselling: an integrated course. Course handouts 154 Session 39: Increasing breast milk and relactation Exercise 39.A Relactation How to do the exercise: • Use the information in the box Amount of milk to give to babies who cannot breastfeed on page 294 in your Participant’s manual, to calculate the total amount of milk the baby needs. • Use the information in the box How to help a woman to increase her supply of breast milk on page 300 in your Participant’s manual, to decide how to decrease the milk as the mother relactates (see third point from the bottom in the box). Example: Ada died soon after her baby was born. Ada’s mother will look after the baby, and she wants to breastfeed him. She breastfed all her own children. The youngest is 12. Ada’s baby is now 4 weeks old and weighs 4.5 kg. Ada’s mother will let the baby suckle, and she will feed the baby formula milk with a supplementer, while she waits for her breast milk to come back. How much artificial milk should Ada’s mother give to the baby in total each day at the beginning? Each day the baby needs 150 mL/kg So she needs (150 × 4.5) = 675 mL milk in total each day After a few days, when Ada’s mother starts to produce a little milk, she will start to reduce the amount of artificial milk by 30 mL each day. How much milk will she give on the first day that she reduces the amount? She will give (675 – 30) mL = 645 mL How much milk will she give the next day? She will give (645 – 30) mL = 615 mL To answer: A baby aged 2 months has been bottle fed for 1 month. She has become very ill with diarrhoea, and formula milk feeds make the diarrhoea worse. Her mother breastfed satisfactorily for the first 4 weeks, and wants to relactate. The baby seems willing to suckle at the breast. You will feed the baby donated expressed breast milk by cup while her mother’s supply of breast milk builds up. You will reduce the volume of expressed breast milk by 30 mL per day. The baby weighs 4.0 kg. How much expressed breast milk will you give the baby by cup each day at the beginning? (Give a total of 600 mL each day.) How much expressed breast milk will you give the baby on the first day that you reduce the amount? (570 mL) How much expressed breast milk will you give on the tenth day of reducing the amount? (300 mL) How much milk will you give at each feed, if you feed the baby 10 times a day? (The baby will need 30 mL; put 35 mL into the cup, as it is difficult to suck every drop.) How many days should it take from when you start to reduce the amount to when you stop giving expressed breast milk altogether? (Cup feeds should stop after about 20 days.) 7. Answer sheets 155 Session 40: Sustaining breastfeeding Exercise 40.A Sustaining breastfeeding with growth monitoring How to do the exercise: ¤ Study the growth charts of the following babies, and the short notes that go with them. ¤ Read the Example of Baby 1 for which the answers are given. ¤ Then look at the charts To answer for Babies 2, 3, 4 and 5, and answer the questions about them. ¤ When you are ready, discuss your answers with the trainer. Example: Baby 1 is exclusively breastfed. She slept with her mother until 8 weeks ago. Now she sleeps in a separate bed. What is Baby 1’s mother doing that you could praise? (Her mother has breastfed exclusively all this time.) What do you think about Baby 1’s recent weight gain? (Her growth is slowing down.) Why may this have happened? (She stopped having night feeds.) What would you suggest to his mother about feeding her now? (Let her baby sleep with her again, to breastfeed at night. Soon she should add complementary foods.) To answer: Baby 2 has come for immunization. Her mother says that she is well. She is a very good baby and cries very little. She only wants to feed about 4–5 times a day, which her mother finds helpful, because she is very busy. What could you say to show that you accept how Baby 2’s mother feels? (You find it helpful to have a contented baby?) What do you think of Baby 2’s weight gain? (She is gaining weight too slowly.) What is the reason? (She does not breastfeed often enough.) What would you like to suggest to Baby 2’s mother about feeding her? (Could she feed her more often? She need not wait for her to show signs of hunger.) Infant and young child feeding counselling: an integrated course. Course handouts 156 Baby 3 was exclusively breastfed until last month. Now her mother gives her drinks of water, because the weather is hot and she seems so thirsty. What do you think of Baby 3’s weight gain? (She gained very well for the first 2 months, but last month she has gained too slowly.) What is the reason for her weight this month? (She has been having drinks of water. Note: Giving water may make a baby suckle less at the breast and take less breast milk.) What relevant information could you give to Baby 3’s mother? Try to give positive information. (Breast milk contains all the water that a baby needs, even in hot weather.) What would you suggest to Baby 3’s mother? (Can you breastfeed more often if she is thirsty, instead of giving drinks of water?) Baby 4 has come for measles immunization. She breastfeeds frequently by day, and sleeps with her mother and breastfeeds at night. Two months ago, her mother started to give her thin cereal porridge once a day. What is Baby 4’s mother doing right? (She is breastfeeding frequently by day and by night.) What do you think of Baby 4’s weight gain? (She gained weight well for the first 6 months of life, but since then he has stopped growing.) What do you think is the reason for the change? (She is not getting enough complementary food. Note: At this age, breast milk alone is not enough.) What two things would you suggest to Baby 4’s mother? (1. Give Baby 4 energy-rich and nutrient-rich complementary foods 4–5 times a day. 2. Continue breastfeeding day and night, in addition to giving more food. Think of breastfeeding until she is 2 years old.) Baby 5’s mother has come for help with family planning. When you have given her this help, you ask about the baby. She was exclusively breastfed until the age of 6 months. Since then, she has had complementary food at first twice, and more recently four times, a day. She continues to breastfeed at night and several times during the day. What do you think about Baby 5’s growth? (She is growing very well. Note: She is not “overweight”. Her growth line is following the standard curve.) What can you say to praise her mother? (You must be pleased that she is doing so well, mainly because you are feeding her in such a healthy way.) What would you suggest to her mother about breastfeeding? (It would be a good idea to continue breastfeeding until she is at least 2 years old.) 7. Answer sheets 157 Session 46: Variety, frequency and quantity of feeding Exercise 46.A Amounts to give Age of child Frequency Amount at each meal 6 months 2 days Two times per day 2 to 3 tablespoonfuls 22 months Three to four meals ( may offer 1–2 snacks) ¾ to 1 cup 8 months Two to three times per day (may offer 1–2 snacks) up to ½ cup 12 months Three to four meals ( may offer 1–2 snacks) ¾ to 1 cup 7 months Two to three times per day (may offer 1–2 snacks) up to ½ cup 15 months Three to four meals ( may offer 1–2 snacks) ¾ to 1 cup 9 months Three to four meals ( may offer 1–2 snacks) ½ cup 13 months Three to four meals ( may offer 1–2 snacks) ¾ to 1 cup 19 months Three to four meals ( may offer 1–2 snacks) ¾ to 1 cup 11 months Three to four meals ( may offer 1–2 snacks) ½ cup 21 months Three to four meals ( may offer 1–2 snacks) ¾ to 1 cup 3 months A trick question! Only breastfeeding Infant and young child feeding counselling: an integrated course. Course handouts 158 Session 50: Feeding during illness and recovery Exercise 50.A Suggestions for feeding during illness Illness/condition Information/suggestion – possible replies Child’s mouth or throat is sore Sour fruits, very sweet foods or spicy foods may irritate the mouth. Could you give soft or smooth foods? It might help to drink through a straw. Child has a blocked nose It often helps to clear the nose before feeding. Could you try to feed slowly, as this would give time to breathe? Child has fever Extra fluids/breastfeeds are good during a fever. Have you tried frequent small amounts of food? Child has chest infection or cough What about sitting the child upright and slowly giving small amounts? Child has diarrhoea Continuing to give some foods during diarrhoea helps the child to avoid losing weight. Extra fluids/breastfeeds are important. Some families give bananas, mashed fruits, soft rice and porridge during diarrhoea. Would you like to try this? If diarrhoea is severe, give oral rehydration solution (ORS). Child is vomiting Could you give frequent fluids/breastfeeds in small amounts? Child is sleepy Could you watch for times the child is alert and feed then? 7. Answer sheets 159 Session 56: Introducing child growth assessment Exercise 56.A Determining a child’s age today and selecting growth charts to use in the Growth record 1. Salaam’s age today: 1 year 9 months The growth charts to be used for Salaam are: • Length-for-age, Boys, 6 months to 2 years, on page 33 • Weight-for-age, Boys, 6 months to 2 years, on page 34 • Weight-for-length, Boys, Birth to 2 years, on page 35 2. Ruby’s date of birth: 1 May 2019 Ruby’s age today: 11 months The growth charts to be used for Ruby are: • Length-for-age, Girls, 6 months to 2 years, on page 33 • Weight-for-age, Girls, 6 months to 2 years, on page 34 • Weight-for-length, Girls, Birth to 2 years, on page 35 3. Ivan’s age today: 12 weeks The growth charts to be used for Ivan are: • Length-for-age, Boys, Birth to 6 months, on page 29 • Weight-for-age, Boys, Birth to 6 months, on page 30 • Weight-for-length, Boys, Birth to 6 months, on page 31 Infant and young child feeding counselling: an integrated course. Course handouts 160 Exercise 56.B Continuing case studies – Nalah and Toman Nalah Note that only minimal information about feeding is recorded on the Personal data page. More details of the child’s feeding history may be recorded in the Visit notes. There is no need to write “still breastfeeding” for Nalah on the Personal data page; leave the line after “Age at termination of breastfeeding” blank until termination occurs. Also leave the line for “Adverse events” blank unless some event has occurred; do not write “none”, as something may happen later. 1. Nalah’s Personal data page should look something such as the following: 2. Nalah’s Visit notes (first row) should appear as follows: 3. The health-care provider should use the following growth charts for Nalah at this visit: • Length-for-age, Girls, Birth to 6 months, page 29 • Weight-for-age, Girls, Birth to 6 months, page 30 • Weight-for-length, Girls, Birth to 6 months, page 31 7. Answer sheets 161 Toman 1. Toman’s Personal data page should look something such as the following: 2. Toman’s Visit notes (first row) should appear as follows: 3. The health-care provider should use the following growth charts for Toman at this visit: • Length-for-age, Boys, 6 months to 2 years, page 33 • Weight-for-age, Boys, 6 months to 2 years, page 34 • Weight-for-length, Boys, Birth to 2 years, page 35 Infant and young child feeding counselling: an integrated course. Course handouts 162 Exercise 56.C Continuing case studies – Nalah and Toman: homework Nalah Nalah’s Visit notes page should appear as follows (ignore the BMI values). Toman Toman’s Visit notes page should appear as follows (ignore the BMI values). 7. Answer sheets 163 Session 59: Plotting points for growth indicators Short-answer exercise 59.A Anna 1. The dots on the graph should be connected. 2a. 98 cm at 3 years and 3 months 2b. 103 cm at 4 years and 2 months Short-answer exercise 59.B Amahl 1. 8 kg 2. 1 year and 1 month 3. 1 year and 6 months, 9.1 or 9.2 kg 4. Completed graph for Amahl: W ei gh t ( kg ) Weight-for-age BOYS 6 months to 2 years (z-scores) 3 2 1 0 1 2 3 Months 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11 1 year Age ( ompleted months and years) 2 years 6 7 8 9 10 11 12 13 14 15 16 17 6 7 8 9 10 11 12 13 14 15 16 17 ● ● ● ● Infant and young child feeding counselling: an integrated course. Course handouts 164 Short-answer exercise 59.C Tran 1. about 97 cm 2. 16 kg 3. Completed graph for Tran: 7. Answer sheets 165 Exercise 59.A Continuing case studies – Nalah and Toman Nalah’s plotted growth trends Infant and young child feeding counselling: an integrated course. Course handouts 166 Toman’s plotted growth trends 7. Answer sheets 167 Infant and young child feeding counselling: an integrated course. Course handouts 168 Session 61: Interpreting trends on growth charts Exercise 61.A Continuing case studies – Nalah and Toman Nalah 1. a. Nalah was an average length at birth but has experienced periods of slow growth and stagnation. Her length-for-age has thus dropped from the median at birth to below –3 z-score at 6 months. b. At 6 months, Nalah is severely stunted. 2. a. Nalah’s weight at birth was just below the median but because of periods of very slow growth (e.g. birth to 6 weeks, 10–13 weeks), followed by inadequate catch-up growth (e.g. at 6–10 weeks and at 3–4 months), her weight-for-age has dropped systematically to below –2 z-score at 6 months. b. Nalah is underweight. 3. a. Nalah’s weight-for-length has fluctuated between –1 z-score and the median since birth, and at 6 months is tracking along the median. b. The weight-for-length chart shows the stagnation in length that occurred when Nalah was 55 cm long but currently it does not indicate a growth problem or risk of a problem. 4. Although Nalah was average length at birth, she became severely stunted by the age of 6 months. Her growth in both length and weight stagnated between the ages of 10 weeks and 13 weeks, perhaps because of the episode of diarrhoea for which she was seen at the end of this period. Her weight has stayed appropriate for her length, so problems are not apparent on the weight-for-length. However, she is severely stunted and underweight according to the length-for-age and weight-for-age charts. Toman 1. a. Toman’s length-for-age has been consistent, staying very close to the 1 z-score line. b. No problem or risk of a problem is evident on the length-for-age chart. 2. a. Toman’s weight is increasing too rapidly in relation to his age. His weight-for-age line has crossed the 2 z-score line and continued rising. b. The weight-for-age chart shows that Toman is very heavy for his age, but a judgement of whether he has a problem with overweight should be based on his weight-for-height. 3. a. Toman’s weight is increasing too rapidly in relation to his length. His weight-for-length has crossed the 2 z-score line and reached the 3 z-score line. b. The weight-for-length chart shows that Toman is overweight and is at risk of becoming obese. 4. Toman has grown normally in length, tracking along the 1 z-score line, but his weight has increased too rapidly for his length and his age, as shown on three of the growth charts (weight-for-age, weight-for-length) where his growth lines are near or on the 3 z-score line. His is overweight and has a definite trend towards obesity. 169 8. Course-completion certificate 170 Notes 171 Notes (contd) 172 Notes (contd)

For more information, please contact: Department of Nutrition and Food Safety World Health Organization Avenue Appia 20 CH-1211 Geneva 27 Switzerland Email: nutrition@who.int Website: https://www.who.int/health-topics/nutrition