Infant and young child feeding counselling: an integrated course: director’s guide

Director’s guide Second edition INFANT AND YOUNG CHILD FEEDING COUNSELLING: AN INTEGRATED COURSE

Director’s guide Second edition INFANT AND YOUNG CHILD FEEDING COUNSELLING: AN INTEGRATED COURSE Infant and young child feeding counselling: an integrated course. Director’s guide, second edition ISBN 978-92-4-003169-2 (electronic version) ISBN 978-92-4-003170-8 (print version) 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). 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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 v Abbreviations used in this course vi Glossary vii 1. Guidance for using the online infant and young child feeding training modules 1 1.1 Step 1: Engage in a population consultation 1 1.2 Step 2: Conduct a situational analysis 1 1.3 Step 3: Select and prioritize training sessions 2 1.4 Step 4: Monitoring and evaluation 2 1.5 Scheduling sessions 2 2. Introduction to the course 4 2.1 Why this course is needed 4 2.2 Course objectives 5 2.3 Course competencies 6 2.4 The course and the materials 14 2.5 Reference materials 17 2.6 Support for the course 21 2.7 Role of the course director 22 3. Making arrangements for the course 23 3.1 Where to hold the course 23 3.2 Classroom facilities 23 3.3 Accommodation and meals 23 3.4 Sites for clinical practice and practical sessions 23 4. Selecting trainers and participants 26 4.1 Selecting trainers 26 4.2 Preparation of trainers 26 4.3 Selecting participants 33 5. Checklists for planning 34 5.1 Overall planning checklist 34 5.2 Checklists of course materials 36 5.3 Checklist of equipment and stationery 38 5.4 Checklist of items needed for demonstrations or exercises 39 5.5 Checklist of background information needed 42 5.6 Timetables 42 6. Guidelines for supportive supervision, mentoring and follow-up after training 49

vAcknowledgements 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. vi Abbreviations used in this course These abbreviations are mentioned throughout the course in the Course handouts, 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 vii Glossary 1 Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/UNICEF statement. Geneva: World Health Organization; 1989 (http://apps.who.int/iris/bitstream/10665/39679/1/9241561300.pdf). Absorbed iron: The iron that passes into the body after it has been released from food during digestion. Only a small proportion of the iron present in food is absorbed. The rest is excreted in the faeces. Accuracy: Correctness. The accuracy of a measurement depends on whether the instrument is correctly calibrated and whether the observer measures correctly (i.e. takes, reads and records the measurement correctly). Active encouragement: Assistance given to encourage a child to eat. This includes praising, talking to the child, helping the child put food on the spoon, feeding the child, making up games. Afterpains: Contraction of the uterus during breastfeeding in the first few days after childbirth, owing to release of oxytocin. AIDS: Acquired immune deficiency syndrome, which means that a person who is living with HIV has progressed to active disease. Allergy: Symptoms when fed even a small amount of a particular food (so it is not dose related). Alveoli: Small sacs of milk-secreting cells in the breast. Amenorrhoea: Absence of menstruation. Anaemia: Lack of red cells or lack of haemoglobin in the blood. Antenatal preparation: Preparation of a mother for the delivery of her baby. Antibodies: Proteins in the blood and in breast milk that fight infection. Anti-infective factors: Factors that prevent or that fight infection. These include antibodies. Appropriate touch: Touching somebody in a socially acceptable way. Areola: Dark skin surrounding the nipple. Artificial feeding: Feeding an infant on a breast-milk substitute. Artificial feeds: Any kind of milk or other liquid given instead of breastfeeding. Artificially fed: Receiving artificial feeds only, and no breast milk. Asthma: Wheezing illness. Attachment: The way a baby takes the breast into their mouth; a baby may be well attached or poorly attached to the breast. Baby-friendly Hospital Initiative (BFHI): An approach to transforming maternity practices, as recommended in the joint World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) statement on Protecting, promoting and supporting breastfeeding: the special role of maternity services (1989).1 Baby-led feeding: See Demand feeding. Bedding-in: A baby sleeping in bed with their mother, instead of in a separate cot. Bilirubin: Yellow breakdown products of haemoglobin, which cause jaundice. Blocked duct: A milk duct in the breast becomes blocked with thickened milk, so that the milk in that part of the breast does not flow out. BMI: Body mass index; a ratio that indicates a person’s weight in proportion to their length/height, calculated as kg/m2. BMI-for-age: A growth indicator that relates BMI to age. Bonding: Development of a close loving relationship between a mother and her baby. Bottle-feeding: Feeding an infant from a bottle, whatever is in the bottle, including expressed breast milk, water, formula milk, etc. Breast pump: Device for expressing milk. Breast refusal: A baby not wanting to suckle from their mother’s breast. Breastfeeding history: All the relevant information about what has happened to a mother and baby, and how their present breastfeeding situation developed. Breastfeeding supplementer: A device for giving a baby a supplement while they are suckling at a breast that is not producing enough milk. Breastfeeding support: A group of mothers who help each other to breastfeed. Breast-milk substitute: Any food being marketed or otherwise represented as a partial or total replacement for breast milk, whether or not it is suitable for that purpose. Calibration: Checking a measuring instrument for accuracy and adjusting if necessary and possible. Calories (or kilocalories): A measure of the energy available in food. Candida: Yeast that can infect the nipple, and the baby’s mouth and bottom. Also known as “thrush”. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition viii Care for development: Care intended to stimulate emotional, intellectual and motor development. Casein: Protein in milk, which forms curds. Cessation of breastfeeding: Completely stopping breastfeeding, including suckling. Chapati: A flat bread made by mixing whole wheat flour with water and then shaping pieces of the dough into flat circles and baking on a griddle (hot metal sheet). Traditionally eaten in India and Pakistan. Cleft lip or palate: Abnormal division of the lip or palate. Closed questions: Questions that can be answered with “yes” or “no”. Colic: Regular crying, sometimes with signs suggesting abdominal pain, at a certain time of day; the baby is difficult to comfort but otherwise well. Cold compress: Cloths soaked in cold water to put on the breast. Colostrum: The special breast milk that women produce in the first few days after delivery; it is yellowish or clear in colour. Confidence: Believing in yourself and your ability to do things. Contaminated: Containing harmful bacteria or other harmful substances. Commercial infant formula: A breast-milk substitute formulated industrially, in accordance with applicable Codex Alimentarius standards,1 to satisfy the nutritional requirements of infants during the first months of life up to the introduction of complementary foods. Complementary feeding: The child receives both breast milk, or a breast-milk substitute, and solid (or semi-solid) food. Complementary food: Any food, whether manufactured or locally prepared, used as a complement to breast milk or to a breast-milk substitute. Counselling: A way of working with people so that you understand their feelings and help them to develop confidence and decide what to do. Cup-feeding: Feeding from an open cup without a lid, whatever is in the cup. Deficiency: Shortage of a nutrient that the body needs. Dehydration: Lack of water in the body. Demand feeding: Feeding a baby whenever they show that they are is ready, both day and night. This is also called “unrestricted” or “baby-led” feeding. Distraction (during feeding): A baby’s attention is easily taken from the breast by something else, such as a noise. 1 Codex Alimentarius. International food standards (http://www.fao.org/fao-who-codexalimentarius/en/). Ducts, milk ducts: Small tubes that take milk to the nipple. Dummy: An artificial nipple made of plastic for a baby to suck. Also known as a pacifier/soother. Early contact: A mother holding her baby during the first hour or two after delivery. Eczema: Skin condition, often associated with allergy. Effective suckling: Suckling in a way that removes the milk efficiently from the breast. Empathize: Show that you understand how a person feels from her/his point of view. Engorgement: The breast is swollen with breast milk, blood and tissue fluid. Engorged breasts are often painful and oedematous and the milk does not flow well. Essential fatty acids: Fats that are essential for a baby’s growing eyes and brain, and that are not present in cow’s milk or most brands of formula milk. Exclusive breastfeeding: An infant receives only breast milk and no other liquids or solids, not even water. Drops or syrups consisting of vitamins, mineral supplements or medicines, including oral rehydration solution, are permitted. Expressed breast milk: Milk that has been removed from the breasts manually or by using a pump. Express: To squeeze or press out. Family foods: Foods that are part of the family meals. Fat: A nutrient that provides energy. Feeding history: All the relevant information about what has happened to a mother/caregiver and baby, and how their present feeding situation developed. Fermented foods: Foods that are soured. For example, yoghurt is fermented milk. These substances can be beneficial and kill pathogens that may contaminate food. Fissure: Break in the skin, sometimes called a “crack”. Flat nipple: A nipple that sticks out less than average. Foremilk: The watery breast milk that is produced early in a feed. Formula milks: Artificial milks for babies made out of a variety of products, including sugar, animal milks, soybean and vegetable oils. They are usually in powder form, to mix with water. Fortified foods: Foods that have certain nutrients added to improve their nutritional quality. Full breasts: Breasts that are full of milk, and hot, heavy and hard, but from which the milk flows. Fully breastfed: Exclusively breastfed. ix Glossary Gastric suction: Sucking out a baby’s stomach immediately after delivery. Germinated seeds/flour: Seeds that have been soaked and allowed to sprout. The sprouted seeds can be dried and milled to make germinated flour. If a little of this flour is added to warm thick porridge, it makes the porridge soft and easy to eat. Gestational age: The number of weeks a baby has completed in the uterus. Ghee: Butter that has been heated so that the fat melts and the water evaporates. It looks clear. It can be made from cow’s or buffalo’s milk and is widely used in India. In the Middle East, it is called samna. Gross motor development: Development of movement and body control related to use of the larger muscles (e.g. development of crawling and walking skills), as contrasted with fine motor development (e.g. use of the hands and fingers to grasp small objects). See also Gross motor milestones. Gross motor milestones: Important achievements related to movement and body control, including sitting without support, standing with assistance, hands-and-knees crawling, walking with assistance, standing alone and walking alone. Growth factors: Substances in breast milk that promote growth and development of the intestine, and that probably help the intestine to recover after an attack of diarrhoea. Growth spurt: Sudden increased hunger for a few days. Gruel: Another name for thin porridge. Examples are atole in Central America and uji in Africa. Gulp: Loud swallowing sounds, owing to swallowing a lot of fluid. “High-needs” babies: Babies who seem to need to be carried and comforted more than other babies. Hindmilk: The fat-rich breast milk that is produced later in a feed. HIV: Human immunodeficiency virus, which causes AIDS. See also AIDS. HIV infected: Refers to a person infected with HIV, but who may not know that they are infected. HIV negative: Refers to a person who has been tested for HIV with a negative result and who knows their result. HIV positive: Refers to a person who has been tested for HIV, whose results have been confirmed and who knows and/or their parents know that they tested positive. HIV status unknown: Refers to a person who has been tested for HIV or who does not know the result of their test. HIV testing and counselling: Testing for HIV status, preceded and followed by counselling. Testing should be voluntary and confidential, with fully informed consent. The expression means the same as the terms: “counselling and voluntary testing”, “voluntary counselling and testing”, and “voluntary and confidential counselling and testing”. Counselling is a process, not a one-off event: for the client living with HIV, it should include life planning, and, if the client is pregnant or has recently given birth, it should include infant feeding considerations. Hormones: Chemical messengers in the body. Hypoglycaemia: Low blood sugar. Immune system: Those parts of the body and blood, including lymph glands and white blood cells, that fight infection. Immunity: A defence system that the body has to fight diseases. Ineffective suckling: Suckling in a way that removes milk from the breast inefficiently or not at all. Infant: A child not more than 12 months of age. Infant feeding counselling: Counselling on breastfeeding, on complementary feeding, and, for women who are living with HIV, on HIV and infant feeding. Infantometer: A board designed to be placed on a horizontal surface to measure the length (lying down) of a child aged less than 2 years. Infective mastitis: Mastitis resulting from bacterial infection. Inhibit: To reduce or stop something. Inspection: Examination by looking. Intolerance (of food): Inability to tolerate a particular food. Inverted nipple: A nipple that goes in instead of sticking out, or that goes in when the mother tries to stretch it out. Jaggery: Brown sugar made from the sap of the palm flower. It is widely used in the Indian subcontinent. Jaundice: Yellow colour of the eyes and skin. Judging words: Words that suggest that something is right or wrong, good or bad. Kwashiorkor: A form of severe undernutrition characterized by generalized oedema, thin, sparse hair and dark or cracking/peeling patches of skin. Lactation: The process of producing breast milk. Lactation amenorrhoea method: Using the period of amenorrhoea after childbirth as a method for family planning. Lactogogue: A special food, drink or herb that people believe increases a mother’s supply of breast milk. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition x Lactose: The special sugar present in all milks. Length/height-for-age: A growth indicator that relates length or height to a child’s age. Lipase: Enzyme to digest fat. Low birth weight: Weighing less than 2.5 kg at birth. Marasmus: A form of severe undernutrition referred to alternatively as “non-oedematous malnutrition”. A child with marasmus is severely wasted and has the appearance of “skin and bones”. Mastitis: Inflammation of the breast (see also Infective mastitis and Non-infective mastitis). Matooke: Green banana. Mature milk: The breast milk that is produced a few days after birth. Meconium: The first dark stools produced by a baby soon after birth. Median: The middle value in a rank-ordered series of values. Median duration of breastfeeding: The age in months when 50% of children are no longer breastfed. Micronutrients: Essential nutrients required by the body in small quantities (such as vitamins and some minerals). Micronutrient supplements: Preparations of vitamins and minerals. Milk ejection: Milk flowing from the breast due to the oxytocin reflex, which is stimulated in response to the sight, touch or sound of the baby. Milk stasis: Milk staying in the breast and not flowing out. Mistaken idea: An idea that is incorrect. Milk expression: Removing milk from the breasts manually or by using a pump. Mixed feeding: Feeding both breast milk and other foods or liquids. Montgomery’s glands: Small glands in the areola that secrete an oily liquid. Multiple birth: Birth of more than one child at the same time, e.g. twins. Natural (passive) immunity: The protection a baby inherits from their mother. “Nipple confusion”: A term sometimes used to describe the way babies who have fed from a bottle may find it difficult to suckle effectively from a breast. Nipple sucking: When a baby takes only the nipple into their mouth, so that they cannot suckle effectively. Non-infective mastitis: Mastitis due to milk leaking out of the alveoli and back into the breast tissues, with no bacterial infection. Non-verbal communication: Showing your attitude through your posture and expression. Nutrients: Substances the body needs that come from the diet. These are carbohydrates, proteins, fats, minerals and vitamins. Nutritional needs: The amounts of nutrients needed by the body for normal function, growth and health. Mother-support group: A community-based group of women providing support for optimal breastfeeding and complementary feeding. Mother-to-child transmission: Transmission of HIV to a child from a woman infected with HIV during pregnancy, delivery or breastfeeding. Obese: Severely overweight; weight-for-length/height or BMI-for-age above the 3 z-score line. Obesity: The condition of being obese. Oedema: Swelling due to fluid in the tissue. Offal/organs: Liver, heart, kidneys, brain, intestines, blood. Open questions: Questions that can only be answered by giving information, and not with just a “yes” or a “no”. Overweight: Weighing too much for one’s length/height; weight-for-length/height or BMI-for-age above the 2 z-score line. Oxytocin: The hormone that makes the milk flow from the breast. Pacifier: Artificial nipple made of plastic for a baby to suck, a dummy. Palpation: Examining by feeling with the hand. Partially breastfed or mixed fed: Breastfed and given some artificial feeds, either milk or cereal, or other food. Pasteurized: Food (usually milk) made safe by heating it to destroy disease-producing pathogens. Pathogen: Any organism that causes disease. Perinatal: Around the time of birth. Perpendicular: Positioned at a right angle (90° angle). Persistent diarrhoea: Diarrhoea that starts as an acute attack, but that continues for more than 14 days. Pesticides: Substances (usually sprays) used by farmers to prevent pests from attacking crops. Phytates: Substances present in cereals, especially in the outer layer (bran), and in peas, beans and nuts. Phytates combine with iron, zinc and calcium in food to form substances that the body cannot absorb. Eating foods containing vitamin C helps protect iron from the adverse effect of phytates. Pneumonia: Infection of the lungs. xi Glossary Poorly protractile: Used to describe a nipple that is difficult to stretch out to form a “teat”. Porridge: Made by cooking cereal flour with water until it is smooth and soft. Grated cassava or other root, or grated starchy fruit can also be used to make porridge. Positioning: How a mother holds her baby at her breast; the term usually refers to the position of the baby’s whole body. Postnatal check: Routine visit to a health facility after a baby is born. Precision: The smallest exact unit that an instrument can measure. For example, the UNISCALE measures with precision to the nearest 0.1 kg. Predominantly breastfed: Breastfed as the main source of nourishment, but also given small amounts of non- nutritious drinks such as tea, water and water-based drinks. Prelacteal feeds: Artificial feeds given before breastfeeding is established. Premature, preterm: Born before 37 weeks’ gestation. Prolactin: The hormone that makes the breasts produce milk. Protein: Nutrient necessary for growth and repair of the body tissues. Protractile: Used to describe a nipple that is easy to stretch out. Psychological: Mental and emotional. Pulses: Foods that include peas, lentils, beans and groundnuts. Puree: Food that has been made smooth by passing it through a sieve or mashing it with a fork, pestle or other utensil. Quinoa: A cereal grown at high altitude in the Andes in South America. Recumbent: Lying down. Reflect back: Repeat back what a person says to you, in a slightly different way. Reflex: An automatic response through the body’s nervous system. Rejection of baby: The mother not wanting to care for her baby. Relactation: Re-establishment of breastfeeding after a mother has stopped, whether in the recent or distant past. Replacement feeding: The process of feeding a child who is not receiving any breast milk with a diet that provides all the nutrients they need until they are fully fed on family foods. During the first 6 months, this should be with a suitable breast-milk substitute. After 6 months, it should be with a suitable breast-milk substitute, as well as complementary foods made from appropriately prepared and nutrient- enriched family foods. Responsive feeding: Feeding infants directly and assisting older children when they feed themselves, being sensitive to their hunger and satiety cues. Restricted breastfeeds: When the frequency or length of breastfeeds is limited in any way. Retained placenta: A small piece of the placenta remaining in the uterus after delivery. Rooming-in: A baby staying in the same room as their mother. Rooting: A baby searching for the breast with their mouth. Rooting reflex: A baby opening their mouth and turning to find the nipple. Rubber teat: The part of a feeding bottle from which a baby sucks. Scissor hold: Holding the breast between the index and middle fingers while the baby is feeding. SD score: Standard deviation score. See z-score. Secrete: Produce a fluid in the body. Self-weaning: A baby more than 1 year old deciding by themself to stop breastfeeding. Sensory impulses: Messages in nerves that are responsible for feeling. Silver nitrate drops: Drops put into a baby’s eyes to prevent infection with gonococcus or chlamydia. Skin-to-skin contact: A mother holding her naked baby against her own skin. Sore nipples: Pain in the nipple and areola when the baby feeds. “Spillover”: A term used to designate the feeding behaviour of new mothers who either know that they are HIV negative or are unaware of their HIV status – they do not breastfeed, or they breastfeed for a short time only, or they mix-feed, because of unfounded fears about HIV, misinformation or the ready availability of breast-milk substitutes. Stadiometer: A board for measuring the standing height of children age 2 years or older. Stagnation: Staying the same. A flat growth line indicates stagnation of growth. Stunted: Short for one’s age; length/height-for-age below the –2 z-score line; severely stunted is below the –3 z-score line. Sucking: Using negative pressure to take something into the mouth. Sucking reflex: A reflex that allows a baby to automatically suck something that touches their palate. Suckling: The action by which a baby removes milk from the breast. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition xii Supplements: Drinks or artificial feeds given in addition to breast milk. Sustaining: Continuing to breastfeed up to 2 years or beyond; helping breastfeeding mothers to continue to breastfeed. Swallowing reflex: A reflex whereby a baby automatically swallows when their mouth fills with fluid. Symmetrical: The same (mirror images) on opposite sides separated by a straight line. Sympathize: Show that you feel sorry for a person, from your point of view. Tare: As used in these modules, to store a weight in the memory of a scale so that an additional weight can be registered independently. In tared weighing, the scale is reset to zero while an adult is still standing on it; when the adult is then given a child to hold, only the child’s weight appears. Taring scale: A scale that can be reset to zero while someone (who has just been weighed) is still standing on it. When they then hold a child on the scale, only the child’s weight appears. Tarwi: A bean grown in the Andes in South America. “Teat”: Stretched out breast tissue from which a baby suckles. Thrush: Infection caused by the yeast Candida; in the baby’s mouth, thrush forms white spots Tortilla: A flat bread made by mixing maize flour and water and then making the dough into a thin round shape. It is cooked on a hot metal griddle. It is traditionally eaten in Central America. Wheat flour can also be used. Toxin: A poisonous substance. Undernourished: Any of the following: • underweight or severely underweight (below the –2 or –3 z-score line in weight-for-age) • wasted or severely wasted (below the –2 or –3 z-score line in weight-for-length/height or BMI-for-age) • stunted or severely stunted (below the –2 or –3 z-score line in length/height-for-age). However, if overweight or trending toward overweight, the child is no longer considered as primarily undernourished. Undernutrition: The condition of being undernourished. Underweight: Weighing too little for one’s age; weight-for- age below the –2 z-score line; severely underweight is below the –3 z-score line. UNISCALE: An electronic scale made by UNICEF that allows tared weighing. Unrestricted feeding: See Demand feeding. Wasted: Weighing too little for one’s length/height; weight- for-length/height or BMI-for-age below the –2 z-score line; severely wasted is below the –3 z-score line. Warm compress: Cloths soaked in warm water to put on the breast. Weight-for-age: A growth indicator that relates weight to age. Weight-for-length/height: A growth indicator that relates weight to length (for children aged less than 2 years) or height (for children aged 2 years and older). Whey: Liquid part of milk that remains after removal of casein curds. Young child: A person from the age of more than 12 months up to the age of 3 years (36 months). z-score: A score that indicates how far a measurement is from the mean, also known as “standard deviation (SD) score”. The reference lines on the growth charts (labelled 1, 2, 3, –1, –2, –3) are called z-score lines; they indicate how far points are above or below the mean (z-score 0). 11. Guidance for using the online infant and young child feeding training modules With rising health concerns facing many countries and regions, comprehensive policies, programmes and plans are essential to address health sector challenges with sustainable and individualized solutions. These strategies must effectively strengthen local health systems through targeted actions aimed at promoting health and building local capacity. This training package aligns with health strategies aimed at improving infant and young child feeding, by allowing you to create a customized training package that will respond directly to the specific learning needs of your health workers. The training modules cover a range of topics, including breastfeeding, complementary feeding, growth assessment and monitoring, HIV and infant feeding, and infant and young child feeding counselling. Depending on the context of your local nutrition situation, it is important for you to select and prioritize sessions that will contribute to the greatest improvement of infant and young child feeding in your area. There are several actions that you can take to select and prioritize which training sessions will best respond to the individual needs of the health workers in your country or region. The following activities should be used as guidance. 1.1 Step 1: Engage in a population consultation Population consultations can be done in many ways (face-to-face dialogues, focus groups, surveys, etc.) and can be undertaken at any stage of a health planning cycle. Population consultations are essential for capturing the population’s demands, opinions and expectations relating to matters of their health1. Action: Engage with your ministry of health, health workers, mothers and caregivers, and the general public, to determine which areas of infant and young child feeding require the most attention. It is important to be inclusive and transparent in this process, in order to build and maintain public trust. 1.2 Step 2: Conduct a situational analysis A situational analysis can be used to gather information on existing infant and young child feeding practices in your country or region. Take into consideration other programmes and policies that may address infant and young child feeding in your region, as well as the current level of knowledge held by course participants. Situational analyses should be done in a participatory and inclusive, analytical, relevant, comprehensive and evidence-based manner2. • Participatory and inclusive: your situational analysis should include input from all relevant stakeholders in the health sector, including participants who will take part in the training. • Analytical: you should understand your local infant and young child feeding situation, including the level of understanding of course materials already held by the participants. • Relevant: focus on local issues in infant and young child feeding, growth monitoring and/or breastfeeding, and consider solutions to these challenges. • Comprehensive: consider all aspects of your local infant and young child feeding situation, including other health systems, programmes, health services, national or regional policies, and multidisciplinary actions that may affect the way that infants and young children are fed in your country or region. • Evidence based: utilize both quantitative and qualitative data to illustrate the local infant and young child feeding situation in your region. Action: You may want to include the following information in your situational analysis: • infant feeding indicators (breastfeeding rates, complementary feeding norms); • breastfeeding/baby-friendly policies at local hospitals and clinics; • materials used locally for feeding infants and young children; • materials used locally for food hygiene; • the availability of local growth charts; 1 Rohrer K, Rajan D. Chapter 2. Population consultation on needs and expectations. In: Schmets G, Rajan D, Kadandale S, editors. Strategizing national health in the 21st century: a handbook. Geneva: World Health Organization; 2016:35–102 (http://apps.who.int/iris/bitstream/handle/10665/250221/9789241549745-chapter2-eng.pdf, accessed 6 July 2021). 2 Rajan D. Chapter 3. Situation analysis of the health sector. In: Schmets G, Rajan D, Kadandale S, editors. Strategizing national health in the 21st century: a handbook. Geneva: World Health Organization; 2016:103–58 (http://apps.who.int/iris/bitstream/handle/10665/250221/9789241549745-chapter3-eng.pdf, accessed 6 July 2021). Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 2 • the use of infant formula milk; • the use of micronutrient supplements; • the percentage of known young children who are malnourished (wasted, underweight or stunted, overweight or obese, with micronutrient deficiencies); • common foods used for complementary feeding; • the local prevalence of HIV; • national health authority infant feeding recommendations for mothers living with HIV; • current knowledge held by health workers; • knowledge gaps of health workers; and • learning goals of health workers. 1.3 Step 3: Select and prioritize training sessions The selection of which sessions to include in your customized training package will be a reflection of the priority areas highlighted in your situational analysis and population consultation. Priority-setting is a complex process that is informed by stakeholder values and community need1. Sessions should be prioritized that align with the national or regional infant and young child feeding priorities revealed in Step 2, as well as the learning needs of health providers in your area. For example, if your situational analysis revealed that the participants have extensive experience in breastfeeding, but are lacking experience in complementary feeding, it may be beneficial to tailor the training sessions towards enhancing their knowledge of complementary feeding (Module 5). Similarly, if the sessions will be held in an area with high HIV prevalence, it may be prudent to focus on Module 7: HIV and infant feeding. Action: Based on the information that you gathered, select the sessions that are most suitable to your population. Take into consideration how many days you have available to conduct the sessions, to ensure that you are using your time wisely. Once you have chosen your sessions, you will be able to download the selected sessions to form a training package that suits the context of the country’s specific needs. During the selection and prioritization process, keep in mind how you will monitor and evaluate these decisions to ensure that the learning objectives of the course are being met. 1.4 Step 4: Monitoring and evaluation After you have selected and prioritized which sessions to include in your training package, it is important to monitor, evaluate and review your choices. Monitoring looks at the process of how the sessions were chosen and prioritized, to analyse the implementation of the training package. Evaluation takes a deeper look at this process, to determine whether the session learning objectives and infant and young child feeding and counselling competencies were met. These findings will allow you to contribute to further strategic prioritization, resource allocation and policy dialogue2. Action: Session 79: Follow-up after training introduces a module for follow-up training that is intended to be conducted 1 to 3 months after the training course. In this session, a trainer will assess the competencies that the participants learnt during the training course. It serves as a good opportunity for participants to discuss successes and difficulties that they have experienced since they had their training. This continued supportive supervision should be planned from the onset of course implementation and will contribute to ongoing monitoring and evaluation of the training course. 1.5 Scheduling sessions The course materials are not intended to be conducted in their entirety. You will need to decide which sessions from which modules to cover, depending on the priorities and context of the country and the participants. The course is divided into various modules and will take different times to complete, according to the modules and sessions selected. The course can be conducted consecutively in a working week, or can be spread in other ways. 1 Terwindt F, Rajan D, Soucat A. Chapter 4. Priority-setting for national health policies, strategies and plans. In: Schmets G, Rajan D, Kadandale S, editors. Strategizing national health in the 21st century: a handbook. Geneva: World Health Organization; 2016:159–234 (http://apps.who.int/iris/bitstream/handle/10665/250221/9789241549745-chapter4-eng. pdf, accessed 6 July 2021). 2 O’Neill K, Viswanathan K, Celades E, Boerma T. Chapter 9. Monitoring, evaluation and review of national health policies, strategies and plans. In: Schmets G, Rajan D, Kadandale S, editors. Strategizing national health in the 21st century: a handbook. Geneva: World Health Organization; 2016:447–90 (http://apps.who.int/iris/bitstream/hand le/10665/250221/9789241549745-chapter9-eng.pdf, accessed 6 July 2021). 1. Guidance for using the online infant and young child feeding training modules 3 The sessions do not need to be conducted in consecutive order, but it is necessary for some aspects of the course sequence to be maintained. The main requirement is that the sessions that prepare participants for a particular clinical practice or practical session are conducted before the practical. For some topics, there are multiple similar sessions to choose from, depending on the local situation. The material could thus be used, for example, to hold a 5-day course on infant and young child feeding counselling, a 5-day course on growth assessment and infant and young child feeding counselling, or courses on specific subjects, such as breastfeeding counselling. The course material may also be used to complement existing courses or as part of the pre-service education of health workers. Schedules can also be made to touch on introductory concepts of each module, and follow-up sessions can be scheduled for more in-depth learning based on interest and need. Sample course timetables are provided in Section 5.6. 42. Introduction to the course 2.1 Why this course is needed 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 the 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. WHO and UNICEF developed the Global strategy for infant and young child feeding1 in 2003, to revitalize world attention to the impact that feeding practices have on the nutritional status, growth, development, health and survival of infants and young children. The sixty-third World Health Assembly Resolution WHA63.23 urges Member States to implement the WHO child growth standards by their full integration into child health programmes.2 In 2015, with the endpoint of the United Nations’ Millennium Development Goals3 and the transition to the Sustainable Development Goals,4 a new set of 17 goals defined the global agenda to end poverty, protect the planet and ensure prosperity for all. The second goal (end hunger, achieve food security and improved nutrition and promote sustainable agriculture) and the third goal (ensure healthy lives and promote well-being for all at all ages) directly link to nutrition actions, though most of the other goals also reflect nutrition issues. The global strategy for women’s, children’s and adolescents’ health 2016–20305 aims to achieve the highest attainable standard of health for all, by putting women, children and adolescents at the heart of the Sustainable Development Goals. The WHO child growth standards,6 published in 2006, were developed using a sample of children from six countries: Brazil, Ghana, India, Norway, Oman and the United States of America. The WHO Multicentre Growth Reference Study (2004)7 was designed to provide data describing how children should grow, by including in the study’s selection criteria certain recommended health behaviours (for example, breastfeeding, providing standard paediatric care and not smoking). A key characteristic of the new standards is that they explicitly identify breastfeeding as the biological norm and establish the breastfed child as the normative model for growth and development,8 and are a most appropriate complement to the WHO/UNICEF Global strategy for infant and young child feeding.1 Many mothers have difficulty breastfeeding from the beginning, and health-care practices in many facilities hinder the process of appropriate infant and young child feeding. However, even mothers who initiate breastfeeding satisfactorily often start complementary feeds or stop breastfeeding within a few weeks of delivery, and children, even those who have grown well for the first 6 months of life, may not receive adequate complementary foods. This may result in malnutrition, which is an increasing problem in many countries. More than one third of children aged under 5 years are undernourished – whether stunted, wasted or deficient in vitamin A, iron or other micronutrients. On the other hand, inappropriate feeding is probably contributing to an increased incidence of overweight/obesity in childhood. Application of the WHO child growth standards and counselling on infant and young child feeding, as presented in this course, aim to address the practices that lead to undernutrition, as well as those that predispose to the accumulation of excessive weight. Information on how to feed young children comes from family beliefs, community practices and information from health workers. Advertising and commercial promotion by food manufacturers is sometimes the source of information for many people, both families and health workers. It has often been difficult for health workers to discuss with families how best to feed their young children, owing to the confusing, and often conflicting, information available. Inadequate knowledge about how to breastfeed, the appropriate complementary foods to give, and good feeding practices is often a greater determinant of malnutrition than the availability of food. 1 Global strategy for infant and young child feeding. Geneva: World Health Organization; 2003 (http://apps.who.int/iris/bitstream/10665/42590/1/9241562218.pdf). 2 Resolution WHA63.23. Infant and young child nutrition. In: Sixty-third World Health Assembly, Geneva, 17–21 May 2010. Resolutions and decisions, annexes. Geneva: World Health Organization; 2010: 47–50 (http://apps.who.int/gb/ebwha/pdf_files/WHA63-REC1/WHA63_REC1-en.pdf). 3 The Millennium Development Goals Report 2015. New York: United Nations; 2015 (http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%20 1).pdf). 4 Sustainable Development Knowledge Platform. Sustainable Development Goals (https://sustainabledevelopment.un.org/sdgs). 5 The global strategy for women’s, children’s and adolescents’ health 2016–2030. Survive, thrive, transform. Geneva: World Health Organization; 2015 (http://www.who.int/pmnch/ media/events/2015/gs_2016_30.pdf). 6 The WHO child growth standards (http://www.who.int/childgrowth/standards/en/). 7 de Onis M, Garza C, Victora CG, Bhan MK, Norum KR, editors. WHO Multicentre Growth Reference Study: rationale, planning and implementation. Food Nutr Bull. 2004;25 (Suppl. 1):S15–26. doi:10.1177/15648265040251S103. 8 de Onis M, Garza C, Onyango AW, Martorell R, guest editors. WHO child growth standards. Acta Paediatr. 2006;Suppl. 450:1–101. 2. Introduction to the course 5 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 skils 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. In addition, there is material on policies and programmes related to infant and young child feeding; supportive supervision/ mentoring and monitoring; and tools/Job aids. The course materials are not intended to be conducted in their entirety. The course facilitators will need to decide which sessions from which chapters to cover, depending on the priorities and context of the country and the participants. For instance, for some topics there are multiple similar sessions to choose from, depending on the situation. The material could thus be used, for example, to hold a 5-day course on infant and young child feeding counselling, a 5-day course on growth assessment and infant and young child feeding counselling, or courses on specific subjects, such as breastfeeding counselling. “Counselling” is an extremely important component of this course material. The concept of “counselling” is new to many people and can be difficult to translate. Some languages use the same word as “advising”. However, counselling means more than simply advising. Often, when you advise people, you tell them what you think they should do. When you counsel, you listen to the people and help every person decide for themselves what is best for them, from various options or suggestions, and you help them to have the confidence to carry out their decision. You listen to them and try to understand how they feel. This course aims to give health workers basic counselling skills, so that they can help mothers and caregivers more effectively. The course material can be used to complement existing courses or as part of the pre-service education of health workers. This course material does NOT prepare people to have responsibility for the nutritional care of young children with severe malnutrition or nutrition-related diseases such as diabetes or metabolic problems. In addition, it does not prepare people to conduct full voluntary confidential counselling and HIV testing – which includes pre-test and post-test counselling for HIV, and follow-up support for those living with HIV. Nor does it cover in depth the topics on treatment, care and management of people living with HIV, including the use of antiretroviral drugs or antiretroviral therapy. The material covers only aspects specifically related to infant feeding in the context of HIV. Participants are encouraged to refer mothers or young children for further services and care as necessary. 2.2 Course objectives After completing this course, participants will be able to counsel and support mothers to carry out WHO/UNICEF-recommended feeding practices for their infants and young children, from birth up to 24 months of age. Each session of the course has a set of learning objectives. The trainer should make sure that they are clear about what these are when preparing to give a session. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 6 Target audience This course is aimed at the following groups of people: • lay counsellors • community health workers • counsellors for prevention of mother-to-child transmission of HIV (PMTCT; first-level counsellors at district level) • primary health-care nurses and doctors – especially if supervising and/or a referral level for lay counsellors, community health workers or PMTCT counsellors • clinicians at first referral level • paediatricians, family practice physicians, nurses, clinical officers, health assistants and nutritionists who measure and assess the growth of children or supervise these activities. Course participants are not expected to have any prior knowledge of infant feeding. 2.3 Course competencies This course is based on a set of competencies that every participant is expected to learn during the course and subsequent practice and follow-up at their place of work. To become competent at something, you need a certain amount of knowledge and to be proficient at certain skills. The following table lists the competencies (column 1), and the knowledge (column 2) and skills required (column 3) for each competency. The “knowledge” part of the competencies will be taught during this course, and is contained in the Participant’s manual for later referral and revision by participants. The “skills” part of the competencies will also be taught during this course. However, there may not be time for each participant to become proficient in every skill. This will depend on their previous experience. During the course, every participant should practise as many of the skills as possible, so that they know what to do when they return to their place of work. The skills will be practised further in the supervised follow-up session. If a participant has had the chance to successfully teach a mother to position and attach her baby to the breast, they will feel more confident in continuing to improve on this skill when returning to work after the course. It is essential that the trainers are competent at the counselling and technical skills required and that the groups are small enough (1 trainer per 3–4 participants) to ensure that the participants get as much practice as possible. It is also crucial that adequate planning is given to where the clinical practice sessions will take place, so that there are enough mothers or caregivers and children for all the participants to practise their skills (see section 3). If time is short, it is tempting to cut down on the time allocated to the clinical practice and practical sessions. However, remember that these slots are the only time that participants will have to practise their skills, so this would not be a wise decision. Most people find that they acquire the “knowledge” part of the competency more quickly than the “skills” part. During a course like this, participants will gain a lot of knowledge, but knowledge on its own does not make someone competent at carrying out a task. For example, you may be able to list the steps of how to teach a mother to cup-feed her baby but have never practised this skill yourself, and so you may not be competent at carrying this out practically. While participants on a course such as this may not learn all the skills listed, they should all have a chance to practise these skills at least once during the course. Then they will understand how to continue to practise them when they return to their place of work. The competencies are arranged according to area/module and in a certain order. The competencies at the beginning of the table are those that are most commonly used, and on which later competencies depend. For example, the competency Use Listening and learning skills to counsel a mother or caregiver is used in many of the other competencies. Take time to read through this table of competencies before the course. All the theory (“knowledge”) required is found in the Trainer’s guide and will be covered in the lecture sessions of the participant’s course. The skills are practised in the classroom practical sessions, the exercises and the clinical practice sessions in wards and clinical facilities. The follow-up assessment of participants at their facilities is based on these competencies. 2. Introduction to the course 7 Competency Knowledge Skills Counselling C1. Use Listening and learning skills to counsel a mother or caregiver • List the six Listening and learning skills • Give an example of each skill • Use the Listening and learning skills appropriately when counselling a mother or caregiver on feeding an infant or young child C2. Use Skills for building confidence and giving support to counsel a mother or caregiver • List the six Skills for building confidence and giving support • Give an example of each skill • Use the Skills for building confidence and giving support appropriately when counselling a mother or caregiver on feeding an infant or young child Breastfeeding basic BF1. Assess a breastfeed • Describe the relevant anatomy and physiology of the breast and suckling action of the baby • Explain the contents and arrangement of the Job aid: Breastfeed observation • Recognize signs of good and poor attachment and effective suckling, according to the Job aid: Breastfeed observation • Assess a breastfeed using the Job aid: Breastfeed observation • Recognize a mother who needs help, using the Job aid: Breastfeed observation BF2. Help a mother to position herself and her baby for breastfeeding • Explain The four key signs of good positioning • Describe how a mother should support her breast for feeding • Explain the main positions for the mother: sitting and lying down • Explain different ways to hold the baby: underarm and across • Recognize good and poor positioning, according to The four key signs of good of positioning • Help a mother to position her baby using The four key signs of good positioning, in different positions BF3. Help a mother to attach her baby to the breast • Explain The four key signs of good attachment • Help a mother to get her baby to attach to the breast once they are well positioned BF4. Explain to a mother about the optimal pattern of breastfeeding • Describe the physiology of breast-milk production and flow • Describe unrestricted (or demand) feeding, and implications for the frequency and duration of breastfeeds, and using both breasts alternately • Explain to a mother about the optimal pattern of breastfeeding and demand feeding BF5. Help a mother to express her breast milk by hand • List the situations when expressing breast milk is useful • Describe the relevant anatomy of the breast and physiology of lactation • Explain how to stimulate the oxytocin reflex • Describe how to select and prepare a container for expressed breast milk • Describe how to store expressed breast milk • Explain to a mother how to stimulate her oxytocin reflex • Rub a mother’s back to stimulate her oxytocin reflex • Help a mother to learn how to prepare a container for expressed breast milk • Explain to a mother the steps of expressing breast milk by hand • Observe a mother expressing breast milk by hand, and help her if necessary BF6. Help a mother to cup-feed her baby • List the advantages of cup-feeding • Estimate the volume of milk to give a baby according to weight • Describe how to prepare a cup hygienically for feeding a baby • Demonstrate to a mother how to prepare a cup hygienically for feeding • Practise with a mother how to cup-feed her baby safely • Explain to a mother the volume of milk to offer her baby and the minimum number of feeds in 24 hours BF7. Take a feeding history for an infant aged from 0 up to 6 months • Describe the contents and arrangement of the Job aid: Feeding history – 0 up to 6 months • Take a feeding history, using the Job aid: Feeding history – 0 up to 6 months and appropriate counselling skills, according to the age of the child BF8. Counsel a pregnant woman about breastfeeding • Discuss why exclusive breastfeeding is important for the first 6 months • List the special properties of colostrum and reasons why it is important • Use counselling skills appropriately with a pregnant woman, to discuss the advantages of exclusive breastfeeding • Explain to a pregnant woman how to initiate and establish breastfeeding after delivery, and the optimal breastfeeding pattern • Apply competencies C1, C2 and BF4 Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 8 Competency Knowledge Skills BF9. Help a mother to initiate breastfeeding • Discuss the importance of early contact after delivery and of the baby receiving colostrum • Describe how health-care practices affect initiation of exclusive breastfeeding • Help a mother to initiate skin-to-skin contact immediately after delivery and for at least 1 hour, and to recognize when her baby is ready to breastfeed • Apply competencies C1, C2, BF2 and BF3 BF10. Support exclusive breastfeeding for the first 6 months of life • Describe why exclusive breastfeeding is important • Describe the support that a mother needs to sustain exclusive breastfeeding • Apply competencies C1, C2 , BF1 to BF7 and GA1 appropriately BF11. Help a mother to sustain breastfeeding up to 2 years of age or beyond • Describe the importance of breast milk in the second year of life • Apply competencies C1, C2, BF7 and GA1, including explaining the value of breastfeeding up to 2 years and beyond BF12. Help a mother with “not enough milk” • Describe the common reasons why a baby may have a low intake of breast milk • Describe the common reasons for apparent insufficiency of milk • List the reliable signs that a baby is not getting enough milk • Apply competencies C1, BF1, BF7 and GA1 to decide the cause • Apply competencies C2 and BF2 to BF6 to overcome the difficulty, including explaining the cause of the difficulty to the mother BF13. Help a mother with a baby who cries frequently • List the causes of frequent crying • Describe the management of a crying baby • Apply competencies C1, BF1, BF7 and GA1 to decide the cause • Apply competencies C2 and BF2 to BF4 to overcome the difficulty, including explaining the cause of the difficulty to the mother • Demonstrate to a mother the positions to hold and carry a colicky baby BF14. Help a mother whose baby is refusing to breastfeed • List the causes of breast refusal • Describe the management of breast refusal • Apply competencies C1, BF1, BF7 and GA1 to decide the cause • Apply competencies C2, BF2 and BF3 to overcome the difficulty, including explaining the cause of the difficulty to the mother • Help a mother to use skin-to-skin contact to help her baby accept the breast again • Apply competencies BF5 and BF6 to maintain production of breast milk and to feed the baby meanwhile BF15. Help a mother who has flat or inverted nipples • Explain the difference between flat and inverted nipples and about protractility • Explain how to manage flat and inverted nipples • Recognize flat and inverted nipples • Apply competencies C2, BF2, BF3, BF5 and BF6 to overcome the difficulty • Show a mother how to use the syringe method for the treatment of inverted nipples 2. Introduction to the course 9 Competency Knowledge Skills BF16. Help a mother with engorged breasts • Explain the differences between full and engorged breasts • Explain the reasons why breasts may become engorged • Explain how to manage breast engorgement • Recognize the difference between full and engorged breasts • Apply competencies C2 and BF2 to BF5 to manage the difficulty BF17. Help a mother with sore or cracked nipples • List the causes of sore or cracked nipples • Describe the relevant anatomy and physiology of the breast • Explain how to treat Candida infection of the breast • Recognize sore and cracked nipples • Recognize Candida infection of the breast • Apply competencies C2, BF1 to BF3, BF5 and BF6 to manage these conditions BF18. Help a mother with mastitis • Describe the difference between engorgement and mastitis • List the causes of a blocked milk duct • Explain how to treat a blocked milk duct • List the causes of mastitis • Explain how to manage mastitis, including indications for antibiotic treatment and referral • List the antibiotics to use for infective mastitis • Explain what is different when treating mastitis in a mother living with HIV following the national health authority programme • Recognize mastitis and refer if necessary • Recognize a blocked milk duct • Manage a blocked duct appropriately • Manage mastitis appropriately using competencies C1, C2 and BF1 to BF6, and rest, analgesics and antibiotics if indicated. Refer to the appropriate level of care • Refer mastitis in a mother living with HIV to the appropriate level of care, according to the national health authority programme BF19. Help a mother to breastfeed a low-birth-weight or sick baby • Explain why breast milk is important for a low- birth-weight or sick baby • Describe the different ways to feed breast milk to a low-birth-weight baby • Estimate the volume of milk to offer a low-birth- weight baby, per feed and per 24 hours • Help a mother to feed her low-birth-weight baby appropriately • Apply competencies, especially BF5, BF6 and GA1, to manage these infants appropriately • Explain to a mother the importance of breastfeeding during illness and recovery Breastfeeding advanced (competencies, knowledge and/or skills acquired in addition to those listed in Breastfeeding basic) BFA1. Assess a breastfeed • Describe the physiology of the lactation hormones • Describe the suckling action of the baby when well attached and when poorly attached • Recognize effective and ineffective suckling • Recognize signs of the oxytocin reflex BFA2. Help a mother to position herself and her baby for breastfeeding • Support the mother’s breast for feeding • Show a mother how to hold and position her baby, by demonstrating with a doll • Help a mother to find a comfortable position for breastfeeding, sitting or lying down BFA3. Help a mother to attach her baby to the breast • Explain the common mistakes of attachment • Help the mother to recognize whether the baby is well attached or not BFA4. Take a feeding history for an infant aged from 0 up to 6 months • Use the feeding history to help decide whether the mother has a diffculty with breastfeeding, and how to counsel her BFA5. Inform women about optimal infant feeding • Explain the recommendations for optimal infant feeding up to 2 years or beyond • List the advantages of exclusive breastfeeding for 6 months and the risks of not breastfeeding • List the advantages of continued breastfeeding with complementry feeding for up to 2 years or beyond • Describe the differences between breast milk and infant formula milk • Talk to women individually or in groups about optimal infant feeding and the risks of unnecessary artificial feeding Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 10 Competency Knowledge Skills BFA6. Counsel a pregnant woman about breastfeeding • Explain the importance of skin-to-skin contact immediately after delivery and the initiation of breastfeeding within 1 hour • Discuss the importance of skin-to-skin contact immediately after delivery • Explain how a baby initiates breastfeeding within about an hour after birth, and about colostrum • Explain about good positioning and attachment and an optimal feeding pattern to establish breastfeeding • Explain about health-care practices and the help that the mother will receive after delivery • Apply competencies C1, C2 and parts of BFA2, BFA3 and BFA5 BFA7. Help a mother and baby to initiate breastfeeding within an hour after delivery • Describe the procedure of putting the baby in skin-to-skin contact immediately after delivery • Describe how a baby moves to the breast and attaches by themself, and how to help the baby if needed • Put a baby onto the mother’s chest prone in skin-to- skin contact immediately after delivery, for at least 1 hour undisturbed • Explain to the mother how she can gently help the baby to the breast if needed • Apply competencies C1, C2, BFA2 and BFA3 BFA8. Support exclusive breastfeeding for the first 6 months of life • Describe the concept of the Seven+ contacts to sustain breastfeeding and the use of the Job aid: Postnatal contacts and the Job aid: Ongoing contacts • Describe how the child’s growth chart can help you to support breastfeeding • Ensure that a mother receives postnatal help within 6 hours after delivery (in hospital) or within 24 hours (after home delivery), to ensure good attachment and feeding pattern, using the Job aid: Postnatal contacts • Ensure at least three additional postnatal contacts within 8 weeks, using the Job aid: Postnatal contacts • Apply competencies C1, C2, BFA1 to BFA4 and GA1 appropriately BFA9. Help a mother to continue breastfeeding up to 2 years of age or beyond • Describe the importance of continuing breastfeeding, with complementary feeding, from the age of 6 to 24 months • Explain the pattern of continued breastfeeding – as often as the child wants, day and night • List the opportunities to support continued breastfeeding at all other contacts with the mother and child (growth monitoring, immunization, family planning) • Explain the value of breastfeeding up to 2 years and beyond, while giving complementary foods • Counsel the mother about breastfeeding at all other contacts, using the Job aid: Ongoing contacts • Explain that the child should continue to breastfeed as often as they want, day and night • Apply competencies C1, C2, BFA4 and GA1 Complementary feeding CF1. Teach a mother the 10 Key messages for complementary feeding • List and explain the six Key messages about what to feed to an infant or young child to fill the nutrition gaps (Key messages 1–6) • Explain when to use the Food consistency pictures, and what each picture shows • List and explain the two Key messages about quantities of food to give to an infant or young child (Key messages 7 and 8) • List and explain the Key message about how to feed an infant or young child (Key message 9) • List and explain the Key message about how to feed an infant or young child during illness (Key message 10) • Explain to a mother the six Key messages about what to feed to an infant or young child to fill the nutrition gaps (Key messages 1–6) • Use the Food consistency pictures appropriately during counselling • Explain to a mother the two Key messages about quantities of food to give to an infant or young child (Key messages 7 and 8) • Explain to a mother the Key message about how to feed an infant or young child (Key message 9) • Explain to a mother the Key message about how to feed an infant or young child during illness (Key message 10) 2. Introduction to the course 11 Competency Knowledge Skills CF2. Help mothers whose babies are aged over 6 months to give complementary feeds • List the gaps that occur after 6 months when a child can no longer get enough nutrients from breast milk alone • List the foods that can fill the gaps • Describe how to prepare feeds hygienically • List recommendations for feeding a non- breastfed child, including the quantity, quality, consistency, frequency and method of feeding at different ages • Apply competencies C1, C2, BF7 and GA1 • Use the Job aid: Food intake – 6 up to 24 months to learn how a mother is feeding her infant or young child • Identify the gaps in the diet, using the Job aid: Food intake – 6 up to 24 months and the Reference tool: Food intake – 6 up to 24 months • Explain to a mother what foods to feed her child to fill the gaps, applying competency CF1 • Demonstrate preparation of a meal for an infant or young child at different ages (8, 10, 15 months) • Practise with a mother how to prepare meals for her infant or young child • Show a mother how to prepare feeds hygienically • Explain to a mother how to feed a non-breastfed child CF3. Help a mother with a breastfed child aged over 6 months who is not growing well • Explain feeding during illness and recovery • Describe how to prepare feeds hygienically • Apply competency BF11 to help a mother to sustain breastfeeding up to 2 years of age or beyond • Apply competencies C1, C2, BF7, CF1 and GA1 • Explain to a mother how to feed her child during illness and recovery • Demonstrate to a mother how to prepare feeds hygienically • Recognize when a child needs follow-up and when a child needs referral CF4. Help a mother with a non-breastfed child aged over 6 months who is not growing well • Explain about the special attention to give to children who are not receiving breast milk • List the recommendations for feeding a non- breastfed child, including the quantity, quality, consistency, frequency and method of feeding • Explain feeding during illness and recovery • Describe how to prepare feeds hygienically • Apply competencies C1, C2, BF7, CF1 and GA1 • Explain to a mother how to feed a non-breastfed child • Explain to a mother how to feed her child during illness and recovery • Demonstrate to a mother how to prepare feeds hygienically • Recognize when a child needs follow-up and when a child needs referral Growth assessment GA1. Plot and interpret a growth chart • Explain the meaning of the standard curves • Describe where to find the age and the weight of a child on a growth chart • Describe where to find the age and the length/ height of a child on a growth chart • Plot the weight of a child on a growth chart • Plot the length/height of a child on a growth chart • Interpret a child’s individual growth curve GA2. Measure weight, length and height • Describe how to measure weight, length and height • Determine when to measure length and when to measure height • Measure the weight of a young child held by a mother and an older child alone • Measure length correctly • Measure height correctly GA3. Plot single points on various growth charts • Explain how to place a point on a graph combining information from two axes • Describe where to find the age, weight and length/height on various growth-indicator charts • Plot weight and length/height points on weight-for- age and length/height-for-age charts • Plot weight points on weight-for-length/height charts GA4. Interpret single points on various indicator charts • Identify growth problems, based on points plotted on a single indicator chart • Define a growth problem, using a combination of indicator charts • Identify children who are stunted, underweight, wasted and overweight, based on points plotted on several indicator charts GA5. Interpret growth trends using a combination of indicators • Interpret trends on growth charts • Identify a child who is growing normally, has a growth problem or is at risk of a growth problem Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 12 Competency Knowledge Skills GA6. Counsel a mother whose child has undernutrition • Describe causes of stunting, wasting and underweight • Involve the mother in identifying possible causes of her child’s undernutrition • Find age-appropriate advice for the problem identified • Set goals for improving the growth of an undernourished child • Identify the key sections of the Job aid: Investigating causes of undernutrition • Use the Job aid: Investigating causes of undernutrition appropriately (find the correct pages for the child’s age, complete the investigation before counselling, counsel using age-appropriate recommendations) • Check the mother’s understanding, using checking questions • Involve the mother in setting goals for improved growth GA7. Counsel a mother whose child is overweight • Describe causes of overweight/obesity • Involve the mother in identifying possible causes of her child’s overweight • Set goals for improving the growth of an overweight child • Identify the key sections of the Job aid: Investigating causes of overweight • Use the Job aid: Investigating causes of overweight appropriately (find the correct pages for the child’s age, complete the investigation before counselling, counsel using age-appropriate recommendations) • Check the mother’s understanding, using checking questions • Involve the mother in setting goals for improved growth HIV and infant feeding HIV1. Counsel a woman living with HIV antenatally about the infant-feeding practices recommended by the national health authority • Explain the risk of mother-to-child transmission (MTCT) of HIV • Outline approaches that can prevent MTCT through safer infant feeding practices • State infant feeding recommendations for women living with HIV, those who are HIV negative or those who do not know their HIV status • Apply competencies C1 and C2 to counsel a woman living with HIV HIV2. Support a mother living with HIV to feed her infant according to national health authority recommendations • Explain exclusive breastfeeding followed by continued breastfeeding while starting complementary foods • Explain how to heat-treat and store breast milk • Describe the criteria for selection of a wet nurse • Explain how to prepare replacement food • Describe hygienic preparation of feeds and hygienic management of utensils • Explain the volumes of replacement food to offer a baby according to weight • Apply competencies C1, C2 and BF1 to BF4 to support a mother to breastfeed exclusively and optimally • Show a mother how to heat-treat breast milk and apply competencies BF5 and BF6 • Apply competencies C1, C2 and BF1 to BF4 to support the wet nurse • Help a mother to prepare the type of replacement feeding she requires • Apply competency BF6 • Show a mother how to prepare replacement feeds hygienically • Practise with a mother how to prepare replacement feeds hygienically • Show a mother how to measure milk and other ingredients to prepare feeds • Practise with a mother how to measure milk and other ingredients to prepare feeds • Explain to a mother the volume of milk to offer her baby and the number of feeds per 24 hours HIV3. Promote appropriate use of nationally recommended antiretroviral therapy (ART) for women living with HIV • Describe the ART regimes recommended by the national health authority • List the antiretroviral drugs included in the recommended regimes for use in women living with HIV • Help women living with HIV to follow the recommended ART regime • Apply competencies C1 and C2 2. Introduction to the course 13 Competency Knowledge Skills HIV4. Follow up the infant of a mother living with HIV who is receiving replacement feeding from 0 up to 6 months • Describe hygienic preparation of feeds • Explain the volumes of milk to give to a baby according to weight • Explain when to arrange follow-up or when to refer • Explain about feeding during illness and recovery • Show a mother how to prepare replacement feeds hygienically • Practise with a mother how to prepare replacement feeds hygienically • Apply competency BF6 • Recognize when a child needs follow-up and when a child needs to be referred • Explain to a mother how to feed her baby during illness or recovery • Use the Counselling cards and flyers appropriately HIV5. Help a mother living with HIV in the event that she needs to stop breastfeeding • Describe the difficulties a mother may encounter when she tries to stop breastfeeding over a short period of time • Explain how to manage engorgement and mastitis in a mother who stops breastfeeding over a short period of time • Show the ways to comfort a baby who is no longer breastfeeding • List what replacement feeds are available and how to prepare them • Explain when to arrange follow-up or when to refer • Explain to a mother how she should prepare to stop breastfeeding early • Practise with a mother how to prepare replacement feeds hygienically • Apply competencies BF5 and BF6 • Manage breast engorgement and mastitis in an mother living with HIV who is stopping breastfeeding (competencies BF16 and BF18) • Explain to a mother ways to comfort a baby who is no longer breastfeeding Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 14 2.4 The course and the materials Structure of the course The course is divided into various modules and will take different times, according to the modules and sessions selected. The course can be conducted consecutively in a working week, or can be spread in other ways. The sessions use a variety of teaching methods, including lectures, demonstrations and work in smaller groups, with clinical practice sessions in wards and clinical facilities and classroom-based practicals and exercises. Order of sessions Sessions can be moved, but it is necessary for some aspects of the sequence to be maintained. The main requirement is that the sessions that prepare participants for a particular clinical practice or practical session are conducted before the session. Course materials Director’s guide The Director’s guide contains all the information that you, the course director, need to plan and prepare for a course, to decide which modules and sessions will be included in the training, and to select trainers and participants, starting several months before the actual training. It contains lists of the materials and equipment needed, examples of timetables, and copies of the forms that need to be photocopied before a course. It also describes the director’s role during the course itself. Trainer’s guide The Trainer’s guide contains what the trainer needs in order to lead participants through the course. The guide contains the information that is required, detailed instructions on how to conduct each session, the exercises that participants will do, together with answers, and the summary sheets, forms, checklists and stories used during the practical sessions of the course. This is the trainer’s most essential tool. It is recommended that trainers use it at all times and add notes to it as they work. These notes will help trainers in future courses. Slides Many sessions use slides. The director should inform trainers which ones to use. It is important that trainers are familiar with the equipment beforehand. All the slides are shown in the Trainer’s guide, so that trainers can make sure they understand the information, pictures or graphs for their sessions. Participant’s manual A Participant’s manual should be provided for each participant, using the modules selected. This contains summaries of information and copies of worksheets and checklists for the clinical practice and practical sessions and exercises participants will do during the course (without answers). This manual can be used for reference after the course, so it is not essential for participants to take detailed notes. Counselling cards and Guidance on the use of counselling cards The Counselling cards are provided as a set and referred to in several modules; they are to be used during the training and when counselling mothers/caregivers/families. Answer sheets These are provided in the Trainer’s guide, as well as separately in the Course handouts, and they give answers to all the exercises. They should be given to the participants after they have worked through the exercises. Forms and checklists Loose copies of the forms and checklists needed for clinical practice and practical sessions and counselling exercises are provided for photocopying in the Course handouts. They are listed next. For general use, or specifically for clinical practice sessions • Listening and learning skills checklist • Counselling skills checklist (includes Listening and learning skills and Skills for building confidence and giving support) • How to use a Counselling card • Clinical practice discussion checklist (for trainers only) • Competency progress form 2. Introduction to the course 15 Job aids and reference tools Items supplied as published materials • Child age calculator (https://www.who.int/tools/child-growth-standards) • Girl’s growth record (https://www.who.int/childgrowth/training/girls_growth_record.pdf) • Boy’s growth record (https://www.who.int/childgrowth/training/boys_growth_record.pdf) • Blank WHO and/or local growth charts (https://www.who.int/childgrowth/standards/en/) • A copy of the WHO training course on child growth assessment. 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 • Guidance on the use of counselling cards Items supplied in the Course handouts • Job aid: Breastfeed observation • Job aid: Feeding history – 0 up to 6 months • Job aid: Postnatal contacts • Job aid: Ongoing contacts • Job aid: Food intake – 6 up to 24 months • Instructions for completing the Job aid: Food intake – 6 up to 24 months • Reference tool: Food intake – 6 up to 24 months • Food consistency pictures • Instructions for use of the Child age calculator • Job aid: Weighing and measuring a child • Growth problems chart General assessment and follow-up • Log of skills practised (for participants only) • Difficulties experienced (for participants only) • Self-assessment in infant and young child feeding: competency practice and progress tracking form Story cards Copies of the histories and counselling stories are provided for photocopying in the Course handouts for some of the sessions. Other items of key information For easy reference, and photocopying if required, other useful items and summaries of key information are also supplied in a separate section of the Course handouts; they are presented in the order they appear in consecutive sessions, although some of them relate to several sessions. Updates Periodic updates on the topics covered on this course will be available on the WHO and UNICEF websites; these sites should be consulted when preparing a course. Training aids Trainers will need a flipchart and blackboard and chalk, or white board and suitable markers for most sessions, and a means of fixing flipchart pages to the wall or notice board – such as masking tape. They will also need approximately one life-size baby doll and one model breast for each small working group of three or four participants. If dolls and breasts are not available, some instructions follow for making them very simply and out of material that is readily available. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 16 How to make a model doll • Find any large fruit or vegetable, a towel or other strong thick cloth, and some rubber bands or string. • Put the fruit or vegetable in the middle of the cloth, and tie the cloth around it to form the baby’s “neck” and “head”. • Bunch the free part of the cloth together to form the baby’s legs and arms, and tie them into shape. • If the cloth is rather thin, you may like to stuff some other cloth inside to give the doll more of a “body”. How to make a model breast • Use a pair of near skin-coloured socks, or stockings, or an old sweater or T-shirt. • Make the cloth into a round bag shape, and stuff it with other cloth or foam rubber to make it breast shaped. • Stitch a “purse string” around a circle in the middle of the breast to make a nipple. • Stuff the nipple with foam or cotton. • Colour the areola with a felt pen. You can also push the nipple in, to make an “inverted” nipple. • If you wish to show the inside structure of the breast, with the larger ducts, make the breast with two layers, for example with two socks. • Sew the nipple in the outer layer, and draw the large ducts and ducts on the inside layer beneath the nipple. • You can remove the outer layer with the nipple to reveal the inside structure. 2. Introduction to the course 17 2.5 Reference materials As a course trainer, you may wish to obtain the following reference materials to answer questions and provide additional information. Breastfeeding • Breastfeeding [videos]. Global Health Media (https://globalhealthmedia.org/videos/breastfeeding/, accessed 9 August 2021). • Butte N, Lopez-Alarcon M, Garza C. Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva: World Health Organization; 2002 (https://apps.who.int/iris/handle/10665/42519, accessed 9 August 2021). • Community-based strategies for breastfeeding promotion and support in developing countries. Geneva: World Health Organization; 2003 (https://apps.who.int/iris/handle/10665/42859, accessed 9 August 2021). • Global nutrition targets 2025: breastfeeding policy brief. Geneva: World Health Organization; 2014 (WHO/NMH/ NHD/14.7; https://apps.who.int/iris/handle/10665/149022, accessed 9 August 2021). • Guideline: counselling of women to improve breastfeeding practices. Geneva: World Health Organization; 2018 (https:// apps.who.int/iris/handle/10665/280133, accessed 9 August 2021). • Guideline: infant feeding in areas of Zika virus transmission. Geneva: World Health Organization; 2016 (https://apps.who. int/iris/handle/10665/208875, accessed 9 August 2021). • Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259386, accessed 9 August 2021). • Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012;(8):CD003517. doi: 10.1002/14651858.CD003517.pub2. • Mastitis: causes and management. Geneva: World Health Organization; 2000 (WHO/FCH/CAH/00.13; https://apps.who. int/iris/handle/10665/66230, accessed 9 August 2021). • The optimal duration of exclusive breastfeeding: report of an expert consultation, Geneva, Switzerland, 28–30 March 2001. Geneva: World Health Organization; 2001 (WHO/FCH/CAH/01.24; https://apps.who.int/iris/handle/10665/67219, accessed 9 August 2021). • Relactation: a review of experience and recommendations for practice. Geneva: World Health Organization; 1998 (WHO/ CHS/CAH/98.14; https://apps.who.int/iris/handle/10665/65020, accessed 9 August 2021). • Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387:491–504. doi:10.1016/S0140-6736(15)01044-2. • Special issue: Impact of breastfeeding on maternal and child health. Acta Paediatr. 2015;104:1–134 (https://onlinelibrary. wiley.com/toc/16512227/2015/104/S467, accessed 9 August 2021). • Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387:475–90. doi:10.1016/S0140-6736(15)01024-7. • World Health Organization, United Nations Children’s Fund. The Global Breastfeeding Collective [website]. New York: United Nations Children’s Fund; 2021 (https://www.globalbreastfeedingcollective.org/, accessed 9 August 2021). • World Health Organization, United Nations Children’s Fund. Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services – the revised Baby-friendly Hospital Initiative. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/272943, accessed 9 August 2021). • World Health Organization, United Nations Children’s Fund. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative: 2018 implementation guidance: frequently asked questions. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/ handle/10665/330824, accessed 9 August 2021). Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 18 Breast-milk substitutes • Acceptable medical reasons for use of breast-milk substitutes. Geneva: World Health Organization; 2009 (https://apps. who.int/iris/handle/10665/69938, accessed 11 August 2021). • The International Code of Marketing of Breast-milk Substitutes. Code and subsequent resolutions [website]. Geneva: World Health Organization; 2021 (https://apps.who.int/nutrition/netcode/resolutions/en/index.html, accessed 11 August 2021). • The International Code of Marketing of Breast-milk Substitutes: frequently asked questions. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/254911, accessed 11 August 2021). • The International Code of Marketing of Breast-milk Substitutes: frequently asked questions on the roles and responsibilities of health workers. Geneva: World Health Organization; 2020 (https://www.who.int/teams/nutrition-and-food-safety/ food-and-nutrition-actions-in-health-systems/netcode/code-and-subsequent-resolutions, accessed 11 August 2021). • WHO policy brief on international trade agreements and implementation of the International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization and United Nations Children’s Fund; 2020 (https://apps. who.int/iris/handle/10665/331897, accessed 11 August 2021). • World Health Organization, United Nations Children’s Fund, International Baby Food Action Network. Marketing of breast-milk substitutes: national implementation of the international code, status report 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/handle/10665/332183, accessed 11 August 2021). Complementary feeding • Complementary feeding: family foods for breastfed children. Geneva: World Health Organization; 2000 (WHO/ NHD/00.1; https://apps.who.int/iris/handle/10665/66389, accessed 11 August 2021). • Five keys to safer food. Geneva: World Health Organization; 2001 (WHO/SDE/PHE/FOS/01.1; https://apps.who.int/iris/ handle/10665/66735, accessed 11 August 2021). • Five keys to safer food manual. Geneva: World Health Organization; 2006 (https://apps.who.int/iris/handle/10665/43546, accessed 11 August 2021). • Guiding principles for complementary feeding of the breastfed child. Washington (DC): Pan American Health Organization; 2003 (https://iris.paho.org/handle/10665.2/752, accessed 11 August 2021). • Guiding principles for feeding non-breastfed children 6–24 months of age. Geneva: World Health Organization; 2005 (https://apps.who.int/iris/handle/10665/43281, accessed 11 August 2021). • World Health Organization, Food and Agriculture Organization of the United Nations. Safe preparation, storage and handling of powdered infant formula. Guidelines. Geneva: World Health Organization; 2007 (https://apps.who.int/iris/ handle/10665/43659, accessed 11 August 2021). Growth monitoring • Childhood stunting: challenges and opportunities report: report of promoting healthy growth and preventing childhood stunting colloquium. Geneva: World Health Organization; 2014 (WHO/NMH/NHD/GRS/14.1; https://apps.who.int/iris/ handle/10665/107026, accessed 11 August 2021). • A critical link: interventions for physical growth and psychological development: a review. Geneva: World Health Organization; 1999 (WHO/CHS/CAH/99.3; https://apps.who.int/iris/handle/10665/66677, accessed 11 August 2021). • de Onis M, Garza C, Victora CG, Bhan MK, Norum KR. WHO Multicentre Growth Reference Study (MGRS): rationale, planning and implementation. Food Nutr Bull. 2004; 25(Suppl. 1):S3–84 (https://journals.sagepub.com/toc/fnba/25/1_ suppl_1, accessed 11 August 2021). • WHO Child Growth Standards. Acta Paediatr. 2006; 95 (Suppl. 450):5–101 (https://www.who.int/childgrowth/ publications/acta_supplement_pub/en/, accessed 11 August 2021). 2. Introduction to the course 19 HIV • Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. 2016 update. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/handle/10665/246200, accessed 11 August 2021). • Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach, 2nd ed. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/ handle/10665/208825, accessed 11 August 2021). • Counselling and voluntary HIV testing for pregnant women in high HIV prevalence countries. Elements and issues. Geneva: Joint United Nations Programme on HIV/AIDS; 2001 (UNAIDS/99.40E; https://www.unaids.org/sites/default/ files/media_asset/jc245-couns_test_en_2.pdf, accessed 11 August 2021). • World Health Organization, United Nations Children’s Fund. Guideline: updates on HIV and infant feeding: the duration of breastfeeding, and support from health services to improve feeding practices among mothers living with HIV. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/handle/10665/246260, accessed 11 August 2021). • World Health Organization, United Nations Children’s Fund. HIV and infant feeding in emergencies: operational guidance: the duration of breastfeeding and support from health services to improve feeding practices among mothers living with HIV. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/272862, accessed 11 August 2021). • World Health Organization, United Nations Children’s Fund, Food and Agriculture Organization of the United Nations, International Atomic Energy Agency, President’s Emergency Plan for AIDS Relief, Joint United Nations Programme on HIV and AIDS et al. Guidelines on HIV and infant feeding 2010. An updated framework for priority action. Geneva: World Health Organization; 2012 (https://apps.who.int/iris/handle/10665/75152, accessed 11 August 2021). General resources on infant and young child nutrition • Community infant and young child feeding counselling package. New York: United Nations Children’s Fund; 2013 (https://www.ennonline.net/iycfcommunityinterventions, accessed 11 August 2021). • Comprehensive implementation plan on maternal, infant and young child nutrition. Geneva: World Health Organization; 2014 (WHO/NMH/NHD/14.1; https://apps.who.int/iris/handle/10665/113048, accessed 11 August 2021). • Essential nutrition actions: mainstreaming nutrition through the life-course. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/326261, accessed 11 August 2021). • Global Nutrition Targets 2025. Childhood overweight policy brief. Geneva: World Health Organization; 2014 (WHO/ NMH/NHD/14.6; https://apps.who.int/iris/handle/10665/149021, accessed 11 August 2021). • Global Nutrition Targets 2025. Low birth weight policy brief. Geneva: World Health Organization; 2014 (WHO/NMH/ NHD/14.5; https://apps.who.int/iris/handle/10665/149020, accessed 11 August 2021). • Global Nutrition Targets 2025. Stunting policy brief. Geneva: World Health Organization; 2014 (WHO/NMH/NHD/14.3; https://apps.who.int/iris/handle/10665/149019, accessed 11 August 2021). • Global Nutrition Targets 2025. Wasting policy brief. Geneva: World Health Organization; 2014 (WHO/NMH/NHD/14.8; https://apps.who.int/iris/handle/10665/149023, accessed 11 August 2021). • Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. Geneva: World Health Organization; 2011 (https://apps.who.int/iris/handle/10665/85670, accessed 11 August 2021). • Infant and young child feeding: model chapter for textbooks for medical students and allied health professional. Geneva: World Health Organization; 2009 (https://apps.who.int/iris/handle/10665/44117, accessed 11 August 2021). • World Health Organization, United Nations Children’s Fund. Global strategy for infant and young child feeding. Geneva: World Health Organization; 2003 (https://apps.who.int/iris/handle/10665/42590, accessed 11 August 2021). Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 20 Maternal, newborn and young child care • Beyond survival: integrated delivery care practices for long-term maternal and infant nutrition, health and development, 2nd ed. Washington (DC): Pan American Health Organization; 2013 (https://iris.paho.org/handle/10665.2/3464, accessed 11 August 2021). • Convention No. 183. Convention concerning the Revision of the Maternity Protection Convention (Revised), 1952. Geneva: International Labour Organization; 2000 (http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ ILO_CODE:C183, accessed 11 August 2021). • Improving early childhood development: WHO guideline. Geneva: World Health Organization; 2020 (https://apps.who. int/iris/handle/10665/331306, accessed 11 August 2021). • Kangaroo mother care: a practical guide. Geneva: World Health Organization; 2003 (https://apps.who.int/iris/ handle/10665/42587, accessed 211 August 2021). • Maternity protection resource package – from aspiration to reality for all. Module 3: Maternity protection at work: Why is it important? Geneva: International Labour Organization; 2012 (http://mprp.itcilo.org/allegati/en/m3.pdf, accessed 11 August 2021). • World Health Organization, United Nations Children’s Fund, World Bank Group. Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/272603, accessed 11 August 2021). • World Health Organization, United Nations Population Fund, World Bank, United Nations Children’s Fund. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd ed. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/handle/10665/249580, accessed 11 August 2021). 21 2.6 Support for the course Clerical and logistical support Make sure that clerical and support staff will be available at the site to make photocopies and to prepare, for example, the evaluation questionnaires and certificates, and to make transport arrangements. They should be able and willing to help with anything that requires their attention. Funds required Make sure that enough funds are available to cover the following: • participants’ travel and per diem expenses • trainers’ travel and per diem expenses, and special compensation if required • payment for clerical support staff • travel to and from the health facility, if necessary • stationery, equipment and items for demonstrations • refreshments • accommodation and meals (if not covered by per diem expenses) • costs of photocopying. If trainers and/or participants need to arrive the day before the course starts, or remain until the day after the course finishes, in order to be present for the whole course, ensure there are sufficient funds to cover accommodation and meals for these nights. Opening and closing ceremonies You may wish to have an opening and closing ceremony for the participants. There may be an invited speaker to open the course and to close the course and present certificates to the participants and any new trainers. It is important to involve representatives from the government and key institutions, so that they are aware of the training, and to acknowledge or obtain their support for infant and young child feeding activities. Decide whom to invite in good time. Send an invitation with a short description of the course and the participants. Make it clear whether or not you want those whom you invite to make a speech. If you do wish them to speak, stress the exact time that will be available. Send them relevant information that would be appropriate for them to mention, for example, about local feeding data, the reasons for the course, and global initiatives to promote optimal infant and young child feeding. Offer to provide additional information if required. If possible, before the course, try to contact personally the individuals who accept the invitation and ensure that they fully understand the context in which they will make their speech. Prepare the course timetable to include the time needed for opening and closing ceremonies. This time has not been included in the course session times. It is important that your course schedule does not get disturbed by lengthy speeches, particularly on the first day. For a residential course, you may find it more convenient to hold the opening ceremony on the evening before the course starts, when all the participants have arrived. This provides a good opportunity to welcome everyone, go over arrangements and give out material. It also means that you can start straight away with Session 1 the following morning. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 22 2.7 Role of the course director The course director has overall responsibility for the planning and preparation of the course and ensuring the course runs smoothly. This includes: • ensuring the pre-planning is carried out • preparing the trainers, and coordinating and assisting trainers during the course • ensuring the course runs according to the planned timetable • introducing the course and conducting the closing session • conducting the course evaluation • discussing follow-up activities. The course director generally should have experience of participating in this course as a trainer and have good planning skills. They will need to allocate some time to the pre-course planning and working with a local organizer in the months preceding the course. If not based in the area, the course director should arrive at the course site 1–2 days before the course, to ensure arrangements are in place, and should be present throughout the entire course. At times, the course director may not be based in the area where the course will take place. In this case, a local organizer or contact person may arrange the facilities, gathering of local information for adaptations and other local activities. The course director is responsible for ensuring the local organizer understands what needs to be done and for confirming that it is done. Checklists and other relevant pages of this guide may be copied for the local organizer. The course director does not normally conduct sessions. However, in sessions that involve a lot of group work, they can assist the trainer assigned to the session with their group of three or four participants, or with parts of that session, so the trainer can assist the group. The course director should not have sole responsibility for a group of participants. 23 3. Making arrangements for the course 3.1 Where to hold the course In order to hold a successful course, you need to arrange: • classroom space for the course and for training the trainers • lodgings and meals for the trainers and participants • sites for the clinical practice sessions. Ideally, a course should be residential, with the classroom and accommodation at the same site. If the course is not residential, allow adequate time for travel between the accommodation and the classroom. It is essential that the course takes place near one or several facilities where participants can observe mothers, caregivers and young children. 3.2 Classroom facilities You need one large room available for seating all facilitators, participants and visitors; and one small classroom per group. The small classroom should have space for each group of 6–8 participants and their trainers to sit at a table during the sessions. You need additional table space to lay out the materials used during the course. The classrooms should be in a place where the participants are not disturbed by too much background noise and should have adequate lighting and ventilation. During the training-of-trainers, one classroom is needed for the director(s) and 6–8 people to work in. 3.3 Accommodation and meals For a residential course, it is necessary to arrange suitable accommodation near the classroom and the health facility. Unsatisfactory accommodation can hinder participants’ learning. If needed, suitable transportation needs to be available, from the accommodation to the classroom and to the facilities for the clinical practice and practical sessions. If participants are travelling long distances, ensure the budget will cover the accommodation for the night before and the last night of the course. Arrangements also need to be made for meals. This should include midday meals and refreshments, such as coffee and teas, near the classrooms. 3.4 Sites for clinical practice and practical sessions The clinical practice and practical sessions should take place at the following sites: • Clinical practice session(s) on breastfeeding counselling (Sessions 21, 22, 41 and 42): a postnatal ward with enough breastfeeding mothers and babies for each participant to talk to at least one mother. • Clinical practice sessions on complementary feeding counselling (Sessions 53 and 54): a child health centre or paediatric outpatient service, with enough mothers/caregivers and children for each pair of participants to counsel the mother or caregiver of at least one child aged 6 months up to 2 years. • Clinical practice session on measuring children (Session 68): - Option 1: an area in the facility where the classroom sessions take place, with enough space to accommodate: scales, measuring boards, chairs for mothers or caregivers and, if possible, for each group of three or four participants and their trainer. For this option, mothers of children (aged under 2 years and 2–5 years) should be invited to the facility. - Option 2: a child health centre or paediatric outpatient service, with enough mothers/caregivers and children for each pair of participants to measure at least one child aged under 2 years and one aged 2–5 years. • Clinical practice session on nutrition counselling (Session 69): a child health centre or paediatric outpatient service, with enough mothers/caregivers and children for each pair of participants to measure a child and counsel the mother or caregiver of at least one child aged under 2 years and one aged 2–5 years. • Practical session on preparation of milk feeds (Session 78): an outside area where fires can be lit to prepare feeds – this may be in the grounds of the building where the course is being held, or the yard of a local home. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 24 If there is no single facility in an area large enough to provide enough mothers, caregivers and children, you may use another nearby facility and send some of the small groups of three or four participants to each site. As discussed earlier, for participants to become competent in the necessary skills, it is important for them to practise, under supervision, as many of the skills as possible during the course. It is important, therefore, that there are enough caregiver/child pairs for each of the clinical practice sessions. Sometimes there seem to be plenty of mothers/caregivers and infants for the first clinical practice session, but the following day there are few new mothers/caregivers and infants for the second clinical practice session and some of these mothers/caregivers may not wish to be seen again. If the facility is not close to the classrooms, make transport arrangements to ensure that the participants can commute between the classrooms and the health facility in the most efficient way, with minimal loss of time. Transport time may need to be included in the timetable for the sessions. Each clinical practice session takes approximately 3 hours. The course timetable cannot be planned until the times of the clinical practice sessions are decided, so their organization is a high priority. Visit the health facility Visit one or more possible health facilities, to find out whether they are appropriate and to talk to the staff. • Talk to the director of the health facility, and explain what the training consists of, what your needs are, and what you want to do. • Ask whether they would be willing for the training to take place in the facility, and for their guidance on where different activities could take place. • If the director agrees in principle, visit the outpatient department or other services. Check the approximate number of caregiver and child pairs you could expect to see on an average day. For about 20 participants, approximately 50 mother/ caregiver/child pairs should be available. • Ask what times of the day are most suitable for holding the clinical practice sessions. This depends on when caregivers and children are likely to be available, and convenience for the facility’s routine. • Talk to the staff, and try to find out whether they are interested in helping with the course; for example, if they are interested in infant feeding, would they be willing to share their experience with the course participants? • Identify spaces or rooms near each clinic area where trainers and participants can have discussions out of caregivers’ hearing. • If the facility is suitable and the staff are interested and willing to help, arrange to make another visit nearer the time of the course to meet with the staff and prepare them. Prepare the facility staff It is important to prepare the health facility that will help during clinical practice sessions. If necessary, arrange to give them an appropriate orientation session, so that they understand the purpose of the course more clearly. At the meeting, explain: • about the course generally • that you need their help to prepare mothers/caregivers and ask their permission before the participants arrive, and to introduce participants to mothers/caregivers to whom they can talk • that you would like a responsible member of the facility staff to be available while the training team is there, in case a mother/caregiver needs a specific intervention; interventions will only take place with the permission and knowledge of facility staff; this will also enable staff to provide follow-up for the child • when you would like to bring participants to the facility for the different sessions; check that these are convenient, and that mothers/caregivers are expected to be available at that time. Leave some copies of reference materials for staff to read. An example of an information sheet is provided on the next page. 3. Making arrangements for the course 25 Example of an information sheet for a clinical practice site (to be adapted according to the content of the course) Infant and young child feeding counselling course After completing this course, participants will be able to assess breastfeeding and complementary feeding, measure children, plot measurements on growth charts, interpret growth indicators and counsel and support mothers, including those living with HIV, to carry out WHO/UNICEF-recommended feeding practices for their infants and young children. On completion of the course, participants should be able to assess the growth of children aged 0–5 years; provide anticipatory feeding guidance, with emphasis on breastfeeding and complementary feeding; assist mothers living with HIV and those with breastfeeding difficulties; assess whether the child is at risk of or has a problem of undernutrition/ overweight; and counsel mothers accordingly. We would like your assistance with the clinical practice sessions of this course. During these sessions, participants practise counselling skills with mothers (or in some situations another caregiver) of children aged between 0 and 2 (or 0 and 5) years. In other clinical practice sessions, participants talk to mothers or caregivers of children aged 0–2 (or 0–5) years and measure the children; they also assess growth and provide counselling on appropriate feeding of children – with emphasis on complementary feeding, and management of undernutrition or overweight as appropriate. In the clinical practice sessions in the postpartum unit, participants talk with mothers and provide breastfeeding counselling and support. Your help is needed to prepare mothers and caregivers, to ask their permission before the participants arrive, and to introduce participants to mothers and caregivers to whom they can talk. If a child/mother/caregiver needs a specific intervention, this will only take place with the permission and knowledge of health-facility staff. This will also enable staff to provide follow-up for the child or caregiver. The visit to your facility would be on: (date) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . from (time) . . . . . . . . . . . . . . . . . . . . . . . . . . Thank you for your assistance. Course organizers:1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Course venue: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Course dates: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Course contact person’s name and address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 For example, child health service. 26 4. Selecting trainers and participants The Ministry of Health or other agency may be planning for a series of courses rather than a single course. Given the effort required to set up a course, the need to train facilitators/trainers, and the need for a series of courses to train a sufficient number of health workers, arrangements will often need to take into account longer-term training plans. There may be a need to build a training team that can conduct courses on an ongoing basis. If so, long-term considerations may affect the choice of trainers and participants for each course. 4.1 Selecting trainers The success of a course depends on the presence of motivated, enthusiastic trainers. There should be one trainer for each group of four participants. When you select trainers, try to be sure that they will be interested and available to conduct other training courses in the future, and that they will be given support to do so. It is important that the experience gained by teaching a course is not wasted. Profile of a trainer Trainers are ideally people who are already involved in the promotion and support of infant and young child feeding and who have some previous training experience. They should: • be convinced that infant and young child feeding is important • be interested in becoming a trainer in Infant and young child feeding counselling: an integrated course • be willing and able to attend the entire course, including the preparation for trainers • be willing and available to conduct other courses in the future • be available to conduct the follow-up assessment of participants. Inviting trainers Invite trainers early and confirm their availability, so that you know how many participants you can invite. You will need one trainer for three or four participants. Include in the invitation the same information as in the course announcement for participants. Provide additional information on the preparation for trainers. Give the exact dates, and make it clear that you expect them to attend the entire course, including the preparation. Explain that the preparation is necessary for the trainers to become familiar with the contents and methods of the course. Give any additional administrative details, such as arrangements about finance and accommodation. If trainers live near to where the course will be held, it might be useful to involve them early in the preparations for the course. Preparation of trainers takes place before the participants’ training and is the responsibility of the course director. The preparation takes approximately 5 days, as outlined next, and includes time for private study and preparation. This preparatory period is extremely important. The course materials are not self-instructional and participants need the guidance of well-trained and supportive trainers. Even if the trainers are already trainers on other similar WHO courses, some of the materials in this course are slightly different from those in the original courses and it is important that the trainers are familiar with them. In addition, time is spent on the training-of-trainers course, to learn about the competencies participants are expected to learn and the assessment of these competencies in the follow-up session at the participants’ facility. It is hoped that trainers will teach on other courses and that some of them will become course directors. Building capacity of new trainers is as important as training participants. 4.2 Preparation of trainers The preparation of trainers will depend on the experience the trainers already have. During the preparation, new trainers need time to discuss the course content and structure, and to practise the different teaching techniques involved in participatory courses. All trainers need time to review the timetable, visit site facilities, check materials and equipment for their sessions and learn how to assess participants for the follow-up assessment. An example of a 5-day timetable for the preparation of trainers is included in section 4.6. Time will also be needed for the trainers to study and prepare sessions on their own. The course director adapts this timetable in the same way as the timetable for participants. Remember the following points: 4. Selecting trainers and participants 27 • first arrange the times that are convenient for clinical practice sessions • make sure that you include sessions of each kind, so that new trainers can practise different training methods as needed • allow time for the sessions that are most difficult to conduct. Be ready to change the timetable during the preparation, according to trainers’ progress, and to help them with particular difficulties. If the trainers have different levels of experience, you will need to arrange the preparation time to ensure their different preparation needs are met. Outline of course training methods Distribute materials If these have not been distributed previously, give each trainer a copy of the Trainer’s guide, the Participant’s manual, the timetables for the course and for the preparation of trainers, and the reference materials. Explain the course structure and timetable Ask trainers to look at their copy of the timetable for the participants’ course. Explain how the course is arranged with lectures, demonstrations, exercises, and clinical practice and practical sessions. Explain how training is conducted partly with the whole class together and partly in small groups of three or four participants with one trainer. Explain what will happen during the preparation days Ask the trainers to look at the timetable for the preparation of trainers, and explain how it is arranged. Explain that some time will be used on the practical aspects of the course management, such as assigning sessions, checking materials and the facilities, and general planning. Tell them that they will go through some of the sessions, partly as “participants” and partly as “trainers”. Explain the objectives of the preparation The objectives are: • to learn how to use the course materials, especially the Trainer’s guide • to become familiar with the information in the materials, and to discuss any points that are not clear • to practise the practical and counselling skills that they will teach • to practise the different teaching techniques, and to prepare to teach the different kinds of session • to discuss the management of the course • to discuss the follow-up assessments of participants. Explain the principles of the course methods The teaching methods used in the course are based on the principles listed next. • Instruction should be performance based: instruction should teach participants the tasks that they will be expected to carry out on the job. This course is based on experience of what those involved in infant feeding counselling need to be able to do to help mothers/caregivers to optimally feed children who are aged 0–24 months. • Active participation increases learning: participants learn how to do a task more quickly and efficiently if they actually do it, rather than just reading or hearing about it. Active participation keeps students more interested and alert. This course involves the participants actively in discussions, exercises and practical work. • Immediate feedback increases learning: feedback is information given to a participant about how well they are doing. It is most helpful if it is given immediately. If a participant does an exercise correctly, praise them. They will be more likely to remember what they have learnt. If a participant does not do an exercise correctly, help them to clear up any misunderstandings before they become strong beliefs, or before they become more confused. In this course, trainers give immediate individual feedback on each exercise or practical task. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 28 • Motivation is essential for instruction to be effective: most participants who come to a course are motivated and they want to learn. Trainers help to maintain this motivation if they: - provide immediate feedback - make sure that participants understand each exercise - encourage them in discussions - respect their original ideas and ways of responding - praise them for their efforts. Discuss teaching various kinds of session There are several different kinds of session, and trainers should be able to conduct each kind. Presentations There are presentations in lecture form with slides. In the course for participants, each of these is conducted by one of the trainers, for the whole class together. Group work Some sessions are conducted in groups of 8–10 participants with two trainers. These include the sessions where participants do a series of written exercises (Sessions 6, 7, 9, 10, 29, 30, 36 and 40); the food demonstration (Session 52) and the session on preparation of milk feeds (Session 78). Some sessions are conducted in small groups of 3–4 participants with one trainer. These include practising counselling skills, role-play and clinical practice and practical sessions. Methods used and training skills required Three methods are used to demonstrate and practise teaching procedures. • The course director acts as a trainer. You demonstrate appropriate behaviours when giving a presentation, leading discussions, facilitating exercises or conducting a clinical practice or practical session. • A trainer practises giving a presentation, leading a discussion, facilitating an exercise or conducting a clinical practice or practical session, while other trainers play the role of participants. The trainer thus both practises and demonstrates the role for other trainers. • One trainer acts as a “participant” doing a written exercise and another acts as a “trainer” providing individual feedback on their answer, while others observe them. Again, the “trainer” is both practising this teaching procedure and demonstrating for other trainers. Practise different kinds of sessions Arrange for each new trainer to practise as many of the different kinds of teaching techniques as possible, to: • give a presentation with slides • demonstrate counselling skills in a role-play • conduct group work with four participants • lead or assist in a clinical practice or practical session. Give feedback to trainers on their performance after each session they practise. Summarize the main training skills required Giving lectures and using visual aids Ask the trainers to turn to the front of the Trainer’s guide and find the Checklist of training skills. Read through and discuss the points mentioned in the list. Ask the trainers to practise these skills when they conduct their practice sessions. When you give feedback after their practice sessions, refer to this list. 4. Selecting trainers and participants 29 Giving individual feedback An important task of trainers is to provide individual feedback, for both the written exercises and the clinical practice and practical sessions. Giving individual feedback is not an easy technique to learn. It is very useful for new trainers to see it being modelled, and then for them to participate in the process so that they understand what is involved. When giving individual feedback, a trainer identifies points that the participant has and has not understood about an exercise, and makes sure that the participant understands the main points. For written exercises, the trainer follows the possible answers in the Trainer’s guide, but accepts other answers that are also appropriate. If the participant’s answer is appropriate, the trainer gives praise. If the participant’s answer is not appropriate, the trainer discusses the question and helps the participant to think of a better answer. The trainer should not tell the participant the suggested answer too quickly. The opportunity should be used to clarify some of the teaching that the exercise is about and to help the participant think of appropriate responses. To practise the technique, one new trainer plays the part of a participant doing an exercise, while the other trainer gives individual feedback on their answer. They sit in front of the class, positioned as a trainer and participant would be, for others to observe and learn from their performance. The questions and comments of the “participant” trainer will probably not be characteristic of actual participants in a course, who may be more shy and less well informed. Ask someone to act as a participant with such characteristics as: • fear of showing the trainer their work • confusion over the relationship of a previous exercise to the exercise being discussed • unwillingness to discuss an exercise at all • the tendency to say that they understand when they clearly do not. This will give new trainers a more realistic, if exaggerated, idea of the difficulties they may face. Remind trainers to speak quietly when they give feedback during the course. They should try to avoid disturbing people who are still working; try not to let other participants overhear the answers before they have thought about an exercise themselves; and try to give the participant who is getting the feedback some privacy. Trainers should sit down next to the participant with whom they are working, rather than standing over them, which can be intimidating. Preparing and giving a demonstration • Study the instructions and collect the equipment. • Prepare your assistant well beforehand. Conducting small-group sessions (practising counselling skills) In Session 47, participants practise role-playing using their counselling skills. Participants work in groups of three or four, using the story cards provided. One of the group plays the “mother” and the other plays the “counsellor”; the other one or two members are observers. The trainer follows the story contained in the Trainer’s guide, to guide participants and make sure that they learn what is intended. The trainer helps the counsellor to improve their skills. Helping participants In addition, trainers should ensure that participants have the forms and other items, as required, and be available to participants to answer questions between sessions. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 30 Review the Trainer’s guide and the other materials Ask the trainers to look at the Trainer’s guide and at the Participant’s manual and to compare the two. Make these points: • The Participant’s manual contains the essential information for Sessions 1–78 that a participant needs to be able to remember or refer to. It contains the exercises and worksheets but without answers. • The Trainer’s guide contains the same information, plus some further information to help to answer questions, and also detailed guidance on how to conduct each session, with possible answers to the exercises. Review the structure of a session in the Trainer’s guide Look at the beginning of a session, and point out the boxes for Objectives, Session outline and Preparation. Explain to the trainers that they should look at these sections before they conduct a session, so that they can make all necessary arrangements. Read the introduction to the Trainer’s guide Ask the trainers to read through the Introduction of their Trainer’s guide carefully, as this contains important information about the course. Remind trainers when they prepare for their sessions, to read through the relevant sections of the Introduction to the Trainer’s guide, to remind them about the teaching methods they will use. • Ask the trainers to look at page 39 in the Trainer’s guide, and to look at the box What the symbols used in this guide indicate. Explain that these symbols are used throughout the guide, and they will soon become familiar. • Find an example of each symbol in the Trainer’s guide. • Ask the trainers to look at that example, to see how the symbol is used. • Explain that if trainers follow the instructions in the Trainer’s guide carefully, they will be able to conduct efficient and interesting sessions. • Explain that the Trainer’s guide is their most essential tool for teaching the course. Suggest that they write their names clearly on their copy, and keep it with them at all times. They can write notes in the guide that may be useful for training in future. Review other materials Show trainers all the other materials, including the worksheets, story cards and Counselling cards. Explain briefly what each is for. Practising the sessions Assign practice sessions to trainers On the first day of the preparation, assign sessions to trainers for them to practise teaching. Write their names on a copy of the timetable. Try to ensure that each new trainer practises giving a lecture and a demonstration, and facilitating group work during the preparatory days. If necessary, divide sessions between two or three new trainers, to make sure they have the necessary practice. For the first few practice sessions, select trainers who are more experienced or those whom you expect to be the best model for the less experienced trainers. Conduct the preparation New trainers should conduct their sessions as described in the Trainer’s guide, with other trainers as “participants”. For all the sessions, it is the course director’s responsibility to make sure that the necessary materials are available, and to give help as required. However, the trainers must request them, and make sure that they have everything ready. Discuss the teaching practice: ask questions such as “What did the trainer do well?”, “What difficulties did you observe?”, “What could the trainer do differently in the future?” 4. Selecting trainers and participants 31 After each practice session, trainers should discuss and comment on the teaching, referring to the Checklist of training skills. Points to consider include: • did the trainer’s movements and speech help the presentation? • did the trainer involve the class in discussion and answer questions clearly? • did the trainer explain points clearly, using the visual aids as needed? • did the trainer use the Trainer’s guide and other materials accurately? • did the trainer include all the main points? • did the trainer keep to time? Ask the class first to point out and praise what the trainer did well, and then to suggest what they could do differently. It is very important for the course director to praise a new trainer who has followed the material and conducted a session well. But it is also important to help new trainers to improve their teaching skills. It is helpful to discuss ways to improve with the whole group, because then everybody learns. However, if you feel that some points may embarrass a new trainer, you may need to discuss them privately. As course director, you should also encourage discussion of your own technique after you have demonstrated a session. Show that you welcome suggestions about how to conduct the session better. Help trainers who have difficulty Discuss difficulties that the trainers had doing the exercises and discuss how they can help participants if they have similar difficulties. Sometimes a trainer shows that they find it particularly difficult to teach a session. This might be, for example, because of lack of confidence, or because they were unable to prepare well enough beforehand. If this happens, discuss the trainer’s performance with them privately and not with the whole group. It might also be useful to help the trainer to prepare for their next session, so that they can develop more confidence. Review the timetable Ask the trainers to look at the timetable for the participants’ course, and read it through. Go through all the sessions, and check who is responsible for conducting each one. Remind trainers that they will all need to actively assist in sessions that include group activities. Make sure that the trainers all agree with what you have asked them to do. Give them the information in writing. Visit sites for practical sessions Visit the teaching facility and ensure that trainers know where the classrooms and the practical cooking areas are, and the arrangements for meals. Check the equipment Check that the projector, electrical extension cords if needed, flipchart and all other equipment are in place, or that the trainers know where to obtain it. Make the following clear: • who is responsible for providing materials, stationery and equipment; appoint someone whom trainers can contact if they need something • that you will be holding daily trainers’ meetings of about half to one hour, which are very important for the success of the course; discuss an acceptable time (usually at the end of the day) • time may be needed in the evenings after the session, to prepare and practise the next day’s sessions • who is responsible for assigning participant groups to trainers; explain that the list will be prepared on the first morning of the course, after participants register. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 32 Thank the trainers for their efforts Thank the trainers for their work during the preparation. Encourage them to continue working hard during the course itself, and promise to help them in any way that they need. Trainers’ meetings • Trainers’ meetings are usually conducted for about 30–60 minutes at the end of each day. Trainers will be tired, so keep the meetings brief. They should be led by the course director(s). • Begin the meeting by encouraging the trainers – praising what they did well during the day. Trainers may become discouraged if they feel the session(s) they led did not go well. • Continue by asking a trainer from each group to describe progress made by their group, to identify any difficulties impeding progress, and to identify any skill, exercise or section of the sessions that participants found especially difficult to do or understand. • Identify solutions to any problems related to any particular group’s progress, or related to difficult skills or sections of the sessions. • Discuss teaching techniques that the trainers have found to be successful. • Provide feedback to the trainers on their performance. Use the notes that you have taken while observing the groups during the day. • Mention a few specific actions that were well done (for example, conducting a lecture session accurately and in an interesting way; keeping to time; providing participants with individual feedback; facilitating a practical session well; demonstrating practical skills carefully and accurately to the group). • Mention a few actions that might be done better (for example, keeping to time; following the lecture sessions accurately without omitting any points; answering questions clearly; explaining more clearly which tasks should be practised during the clinical practice or practical session). Remind trainers of certain actions that you consider important. Some examples are provided next. • Discuss difficulties with a co-trainer. If co-trainers cannot solve problems together, they should go to the course director. The course director may be able to deal with these situations (for example, by discussing matters privately with the individuals concerned). • Speak softly while giving feedback, to avoid disturbing others. Put chairs out in the hall so that a participant and a trainer can talk without disturbing the rest of the group. • Always be open to questions. Try to answer immediately, but if a question takes too long to answer, diverts the attention of the group from the main topic, or is not relevant at the moment, suggest that the discussion be continued later (for example, during free time or over dinner). If a question will be answered later in the course, explain this. If unsure of the answer to a question, offer to ask someone else and then come back later with an explanation. • Interact informally with participants outside of scheduled class meetings. • For participants who cannot read the sessions and/or do the exercises as quickly as others, the trainers should: - avoid doing exercises for them - reinforce small successes - be patient (or ask another facilitator to help). Before closing the meeting: • Review important points to emphasize in the clinical practice session or in the sessions the next day. • Remind the trainers to consult the Trainer’s guide and gather together any supplies needed for the next day. • Make any necessary administrative announcements (for example, location of equipment for the demonstrations, room changes, transportation arrangements, etc.). 4. Selecting trainers and participants 33 4.3 Selecting participants Try to ensure that appropriate and motivated participants come to the course. This will make the training successful, and may stimulate the interest of others in infant feeding, so that they will also want to acquire the skills and do the work. Participants should be free of other work during the course, so that they may fully participate. The number of participants who can be invited for a course depends on: • your budget • your classroom and residential accommodation • the number of trainers available (you need one trainer for each four participants) • the number of mother/caregiver and young child pairs who can be seen on an average day in the health facility where you will conduct the clinical practice sessions (you need about eight pairs per session per group of four participants). It is recommended that you do not invite more than 24 participants to a course. If possible, try to include one or more of the staff of the health facility in which the clinical practice sessions will be conducted. You may plan to train a number of people from a certain area, or to train all appropriate health workers in a given area or institution with a series of trainings. You may ask health facilities in an area each to select 1–3 participants to attend the course. An example of a course announcement notice is provided below. Example of a course announcement Infant and young child feeding counselling course Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Venue: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Course organizers:1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Objectives of the course: after completing this course, participants will be able to assess breastfeeding and complementary feeding, measure children, plot measurements on growth charts, interpret growth indicators and counsel and support mothers, including those living with HIV, to carry out WHO/UNICEF-recommended feeding practices for their infants and young children. Who should attend: the course is for primary health-care nurses and doctors, clinicians at first referral level, lay counsellors and community health workers. They should be fluent in [state required language]. Outline of course: [section to be completed according to the content selected] Accommodation: accommodation and meals will be available from [evening before course to morning after depending on travel arrangements]. Participants should arrive by 8 am on [first day of course] and are free to leave after 5 pm on [last day of course]. Travel costs will be refunded. Registering for the course: send the names and contact details of candidates who wish to apply, to [name and address] before [date]. When participants have been selected, further information will be sent to them and to their health facility. Certification: participants who complete the entire course will receive a certificate of completion. 1 For example, child health service. 34 5. Checklists for planning 5.1 Overall planning checklist In the following pages, you will find the checklists referred to in the preceding pages. You can tick off each item as it is completed. If the course director is coming from a long distance, a local organizer may arrange for most of these actions. Initial planning 1. Decide the course schedule. For example, a 5-day course or 1-day meeting each week for 5 weeks. Allocate 8 teaching hours per day, with meal times in addition. 2. Choose a training venue. This must include a large classroom, 2–3 smaller classrooms and a facility to conduct the clinical practice sessions. Ideally, these should be at the same site. Make sure that the following are available: - easy access from the classroom to the area for the clinical practice sessions - a large room and 2–3 smaller rooms that can seat all participants and trainers for sessions, including space for guests invited to the opening and closing ceremonies; there should be space for each group of 6–8 participants and their trainers to sit at a table, with enough space for each to open up their course materials - for training-of-trainers, one classroom that can accommodate 8–10 people - adequate lighting and ventilation, and wall space to post up large sheets of paper in each of the rooms - at least one table for each group of 6–8 participants and additional table space for materials - freedom from disturbances such as loud noises or music - arrangements for providing refreshments - space for at least one member of clerical or logistic support staff during training - a place where supplies and equipment can be safely stored and locked up if necessary. When you have chosen a suitable site, book it in writing and subsequently confirm the booking some time before the course, and again shortly before the course. 3. Choose lodging for the participants. Ideally, the course should be residential. If lodging is at a different site from the course, make sure that the following are available: - reliable transportation to and from the course site - meal service that is convenient for the course timetable. When you have identified suitable lodging, book it in writing and subsequently confirm the booking some time before the course, and again shortly before the course. 4. Visit the health facility or other facilities that you will use for the clinical practice sessions. - Confirm the hours during which it is possible to see mothers and young children (if you plan to visit more than one facility at each session, it is important to make sure they are available at the same time). When you have chosen a suitable site, confirm it in writing and reconfirm shortly before the course. 5. Decide the exact dates of the course. 6. Arrange for a responsible authority (for example ministry of health, national nutrition programme) to send a letter to the district/regional office or to health facilities asking them to identify participants. This letter should: - explain that the course will be held, and explain the aims of the course - give the site and dates of the course - state the total number of places for participants on the course (12–24), and suggest the number of places to offer to participants from each facility (this depends on how many facilities are involved) - state clearly that nominated participants should be people who are responsible for measuring children and providing assistance on feeding young children aged 0–24 months 5. Checklists for planning 35 - explain the duration of the course and that individuals should arrive in time and attend the entire course - give the date by which nominated course participants will be selected and contact details of the person to whom the names of nominated participants should be sent - say that a letter of invitation will be sent to participants once they are selected. 7. Select and invite trainers. It is necessary that: - there is at least one trainer per four participants. - trainers are experienced (see section 4.1) - trainers are able and willing to attend the entire course, including the preparatory period (training-of-trainers) before the course. 8. Identify suitable participants, and send them letters of invitation, stating (see section 4.3): - the objectives of the training and a description of the course - the desired arrival and departure times for participants - that it is essential to arrive in time and to attend the entire course - administrative arrangements, such as accommodation, meals and payment of other costs. 9. Arrange to obtain enough copies of the course materials (see section 5.2). 10. Arrange to obtain: - necessary supplies and equipment (see section 5.3) - the items needed for demonstrations (see section 5.4) - the necessary background information for the area (see section 5.5). 11. Arrange to send materials, equipment and supplies to the training venue. 12. Arrange to send travel authorizations to trainers and participants. 13. Invite officials for the opening and closing ceremonies (see section 2.6). Arrangements at the training venue before the course begins The course director (or a designated trainer) should arrive at the course site early, to ensure that the arrangements described next are made. Plan to arrive there at least a day or two before the preparatory period for trainers, and continue with the organization during the preparatory days. During the course, the course director needs to work with local staff to ensure that arrangements go well and that the trainers’ and participants’ work is not unduly interrupted. 14. Confirm arrangements for: - lodging for all trainers and participants - classrooms - daily transportation of participants from lodgings to their classroom and to and from the sites for clinical practice sessions; ensuring that clinic staff are briefed on the visits and that that children and their mothers/caregivers will be available when needed; and determining a suitable way of thanking the mothers/caregivers and children for their time – for example, small toys or fruit (bananas are easy to hand out) may be given to the children - meals and refreshments - opening and closing ceremonies with relevant authorities; check that invited guests are able to come - a Course-completion certificate (if one will be given) and when a group photograph will be taken in time to be printed before the closing ceremony (optional) - arrangements for typing and copying of materials during the course (for example, timetables, lists of addresses of participants and trainers). 15. Arrange to welcome trainers and participants at the hotel, airport or railway/bus station, if necessary. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 36 16. Prepare timetables for preparation of trainers and for course for participants. Examples are given in section 4.6. 17. Adapt the Evaluation questionnaire for participants, and make enough copies for each trainer and participant (see Course handouts). Actions during the preparation of trainers 18. Provide a timetable for the training-of-trainers on the first day. 19. By the end of the preparation of trainers, assign pairs of trainers to work together during the course. 20. By the end of preparation, assign sessions to trainers, for them to conduct. 21. Organize course materials, supplies and equipment, and place them in the appropriate rooms at the course site. Actions during the course 22. After registration, assign groups of three to four participants to one trainer. Post up the list of participants assigned to the different pairs of trainers, where everyone can see it. 23. Provide all participants and trainers with a course directory, which includes the names and addresses of all participants and trainers and the course director. 24. Arrange for a group photograph, if desired, to be taken. 25. Prepare a Course-completion certificate for each participant. 26. Make arrangements to reconfirm or change airline, train or bus reservations for trainers and participants, if necessary. 27. Allocate a time for payment of per diem and for travel/lodging arrangements that does not take time from the course. Add any other points you need to check: 5.2 Checklists of course materials The checklists give the materials needed for a course with 24 participants and 6 trainers plus a few spares. Some of the materials relate to specific modules and should be used only if the module is included in the training. Items supplied as published materials Item Total copies Director and trainers Participants Director’s guides 8  — Trainer’s guides 8  — Set of slides 1 per group — Participant’s manuals 32   Child age calculator 32   Girl’s growth record 32   Boy’s growth record 32   Blank WHO and/or local growth charts 32   Photo booklet1 32   Job aid: Investigating causes of undernuitrition and overweight 32   Counselling cards 32   Guidance on the use of counselling cards 32   1 WHO training course on child growth assessment. Photo booklet. Geneva: World Health Organization; 2008 (http://www.who.int/childgrowth/training/module_e_photo_booklet. pdf). 5. Checklists for planning 37 Items to be photocopied With the exception of the timetables, which need to be produced by the course director, the items in this table are supplied in the Course handouts. Item Total copies Director and trainers Participants Course timetable for trainers 8  — Course timetable for participants 32   Course registration form 30   Summary participant list 1  — Evaluation questionnaire for participants 24 —  Evaluation form for participants and trainers 32   Evaluation form for trainers 8  — Listening and learning skills checklist 32   Counselling skills checklist (including Listening and learning skills and Skills for building confidence and giving support) 32   How to use a Counselling card 32   Clinical practice discussion checklist (with counselling skills on back) 8  — Competency progress form 32   Job aid: Breastfeed observation 64   Job aid: Feeding history – 0 up to 6 months 64   Job aid: Postnatal contacts 32   Job aid: Ongoing contacts 32   Job aid: Food intake – 6 up to 24 months 90 — 3 per participant Instructions for completing the Job aid: Food intake – 6 up to 24 months 32   Reference tool: Food intake – 6 up to 24 months* 32   Food consistency pictures* 32   Instructions for use of the Child age calculator 32   Job aid: Weighing and measuring a child 32   Growth problems chart 32   Log of skills practised 24 —  Difficulties experienced 24 —  Self-assessment in infant and young child feeding: competency practice and progress tracking form 24 —  Copies of demonstrations 2 of each — For participants helping with demonstrations Copies of scripts for role-play 2 of each — For participants helping with demonstrations Materials for group exercises 8 — 1 per group of 4 Answer sheets 24 — 1 per participant Course-completion certificate 32   *If possible, copy the Reference tool: Food intake – 6 up to 24 months with the Food consistency pictures on the back. Use card or heavy paper, if available. Other items for photocopying are supplied in the Course handouts, under the heading Other items of key information, for use as required. Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 38 5.3 Checklist of equipment and stationery Item(s) needed Number needed for the course Laptop 1 PowerPoint projector 1 Equipment for typing/word processing Access needed Photocopying equipment Access needed Photocopying paper Two reams (200 sheets) just for timetables and other incidentals. More if worksheets, etc. are done at course Flipchart stands or blackboards 3 Markers for flipchart 3 each of red, black and green Chalk 2 boxes Chalk erasers 2 Name tags and holders 32 Pads or notebooks of ruled paper 32 No 2 pencils 32 Erasers 32 Ballpoint pens – blue or black 32 Highlighters 32 Hand-held staplers 2 Staples 1 box Scissors 2 pairs Pencil sharpeners 5 Paper clips, large Approx. 100 Masking tape to stick flipchart sheets onto walls or other surfaces 2 rolls Simple files for trainers to store papers 10 5. Checklists for planning 39 5.4 Checklist of items needed for demonstrations or exercises General • 4 chairs that can be brought to the front of the room for demonstrations • A bowl or cup that would be used when feeding a young child – approximately 250 mL • 4 life-size baby dolls – these can be made yourself if necessary • 1 model breast – this can be made yourself if necessary Individual sessions Session 13 • Pillows and a blanket • Somewhere for the “mother” to lie down, e.g. a bed or a table Session 14 • Pillows and a blanket • Somewhere for the “mother” to lie down, e.g. a bed or a table Session 17 • Some examples of suitable containers to collect expressed breast milk, which would be available to ordinary mothers (for example, cups, jam jars) • Some examples of locally available breast pumps (if any are used in your area) Session 18 • A small cup (available locally) that is suitable for cup-feeding a young baby. The cup should hold 60 mL of fluid • A cloth or bib • A doll Session 19 • A 20 mL disposable syringe Session 25 • Pillows and a blanket • Somewhere for the “mother” to lie down, e.g. a bed or a table Session 27 • Pillows and a blanket • Somewhere for the “mother” to lie down, e.g. a bed or a table Session 39 • A fine feeding tube and some tape for dressings (e.g. zinc oxide tape) • A cup or other container for milk • A 5 mL or 10 mL syringe, with a short length (about 5 cm) of fine tubing attached to the adaptor • A dropper, if locally available. Session 44 Consistency demonstration: • Extra table or tray in case of porridge spills • Two see-through containers that each hold 200 mL (not more) when filled to the top for the “stomach”. This could be a drinking glass, or a plastic container such as a used soft drink bottle, cut to the right size • Sharp scissors or knife to cut the soft drink bottles if needed Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 40 • Measuring jug to measure 200 mL • 400 mL made-up porridge/gruel from a suitable local staple. Processed baby cereal can be used if convenient • Two additional containers: one bowl or container that holds at least 500 mL; the other container should be at least 250 mL • Extra water (about 200 mL) • A large eating spoon • Cleaning materials to tidy up afterwards, including hand-washing facilities Session 45 • A bowl or plate that would be used when feeding a young child • Examples of locally available industrially produced complementary foods (empty packets are suitable); this could include brand-name “baby foods” and/or special fortified cereal products made locally, or subsidized food-programme items Session 46 • A common local cup, bowl or other container to demonstrate amounts of food to give a young child. Session 47 • A typical bowl that a young child would use locally – one for each group of four participants Session 48 • Teaspoon, medium-size spoon and a very large spoon • Feeding bowl with some mashed food in it (for example, banana) • Piece of bread or other finger food • Cloth to use as a bib • Basin, water, soap and towel for hand-washing (as part of the demonstration) • Mat or chairs to sit on while demonstrating how to feed a young child Session 52 • A room you can bring food into; this session can be conducted in the canteen following lunch, if suitable • A table for each group to work at • A variety of common foods (cooked if needed) that young children would eat, enough to make a child size bowlful for each group, from the kitchen at the course facilities or elsewhere. Include some inappropriate food, if possible. Do not divide the food for the groups. Cover the food until you are ready to use it • One small bowl, knife, fork and eating spoon for each group. A plate to prepare food on or a chopping board • A local measure that holds 250 mL. Do not distribute this until after the plate of food is prepared by the group • Facilities for washing hands before and after preparing food • Waste container and materials for cleaning up afterwards Session 57 • A taring scale (if available) • A length/height board set up to measure height • A length/height board set up to measure length • Paper towels or soft cloth to cover the length/height board • A large doll is very helpful Session 62 • A typical bowl that a young child would use – one for each group of four participants. 5. Checklists for planning 41 Session 70 • Examples of a local growth chart – one per participant Session 75 • Two dolls • Two cloths for wrapping the dolls Session 78 • Cooking equipment – fireplace, charcoal or paraffin stove or other locally used fuels and stoves (check stoves work, wood is dry), kettle • Matches, kindling and other equipment needed to use stoves; firewood • Mat or newspapers to make a clean surface • Source of water near to the cooking area • Pots and pans for heating water • Soap and disinfectant • Bowl of hot water • Towel/paper napkins • Clean container with an amount of clean water in it • Tin of formula milk powder with scoop • One dinner knife • Bottle and/or feeding cup For the heat-treatment of expressed breast milk: • Bowl of hot water • Soap and towel/paper napkins • Pan of clean water large enough to boil all utensils • Cup with 80 mL of “expressed breast milk” for one feed (use the formula milk previously made) • Small heat-proof jar for the breast milk • Small pan with cool water in it • Container of cool water • Small cup for feeding the baby • Device for heating the pan of water and milk Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 42 5.5 Checklist of background information needed • How does this course link to local programmes such as Integrated Management of Childhood Illnesses? • What are the follow-up plans for course participants? • What are the infant feeding indicators (breastfeeding, complementary feeding)? • What is the breastfeeding/baby-friendly policy for local hospitals and clinics (if available)? • Are there any locally used materials on feeding infants and young children? • Are there any locally used materials on food hygiene? • Are there local growth charts? • Is generic infant formula milk available? • Is a micronutrient supplement available in the local clinics? What is the policy for giving out these supplements? • Is the percentage known of young children who are malnourished (wasted, underweight or stunted, overweight or obese, with micronutrient deficiencies)? • Is the local culture vegetarian or meat eating? • Are germinated flours or fermented porridge used in the area? • Are there any local or national nutrition supplementation programmes and policies? • Are there any local systems for providing food, vouchers or cash to families living in poverty? • What is the prevalence of HIV? Are there regional differences? • What is the national health authority infant feeding recommendation for mothers living with HIV? 5.6 Timetables The following pages contain examples of timetables for the training-of-trainers and the participants. The timetable for training-of-trainers is flexible and should be adjusted, depending on the experience of the trainers and which of the previous WHO infant feeding courses they have participated in. It is recommended that the first national training (training-of-trainers and first course for participants) includes all sessions, even if the subsequent courses will be conducted without HIV sessions, so that the trainers fully understand the issues involved in HIV and infant feeding. The participants’ timetable is less flexible, as the sessions should be conducted in a logical sequence. It is possible to change the order of some of the sessions. The course director should make these decisions. An example of a timetable for participants without the sessions on HIV is included, for use in areas of low HIV prevalence. In this case it is recommended that Session 72 is included, so that participants have an overview of HIV and infant feeding. Training-of-trainers These are example timetables for the “training-of-trainers” course. This can be adjusted depending on the skills and experience of the trainers. That is, with experienced trainers, the duration of some sessions may be shortened. Time needs to be allocated for discussion of the competencies participants will be expected to learn. In addition, time needs to be spent going through the Guidelines for follow-up after training (see section 6). Allocation for time to discuss policies and hospital practice, such as the Baby-friendly Hospital Initiative and the International code of marketing of breast-milk substitutes may be considered during these training sessions or as a separate training course. 5. Checklists for planning 43 Example 1: Trainers’ preparation timetable Day 1 Day 2 Day 3 Day 4 Day 5 08:30–09:30 Welcome and distribution of materials Distribution of timetable 08:30–09:45 Positioning a baby at the breast 1 (Session 14) 08:30–09:30 Overview of HIV and infant feeding (Session 71 or 72) 08:30–09:30 The importance of complementary feeding (Session 43) 08:30–09:30 Food demonstration (Session 52) 09:30–10:30 Introduction to the course, target audience and logistics 09:45–10:30 Buidling confidence and giving support: exercise 1 – breastfeeding (Session 9) 09:30–10:00 Antiretroviral therapy and infant feeding (Session 73) 09:30–10:30 Variety, frequency and quantity of feeding (Session 46) 09:30–10:15 Building confidence and giving support: exercise 2 – complementary feeding (Session 10) 10:00–10:30 Supporting national health authority infant feeding recommendations for women living with HIV (Session 77) 10:15–10:30 Foods to fill the energy gap (Session 44) 10:30–11:00 Coffee 10:30–11:00 Coffee 10:30–11:00 Coffee 10:30–11:00 Coffee 10:30–11:00 Coffee 11:00–12:00 Discussion of competencies of participants are expected to learn 11:00–12:00 Assessing a breastfeed 1 (Session 13) 11:00–11:15 [Continutation] Supporting national health authority infant feeding recommendations for women living with HIV (Session 77) 11:00–12:30 Gathering information on complementary feeding practices (Session 47) 11:00–11:30 [Continuation] Foods to fill the energy gap (Session 44) 12:00–12:30 Introduction to infant and young child feeding (Session 1) 12:00–12:30 Taking a feeding history – 0 up to 6 months 1 (Session 15) 11:15–12:30 Communication and support of breastfeeding in the context of HIV (Session 76) 11:30–12:30 Foods to fill the iron and vitamin A gaps (Session 45) 12:30–13:30 Lunch 12:30–13:30 Lunch 12:30–13:30 Lunch 12:30–13:30 Lunch 12:30–13:30 Lunch 13:30–14:40 Listening and learning (Session 5) 13:30–15:30 Clinical practice session 2: Building confidence and giving support – positioning a baby at the breast (Session 22) 13:30–14:40 Supporting women living with HIV to breastfeed or to use replacement feeding (Session 74 or 75) 13:30–16:30 Clinical practice session 8: Gathering information and counselling on complementary feeding practices and growth (Session 69) 13:30–13:50 [Continuation] Foods to fill the iron and vitamin A gaps (Session 45) 14:40–16:00 Growth charts (Session 70) 15:30–16:30 Respnsive feeding (Session 48) 14:40–17:00 Practical session: preparing milk feeds for babies who require expressed breastmilk or replacement feeding (Session 78) 13:50–15:00 Follow-up after training (Session 79) 16:00–16:30 Hygienic preparation of feeds (Session 49) 15:00–16:30 Discussion of follow- up assessment and distribution of guidelines and materials 16:30–17:00 Discussion on progress 16:30–17:00 Discussion on progress 16:30–17:00 Discussion on progress 16:30–17:00 Discussion on progress Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 44 Example 2: Trainers’ preparation timetable when training using Module 4: Breastfeeding advanced Day 1 Day 2 Day 3 Day 4 Day 5 08:30–09:20 Welcome and introduction of materials, course methods and competencies 08:30–10:00 Breast conditions 2 (trainees present) (Session 28) 08:30–09:45 How breastfeeding works (Session 24) 08:30–09:30 Taking a feeding history – 0 up to 6 months 2 (trainees present) (Session 31) 08:30–09:30 Observing a breasfeed (experienced trainees lead, helped by course director) (Session 26) 09:20–10:30 Listening and learning (Session 5) 10:00–10:30 Breast conditions: exercise (Session 29) 09:45–10:30 Building confidence and support (trainees present) (Session 8) 09:30–10:30 Taking a feeding history – 0 up to 6 months: exercise (trainees do exercise, course director leads) (Session 32) 09:30–10:30 Counselling practice and discussion of technique (Session 37) 10:30–11:00 Coffee 10:30–11:00 Coffee 10:30–11:00 Coffee 10:30–11:00 Coffee 10:30–11:00 Coffee 11:00–12:00 Listening and learning – exercises 1 (Session 6) 11:00–11:30 [Continuation] Breast conditions: exercise (Session 29) 11:00–12:30 Building confidence and giving support: exercises 1 and 2 (Sessions 9 and 10) 11:00–12:00 Expressing breasmilk 2 (trainees demonstrate) (Session 33) 11:00–13:00 Follow-up after training (Session 79) 12:00–13:00 Listening and learning – exercise 2 (Session 7) 11:30–12:30 Refusal to breastfeed (trainees present and do exercises) (Session 30) 12:30–13:00 Positioning the baby at the breast 2 (trainees present with help from directors) (Session 27) 12:00–13:00 Sustaining breastfeeding (trainees present and give feedback) (Session 40) 12:30–13:00 “Not enough milk” (trainees present with help from course director) (Session 34) 13:00–14:00 Lunch 13:00–14:00 Lunch 13:00–14:00 Lunch 13:00–14:00 Lunch 13:00–14:00 Lunch 14:00–15:00 Assessing a breastfeed 2 (experienced trainees lead, helped by course director) (Session 25) 14:00–14:30 [Continuation] “Not enough milk” (trainees present with help from course director) (Session 34) 14:00–15:00 Positioning the baby at the breast 2 (trainees present with help from directors) (Session 27) 14:00–15:00 Feeding low birth- weight sick babies (trainees present and do exercises) (Session 38) 14:00–15:30 Discussion of follow- up assessment and distribution of guidelines and materials 14:30–15:00 Crying (trainees present) Session 35 15:00–17:00 Clinical practice session: listening and learning – assessing a breastfeed (course director demonstrates and leads feedback) (Session 21) 15:00–16:00 “Not enough milk” and Crying: exercises (Session 36) 15:00–17:00 Clinical practice session: building confidence and giving support – positioning a baby at the breast (trainees practice leading feedback with directors guiding) (Session 22) 15:00–17:00 Clinical practice session: taking a feeding history – 0 up to 6 months (trainees practice leading feedback, course director supervises) (Session 41) 16:00–17:00 Director role-play demonstration of giving feedback using “Not enough milk”and Crying: exercise Trainees give feedback to each other 5. Checklists for planning 45 Participants These are example timetables for the training of participants. Allocation for time to discuss policies and hospital practice, such as the Baby-friendly Hospital Initiative and the International code of marketing of breast-milk suststitutes may be considered during these training sessions or as a separate training courses. Example 1: Timetable for participants (infant and young child feeding and growth) This example is 5-day course incorporating introductory concepts of breastfeeding, complementary feeding, growth assessment, and infant and young child feeding counselling. Day 1 Day 2 Day 3 Day 4 Day 5 08:00–08:30 Opening ceremony; introduction of course objesctives and participants 08:00–09:40 Introducing child growth assessment (Session 56) 08:00–10:00 Clinical practice session 1: Listening and learning – assessing a breastfeed (Session 21) 08:00–09:00 The importance of complementary feeding (Session 43) 08:00–08:30 Hygienic preparation of feeds (Session 49) 08:30–08:50 Introduction to infant and young child feeding (Session 1) 08:30–09:30 Food demonstration (Session 52) 08:50–09:05 Introduction to the WHO child growth standards (Session 2) 09:40–10:25 Building confidence and giving support (Session 8) 09:00–09:45 Foods to fill the energy gap (Session 44) 09:30–10:20 Responsive feeding (Session 48) 09:05–10:05 Why breastfeeding is important 1 (Session 11) 10:05–10:30 Coffee 10:25–10:45 Coffee 10:00–10:30 Coffee 09:45–10:15 Coffee 10:20–10:45 Coffee 10:30–11:30 How breastfeeding works 1 (Session 12) 10:45–11:45 Measuring weight, length and height (Session 57) 10:30–12:30 Clinical practice session 2: Building confidence and giving support – positioning a baby at the breast (Session 22) 10:15–11:35 Foods to fill the iron and vitamin A gaps (Session 45) 10:45–11:35 Growth assessment results and feeding counselling when the child is growing well (Session 62) 11:30–12:30 Assessing a breastfeed 1 (Session 13) 11:35–12:35 Variety, frequency and quantity of feeding (Session 46) 11:35–12:05 Checking understanding and arranging follow-up 2 (Session 66) 12:30–13:30 Lunch 11:45–13:00 Lunch 12:30–13:30 Lunch 12:35–13:30 Lunch 12:05–13:00 Lunch 13:30–14:45 Positioning a baby at the breast 1 (Session 14) 13:00–13:30 Measuring: it’s not so easy (Session 58) 13:30–15:00 Common breastfeeding difficulties (Session 16) 13:30–14:30 Investigating causes of undernutrition (Session 63) 13:00–16:00 Clinical practice session 8: Gathering information and counselling on complementary feeding practices and growth (Session 69) 14:45–16:00 Listening and learning (Session 5) Homework: Listening and learning: exercises 1 and 2 (Sessions 6 and 7) 13:30–14:30 Plotting points for growth indicators (Session 59) 15:00–15:45 Expressing breast milk 1 (Session 17) 14:30–15:10 Counselling a mother or caregiver whose child has undernutrition (Session 64) 16:00–16:30 Taking a feeding history – 0 up to 6 months 1 (Session 15) 14:30–16:30 Interpreting trends on growth charts (Session 61) 15:45–16:30 Cup-feeding (Session 18) 15:10–16:30 Investigating causes and counselling a mother whose child is overweight (Session 65) 16:00–16:30 Closing ceremony Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 46 Example 2: Timetable for participants with training using Module 4: Breastfeeding advanced This example of a 5-day course incorporates advanced sessions on breastfeeding, common breastfeeding problems and breastfeeding counselling. Day 1 Day 2 Day 3 Day 4 Day 5 08:00–08:30 Opening ceremony; introduction of course objesctives and participants 08:00–09:10 Listening and learning (Session 5) 08:00–10:00 Clinical practice session 2: Building confidence and giving support - positioning a baby at the breast (Session 22) 08:00–09:10 “Not enough milk” (Session 34) 08:00–09:30 Counselling practice (Session 37) 08:30–09:00 Local infant and young child feeding situation (Session 3) 09:10–10:10 Listening and learning: exercises 1 (Session 6) 09:10–09:40 Crying (Session 35) 09:30–10:30 Feeding low-birth-weight and sick babies (Session 38) 09:00–10:30 Why breastfeeding is important 2 (Session 23) 10:30–11:00 Coffee 10:10–10:30 Coffee 10:00–10:30 Coffee 09:40–10:00 Coffee 10:30–11:00 Coffee 11:00–12:15 How breastfeeding works 2 (Session 24) 10:30–12:00 Positioning a baby at the breast 2 (Session 27) 10:30–11:30 Refusal to breastfeed (Session 30) 10:00–12:00 Clinical practice session 3: Taking a feeding history – 0 up to 6 months (Session 41) 11:00–12:00 Sustaining breastfeeding (Session 40) 11:30–12:30 Taking a feeding history – 0 up to 6 months (Session 31) 12:15–13:00 Lunch 12:00–13:00 Lunch 12:30–13:30 Lunch 12:00–13:00 Lunch 12:00–13:00 Lunch 13:00–14:00 Assessing a breastfeed 2 (Session 25) 13:00–15:00 Clinical practice session 1: Listening and learning – assessing a breastfeed (Session 21) 13:30–14:30 Taking a feeding history – 0 up to 6 months: exercise (Session 32) 13:00–14:30 Breast conditions 2 (Session 28) 13:00–15:00 Clinical practice session 4: Counselling mothers in different situations (Session 42) 14:00–15:00 Observing a breastfeed (Session 26) 15:00–15:15 Tea 15:00–15:15 Tea 14:30–14:45 Tea 14:30–14:45 Tea 15:00–15:20 Tea 15:15–16:00 Building confidence and giving support (Session 8) 15:15–16:00 Building confidence and giving support: exercises 1 – breastfeeding (Session 9) 14:45–16:00 Expressing breast milk 2 (Session 33) 14:45–16:00 Breast conditions: exercise (Session 29) 15:20–15:50 Increasing breast milk and relactaion (Session 39) 15:50–16:00 Plenary and closing 5. Checklists for planning 47 Example 3: Timetable for participants for with training on infant feeding and HIV This example 5-day course incorporates introductory concepts of breastfeeding and breastfeeding counselling, with a focus on HIV and infant feeding. Day 1 Day 2 Day 3 Day 4 Day 5 08:00–08:25 Opening ceremony; introduction of course objesctives and participants 08:00–10:00 Clinical practice session 1: Listening and learning – assessing a breastfeed (Session 21) 08:00–10:00 Clinical practice session 2: Building confidence and giving support – positioning a baby at the breast (Session 22) 08:00–10:00 Practical session: Preparation of milk feeds for babies who require expressed breast milk or replacement feeding (Session 78) 08:00–09:00 Responsive feeding (Session 48) 08:25–08:45 Introduction to infant and young child feeding (Session 1) 08:45–09:00 Introduction to the WHO child growth standards (Session 2) 09:00–10:00 Gathering information on complementary feeding practices (Session 47) 09:00–10:00 Why breastfeeding is important 1 (Session 11) 10:00–10:30 Coffee 10:00–10:30 Coffee 10:00–10:30 Coffee 10:00–10:30 Coffee 10:00–10:30 Coffee 10:30–11:30 How breastfeeding works 1 (Session 12) 10:30–11:45 Growth charts (Session 70) 10:30–11:30 Overview of HIV and infant feeding (Session 71 or 72) 10:30–11:15 Supporting national health authority infant feeding recommendations for women living with HIV (Session 77) 10:30–10:45 [Continuation] Gathering information on complementary feeding practices (Session 47) 10:45–11:00 Checking understanding and arranging follow-up 1 (Session 51) 11:30–12:30 Assessing a breastfeed 1 (Session 13) 11:45–12:30 Building confidence and giving support (Session 8) 11:30–11:55 Antiretroviral therapy and infant feeding (Session 73) 11:15–12:15 The importance of complementary feeding (Session 43) 11:00–11:45 Feeding during illness and feeding low-birth-weight babies (Session 55) 11:55–12:30 Supporting women living with HIV to breastfeed (Session 74) 12:30–13:30 Lunch 12:30–13:30 Lunch 12:30–13:30 Lunch 12:15–13:15 Lunch 11:45–12:30 Lunch 13:30–14:40 Listening and learning (Session 5) 13:30–14:00 Taking a feeding history – 0 up to 6 months 1 (Session 15) 13:30–14:10 Supporting women living with HIV to use replacement feeding (Session 75) 13:15–14:00 Foods to fill the energy gap (Session 44) 12:30–14:30 Clinical practice session 5: Gathering information on complementary feeding practices 1 (Session 53) 14:40–16:00 Positioning a baby at the breast 1 (Session 14) 14:00–15:30 Common breastfeeding difficulties (Session 16) 14:10–14:40 Hygienic preparation of feeds (Session 49) 14:00–15:20 Foods to fill the iron and vitamin A gaps (Session 45) 14:40–15:30 Expressing breast milk 1 (Session 17) 15:20–16:05 Feeding during illness and recovery (Session 50) 14:30–15:30 Food demonstration (Session 52) 15:30–16:00 Cup-feeding (Session 18) 15:30–16:00 Closing ceremony Infant and young child feeding counselling: an integrated course. Director’s guide, second edition 48 Example 4: Timetable for participants for training on infant feeding, with a focus on complementary feeding This example 5-day course incorporates introductory concepts of breastfeeding and infant and young child feeding counselling, with a focus on complementary feeding. Day 1 Day 2 Day 3 Day 4 Day 5 08:00–08:30 Opening ceremony; introduction of course objesctives and participants 08:00–10:00 Clinical practice session 1: Listening and learning – assessing a breastfeed (Session 21) 08:00–10:00 Clinical practice session 2: Building confidence and giving support – positioning a baby at the breast (Session 22) 08:00–09:00 The importance of complementary feeding (Session 43) 08:00–10:00 Clinical practice session 5: Gathering information on complementary feeding practices 1 (session 53) 08:30–08:50 Introduction to infant and young child feeding (Session 1) 08:50–09:05 Introduction to the WHO child growth standards (Session 2) 09:00–09:45 Foods to fill the energy gap (Session 44) 09:05–10:05 Why breastfeeding is important 1 (Session 11) 10:05–10:30 Coffee 10:00–10:30 Coffee 10:00–10:30 Coffee 09:45–10:15 Coffee 10:00–10:30 Coffee 10:30–11:30 How breastfeeding works 1 (Session 12) 10:30–11: 45 Positioning a baby at the breast 1 (Session 14) 10:30–11:00 Taking a feeding history – 0 up to 6 months 1 (Session 15) 10:15–11:35 Foods to fill the iron and vitamin A gaps (Session 45) 10:30–10:45 Checking understanding and arranging follow-up 1 (Session 51) 11:30–12:30 Assessing a breastfeed 1 (Session 13) 11:45–12:30 Building confidence and giving support (Session 8) 11:00–12:30 Common breastfeeding difficulties (Session 16) 11:35–12:35 Variety, frequency and quantity of feeding (Session 46) 10:45–11:45 Food demonstration (Session 52) 12:30–13:30 Lunch 12:30–13:30 Lunch 12:30–13:30 Lunch 12:35–13:30 Lunch 11:45–12:45 Lunch 13:30–14:40 Listening and learning (Session 5) 14:00–14:45 Building confidence and giving support: exercises 1 – breastfeeding (Session 9) 13:30–14:15 Expressing breast milk 1 (Session 17) 13:30–14:15 Building confidence and giving support: exercises 2 – complementary feeding (Session 10) 12:45–14:45 Clinical practice session 6: Gathering information on complementary feeding practices 2 (session 54) 14:15–14:45 Cup-feeding (Session 18) 14:15–15:05 Responsive feeding (Session 48) 14:40–15:00 Tea 14:45–15:00 Tea 14:45–15:00 Tea 15:05–15:20 Tea 14:45–15:00 Tea 15:00–16:00 Listening and learning: exercises 1 (Session 6) 15:00–16:00 Breast conditions 1 (Session 19) 15:00–16:00 Hygienic preparation of feeds (Session 49) 15:00–16:00 Follow-up after training (Session 79) 49 6. Guidelines for supportive supervision, mentoring and follow-up after training It is unlikely that participants will learn all the competencies listed in this Director’s guide during the course. They should have a sound theoretical knowledge at the end of the course, and have practised the counselling skills in many different situations. However, practical skills (e.g. helping a mother to position and attach her baby; helping a mother with engorged breasts to express her milk; counselling a mother living with HIV about different feeding options; gathering information on complementary feeding) need time to practise in many different situations before participants will become really confident. Follow-up after this course in the participants’ place of work is essential, not only to evaluate the training but also to build participants’ confidence, listen to situations that they have found difficult to manage, and assess their practical and counselling skills after the training. As course director, you will organize the follow-up sessions and allocate trainers to conduct them. The follow-up will be discussed with the participants in Session 79 of the course. The participants will also be asked to prepare some exercises and a log of skills ready for this follow-up. A document entitled Guidelines for follow-up after training, provided with the Trainer’s guide, gives details of how to conduct the follow-up session after training at the participant’s place of work. It also contains the necessary forms and paperwork. The follow-up is designed to take one working day at the participants’ place of work. Ideally, several participants from one facility or area can be assessed on the same day. The maximum number of participants that can be assessed during one day is four. The follow-up will start with an introduction and welcome to the participants. It is important to emphasize to participants that this is not an examination, but is a way for the course director to assess the training and to help with situations they have found difficult to manage since they attended the course. The counselling and technical skills of participants will then be assessed in a practical situation. It will not be possible to assess all competencies for all participants. You will provide the trainers with a list of suggested competencies to be assessed. The afternoon is spent in a classroom setting. Trainers will look at the log of skills that the participants have kept, detailing the competencies they have practised in their work setting. This can be done as a group with all the participants together. Trainers can use this opportunity to facilitate a group discussion of skills that participants have found hard to learn and situations that they have found difficult to manage. If there are any conditions in their facility that affect the implementation of infant feeding counselling, then these should be discussed. Trainers will be asked to make a record of these. Finally, trainers will go through the individual written exercises that the participants have completed. This will give you further opportunities to reinforce both knowledge and application of counselling skills. When all the trainers have completed their follow-up visits, a meeting will be held at the district level to discuss the findings and any actions needed. The purpose of this meeting is to describe the progress of infant feeding training in the district, any important or recurring problems and any actions needed. In addition to Session 79 and the Guidelines for follow-up after training, two further stand-alone documents on supportive supervision/mentoring and monitoring after training are provided with the Trainer’s guide. If it is decided that it would be better to train on this section, you as course director should schedule this training, following the timeline included in the section and making copies of that section, including the toolkit.

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