trainee handbook 2 - Alive & Thrive

Ha Noi, July 2011

TRAINEE HANDBOOK 2: Counseling on infant and young child feeding

at a health facility

ACKNOWLEDGEMENT

Alive & Thrive (A&T) acknowledges the special cooperation of the National Institute of Nutrition (NIN)in reviewing and giving helpful feedback on the three training manuals on Infant and Young Child

Feeding (IYCF) for health-facility and community-based health workers.

We would like to express our sincere gratitude to the following experts in Infant and Young Child

Nutrition (IYCN), training and behavior change communication (BCC), without whose support, the

development of these training manuals would not have been possible:

1. Dr. Pham Thi Thuy Hoa, Director of Food and Nutrition Training Center - NIN

2. MA. Huynh Nam Phuong, Specialist of Food and Nutrition Training Center - NIN

3. MA. Trinh Ngoc Quang, Head of Education and Training Department - Center for Health Education and Communication - Ministry of Health (MoH)

4. MA. Tran Thi Nhung - Center for Health Education and Communication - MoH

We would also like to express our appreciation to health workers and Viet Nam Women’s Union

members from fourteen provinces for participating in our training to become the provincial trainers for

A&T and for contributing useful comments that enabled the finalization of these manuals.

We extend our gratitude to A&T team members in Viet Nam who worked closely with the consultant

team to review and provide comments on these training manuals. The special support of the A&T

monitoring and evaluation team in developing the pre and post-tests and effectively evaluating the

trainings of trainers has been critical in finalization of these manuals.

We thank Maryanne Stone-Jimenez, Technical Consultant, for her comments on the technical content

and layout of the training manuals.

We would also like to thank the World Health Organization (WHO), the United Nations Children’s Fund

(UNICEF), the Pan American Health Organization (PAHO), and other organizations whose training

materials and references made our task of putting this manual together a great deal easier.

Finally, we would like to express our sincere gratitude to the Department of Maternal and Child Health,

MoH Viet Nam for their support and guidance in the development of these training manuals.

A&T is grateful for the financial support from the Bill & Melinda Gates Foundation.

Acknowledgement

Counseling on infant and young child feeding at health facility .i

INTRODUCTION

Addressing child nutrition, particularly stunting among children under two years old, is a high priority

for the Government of Viet Nam. In recent years, Viet Nam has made substantial efforts to reduce the

malnutrition rate among children under five years old - reducing this rate from 38.7% in 1999 to 31.9%

in 2009 (NIN). However, underweight and, in particular, stunting among children under two years old

remain high in Viet Nam in comparison to countries with the same economic status in the region. An

extremely low rate of exclusive breastfeeding (EBF) for the first six months, and poor complementary

feeding (CF) practices are the main reasons for this high stunting rate among children under two years

old in Viet Nam.

To support the government’s efforts to reduce the high malnutrition rate among children under five

years old, Save the Children (SC), through a partnership with the Academy for Educational Develop-

ment (AED), GMMB, the International Food Policy and Research Institute (IFPRI) and the University

of California Davis, is implementing the A&T project in Viet Nam over a period of five years (2009-2013). The project goal is to reduce malnutrition and death caused by sub-optimal IYCF practices by

improving the rate of EBF and CF practices for children aged 0 up to 24 months.

In order to achieve this, A&T will support health facilities in fifteen provinces to establish IYCF coun-

seling services in rural and urban areas using a social-franchise model. In addition, A&T will establish

IYCF support groups will be established in mountainous areas. to guide this work, A&T produced a

package of training manuals on IYCF and counseling skills for health-facility managers and staff and

community-based workers, including nutrition collaborators, village health workers, and Viet Nam

Women’s Union members. The participants who are trained using these manuals will be able to provide

IYCF counseling services in health facilities and in the community. The package includes a set of four

manuals and four trainee handbooks as follows:

Introduction

Counseling on infant and young child feeding at health facilityii.

MANUALNO.

TOPICTRAINERMANUALS

TRAINEEHANDBOOKS

1.Management and Operation of IYCF Franchise Model(Mat troi be tho) ü ü

2. Counseling on IYCF at Health Facility ü ü

3. BCC on IYCF at Community (Franchise Model) ü ü

4. BCC on IYCF in Remote Areas (IYCF Support Group Model) ü ü

* This fourth manual is designed for use only in project area where residents have difficulty accessing

health facility and where IYCF Support Groups are already established.

This book you are reading is Trainee Handbook Two, which will be used as a reference for health-

facility workers who have been trained to provide IYCF counseling services at the franchise “M t tr ibé th ”.

We would appreciate any comments and suggestion users have about this trainee handbook. Kindly

direct comments, suggestions, and questions to Mrs. Tran Thi Kiem - A&T Office - E4B Trung Tu

Diplomatic Compound, 6 Dang Van Ngu, Dong Da, Ha Noi or via email:

[email protected]

This handbook may be reproduced in part or full with prior permission from A&T.

Thank you.

Introduction

Counseling on infant and young child feeding at health facility .iii

ACRONYMS

A&T Alive and Thrive

AED Academy for Educational Development

AV Audio-visual

BCC Behavior Change Communication

BF Breastfeeding

BMI Body Mass Index

CBW(s) Community-based worker(s)

CF Complementary Feeding

CHC(s) Commune Health Center(s)

EBF Exclusive Breastfeeding

HIV/AIDS Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome

IFPRI International Food Policy Research Institute

IYCF Infant and Young Child Feeding

M&E Monitoring and Evaluation

MoH Ministry of Health

NIN National Institute of Nutrition

NGO(s) Non-governmental organization(s)

PR Public Relations

SC Save the Children

SL Slide

UN United Nations

VWU Viet Nam Women’s Union

WHO World Health Organization

Acronyms

Counseling on infant and young child feeding at health facilityiv.

CONTENTS

ACKNOWLEDGEMENT...........................................................................................................i

INTRODUCTION .....................................................................................................................ii

ACRONYMS ...........................................................................................................................iv

IYCF INDICATORS ................................................................................................................vii

TRAINING SCHEDULE ........................................................................................................viii

Session 1: Introduction - Ice-breaker ............................................................................................1

Session 2: Objective - Training Schedule .....................................................................................2

Session 3: Introduction of IYCF ....................................................................................................3

Session 4: Current Situation of IYCF in Viet Nam.........................................................................7

Session 5: Introduction of A&T and the Social-Franchise Model on Infant and Young Child Nutrition Counseling ..............................................................................10

Session 6: IYCF Franchise Services: Opportunities of Individual and Group Contacts..............15

Session 7: Behavior Change Communication.............................................................................18

Session 8: Good Communication Skills ......................................................................................23

Part 1 – Listening, Learning, and Observing .............................................................23

Session 9: Good Communication Skills ......................................................................................26

Part 2 - Building Confidence and Giving Support. How to Use Counseling Cards....26

Session 10: Individual Counseling for Mothers and Caregivers..................................................28

Session 11: Group Counseling for Mothers on IYCF ..................................................................31

Session 12: Health and Nutrition Care for Pregnant Women and Lactating Mothers .................35

Session 13: The Significance of BF ............................................................................................39

Session 14: Nutrient Demands of Children under Six Months ....................................................46

Session 15: Breastmilk Production .............................................................................................50

Session 16: In-classroom Practice - Individual Counseling on BF..............................................55

Session 17: In-classroom Practice Group-Counseling on BF .....................................................58

Session 18: Positioning and Attachment.....................................................................................60

Session 19: Assessing a Breastfeed...........................................................................................66

Session 20: Expressing and Storing Breastmilk .........................................................................70

Session 21: Common BF difficulties............................................................................................75

Session 22: Field Practice...........................................................................................................84

Contents

Counseling on infant and young child feeding at health facility .v

Session 23: Importance of CF.....................................................................................................87

Session 24: CF - Quantity and Quality........................................................................................91

Session 25: Feeding Technique ................................................................................................103

Session 26: In-classroom Practice - Appropriate CF Promotion and Management ..................105

Session 27: Preparing a Hygiene Meal and Food Safety .........................................................108

Session 28: Feeding Ill (Sick) Children and Children With HIV-infected Mothers .....................113

Session 29: Assessing Nutrition Status ....................................................................................120

Session 30: Decree 21..............................................................................................................130

APPENDICES .....................................................................................................................143

Appendix 1: Roles of Community-Based Worker, Health-facility Worker and Health-Facility Managers ......................................................................................144

Appendix 2: Client Recording and Reporting Forms ................................................................147

FIGURES

Figure 1: Tools Diagram.............................................................................................................147

Figure 2: Form Y1 - List of Women 7-9 Months Pregnant and Mothers with Children under 2 Years ...............................................................................................149

Figure 3: Form YB – Monthly CBW report.................................................................................152

Figure 4: PYB – Summary CBW report .....................................................................................154

Figure 5: Franchise Management Book P1 - Form P1.1 - Franchise Staff’s Training follow-up (Franchise staff and counselor) ..................................................................156

Figure 6: Franchise Management Book P1 - Form P1.2 - Franchise’s BCC material Management Follow-up Card (Franchise manager) ..................................................157

Figure 7: Franchise Management Book P1 - Form P1.3 - Franchise Item Half Year count, Page 1 (Franchise manager) ..................................................................158

Figure 8: Franchise Management Book P1 - Form P1.3 - Franchise ItemHalf Year Count, Page 2 (Franchise manager) .................................................................159

Figure 9: Form P2 - Mother Card at the Franchise, Page 1 ......................................................161

Figure 10: Form P2 - Mother Card at the Franchise, Page 2 ....................................................162

Figure 11: Form P3 - Daily Service Records at the Franchise ..................................................165

Figure 12: Form P4 - Group Counseling and Baby Competition (Franchise manager) ............168

Figure 13: Form P5 - Client Referral Form................................................................................170

Figure 14: Form PB - Franchise Monthly Report (Franchise manager) ....................................172

Figure 15: Form M2 - Client Satisfaction Questionnaire ...........................................................174

Contents

Counseling on infant and young child feeding at health facilityvi.

IYCF indicators

Counseling on infant and young child feeding at health facility .vii

IYCF INDICATORS

Breastfeeding (BF) Indicators

1. Initiation of BF: The proportion of infants who are breasted within the first hour after delivery.

2. EBF under 6 months: The proportion of infants who are fed exclusively with breastmilk for the

first six months (180 days). That means an infant receives only breastmilk and no other liquids or

solids, not even water, with the exception of drops or syrups consisting of vitamins, minerals

supplements or medicine according to health-worker instructions.

3. Continued BF at 1 years: The proportion of children 12-15 months of age who are fed breastmilk.

4. Continued BF at 2 years: The proportion of children 20-23 months of age who are fed breastmilk.

CF Indicators

5. Introduction of complementary foods: The proportion of infants 6-8 months of age who receive

solid, semi-solid, or soft food.

6. Dietary diversity: The proportion of children 6-23 months of age who receive foods from four or

more food groups.

7. Consumption of iron-rich or iron-fortified foods: The proportion of children 6-23 months of age

who receive iron-rich food or iron-fortified food that is specially designed for infants and young

children, or that is fortified in the home.

Types of Malnutrition

8. Underweight: refers to humans who are considered to be under a healthy weight. The definition

is usually made with reference to the body mass index (BMI). (Weight-for-age Z score <-2).

9. Stunting: is a reduced growth rate in human development. It is a primary manifestation of malnu-

trition in early childhood, including malnutrition during fetal development brought on by the

malnourished mother. (Height-for-age Z score <-2).

10. Wasting: refers to the process by which a debilitating disease causes musclehttp: muscle and fat

tissue to "waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is be-

lieved that episodes of wasting have a short duration, in contrast to stunting, which is regarded as

chronic malnutrition. (Weight-for-height Z score <-2).

11. Overweight: refers to the process when accumulated muscle and fat tissue causes the body

weight to be over the standard of the same age and gender. Overweight is identified when weight-

for-age Z score >2.

Training schedule

Counseling on infant and young child feeding at health facilityviii.

TIM

ED

AY

1D

AY

2 (

BF

)D

AY

3 (

BF

)D

AY

4 (

CF

)D

AY

5 (

CF

)

7:30

- 8:

00P

re-t

est

Revi

ew

Revi

ew

Revi

ew

Revi

ew

8:00

- 8:

30Se

ssio

n 1:

In

troduct

ion –

Ice

-bre

ake

r

Sess

ion

12:

Health

and n

utr

ition c

are

for

pre

gnant

wom

en &

lact

atin

g m

oth

ers

Sess

ion

18:

Posi

tionin

g &

attach

ment

Sess

ion

23:

Import

ance

of C

F

Sess

ion

29:

Ass

ess

ing n

utr

itional

statu

s

8:30

- 9:

00Se

ssio

n 2:

Obje

ctiv

e –

Tra

inin

g S

chedule

Sess

ion

13:

Sig

nifi

cance

of B

FE

arly

initi

atio

n a

nd E

BF

defin

ition

Com

posi

tion o

f bre

ast

milk

– c

olo

stru

m,

matu

re m

ilk

Sess

ion

19:

Ass

ess

ing a

bre

ast

feed

Sess

ion

24:

CF

– q

uantit

y and q

ualit

yQ

&A

:CF

9:00

- 9:

30Se

ssio

n 3:

Intr

oduct

ion o

f IY

CF

Win

dow

of

Opport

unity

Key

IYC

F p

ract

ices

9:30

- 10

:00

Sess

ion

4: IY

CF

in V

iet N

am

Sess

ion

20:E

xpre

ssin

g a

nd

st

oring b

reast

milk

10:0

0 - 1

0:30

TE

A B

RE

AK

10:3

0 - 1

1:00

Sess

ion

5:In

troduct

ion o

f A&

Tpro

ject

and the s

oci

al f

ranch

ise

model o

n IY

CF

counse

ling

Sess

ion

14:

Nutr

ition d

em

and o

f ch

ildre

n u

nder

six

month

sSe

ssio

n 21

: C

om

mon B

F D

iffic

ulti

es

Sess

ion

24:

CF

– q

uantit

y and q

ualit

y(c

ont.)

Post

-test

and

train

ing e

valu

atio

n

11:0

0 - 1

1:30

Sess

ion

6:IY

CF

fra

nch

ise s

erv

-ic

es.

Opport

uniti

es

for

indiv

idual &

gro

up c

onta

cts

Sess

ion

15:

Bre

ast

milk

pro

duct

ion

Sess

ion

25:

Feedin

g tech

niq

ue

LU

NC

H

13:3

0 - 1

4:00

Sess

ion

7:

BC

C S

tages

of C

hange

Sess

ion

16:

In c

lass

-room

pra

ctic

e : in

div

idual

counse

ling o

n B

F

Sess

ion

30: D

ecr

ee 2

1

Sess

ion

27:

Pre

paring a

hyg

ienic

meal

and food s

afe

ty

Sess

ion

28:

Feedin

g il

l (si

ck)

child

ren

and c

hild

ren h

avi

ng H

IV-in-

fect

ed m

oth

ers

Sess

ion

26:

In c

lass

-room

pra

ctic

e: A

p-

pro

priate

CF

Pro

motio

n &

Managem

ent

Intr

oduct

ion o

f re

cord

-in

g form

s and b

ooks

at fr

anch

ise

Pla

nnin

g for

the im

ple

-m

enta

tion o

f fr

anch

ise

model a

t lo

calit

y

14:0

0 - 1

4:30

Sess

ion

8:

Good c

om

munic

atio

n s

kills

14:3

0 - 1

5:00

Sess

ion

9:

Good C

om

unic

atio

n S

kills

(con

t.)Se

ssio

n 22

: Pra

ctic

e

15:0

0 - 1

5:30

Sess

ion

10:

Indiv

idual c

ounse

l-in

g for

moth

ers

& c

are

giv

ers

Sess

ion

17:

In c

lass

-room

pra

ctic

e: gro

up c

ounse

l-in

g o

n B

F

15:3

0 - 1

6:00

TE

A B

RE

AK

Pre

- and p

ost

-test

re

sults

Cert

ifica

tes

Clo

sing

16:0

0 - 1

7:00

Sess

ion

11: G

roup c

ounse

ling for

moth

ers

on IY

CF

Sess

ion

17: I

n c

lass

-room

pra

ctic

e :

gro

up c

ounse

ling o

n B

F (

cont.)

Revi

ew

of F

ield

Pra

ctic

eQ

&A

on B

F

Sess

ion

26:

In c

lass

-room

pra

ctic

e(c

ont.)

17:0

0 - 1

7:15

DA

ILY

EV

AL

UA

TIO

N

TR

AIN

ING

SC

HE

DU

LE

Session 1: Introduction – Ice-breaker

Counseling on infant and young child feeding at health facility .1

SESSION 1: INTRODUCTION – ICE-BREAKER

Objectives

1. Introduce participants.

2. Create a warm and friendly training atmosphere.

Session 2: Objective – Training Schedule

Counseling on infant and young child feeding at health facility2.

SESSION 2: OBJECTIVE – TRAINING SCHEDULE

Objectives

After completing this training, trainees will be able to:

1. State the concepts of social franchising and the A&T franchise model on IYCF counseling

services.

2. Understand key concepts of BCC.

3. Understand the key content of IYCF counseling at a health facility.

4. Develop skills to provide individual counseling for clients (mothers, fathers, and caregivers) on

IYCF.

5. Develop skills to provide group counseling on IYCF.

6. Develop plans to apply knowledge and skills to conduct IYCF franchise services at a health

facility.

Session 3: Introduction of IYCF


SESSION 3: INTRODUCTION OF IYCF

Objectives:

After completing this session, trainees will be able to:

1. Point out the importance of IYCF and the significance of the Window of Opportunity.

2. Provide current nutritional recommendations for children from 0-24 months of age.

Importance of IYCF

It is estimated that up to 150 million children under five years are malnourished worldwide (WHO 2004).Child malnutrition leads to the decreased mental and physical development capacity of children, the

national future generation, thus affecting the capacity to attain Millennium Development Goals 1, 4,

and 5 of reducing fatality and disease in children. Moreover, child malnutrition also affects the socio-

economic development of a country in the long run.

According to WHO statistics (in the chart below), it is proven that the stunting rate sharply increases

during 6-12 months. Causes include infections such as diarrhea and respiratory infection, and defi-

ciency in absorbing important micro-nutrients. Once the child is over two years old, it is very difficult to

change the stunting that has already occurred. Therefore, the period from delivery until two years old

is an important “window” for the child’s optimal development and growth, both mentally and physically.

This is also the “window of opportunity” for the interventions to be implemented the most effectively.

0

5

10

15

20

25

30

35

40

45

0-6 6-12 12-24 24-36 36-48 48-60

Window ofopportunity is 6-24

months

Months

Stu

nti

ng

rat

e (%

)

STUNTING PREVALENCE BY AGE(2007, WHO)

nourish. nurture. grow.



Research shows that a child’s height at three years is highly related to his/her height as an adult – by

adding about 77 cm to a child’s height at age three you can predict their height as adults. Therefore

someone who is severely stunted as a child will be a short adult while someone who is well nourished

as a child will be a tall adult.

Hence, in order to ensure all children will become tall and healthy adults in the future, we need to focus

on improving IYCF practices to prevent stunting from a very early age. This intervention needs to be

implemented by appropriate activities at different ages: from the seventh month of pregnancy until the

child is 24 months old.

The “Window of Opportunity” and appropriate times for the most effective IYCF interventions

The “Window of Opportunity” period (from the time of delivery until 24 months) is an important period

to implement appropriate activities to prevent child malnutrition. However, for each of these times, there

are different messages on behavior change communication to suit the child’s needs at different ages.

Therefore, there are three windows of opportunity as follows:

Severe Moderate Mild Well-nourished

94.589.585.3

81.2

158.0162.5

167.3

170.9

Average growth from 3-18 years 77cm

Heightat 18 y

Heightat 3 y

STUNTED 3 YEAR OLD - STUNTED ADULT(GUATEMALA, INCAP ORIENTE STUDY)


Impact of the “Window of Opprtunity” to the child development



Each “window” has specific intervention activities:

In pregnancy, a mother needs to be cared for and receive good nutrition. Especially in the

last trimester of pregnancy, a mother needs to be provided with knowledge on BF.

When the child is 0- 6 months, a mother needs support to ensure that the child is breastfed

immediately after birth, and exclusively for the first six months.

When the child is 6 -24 months, a mother needs to know how to give age-appropriate CF

and continue BF until the child is 24 months.

In conclusion, 0-24 months is the critical period during a child’s development. We call it the “Windowof Opportunity”, which is the ideal time to implement the most effective interventions.

Ideal practices on child feeding

Poor BF and CF practices are leading reasons for child malnutrition during the first two years of life.

Therefore, IYCF plays a critical role in improving a child’s health and survival. WHO and UNICEF

recommend that a child needs EBF for the first six months and adequate and appropriate CF along

with continued BF until the child is two years old or beyond (WHO/PAHO).

Preconception through

pregnancy

0-6 mo: Exclusive

Breastfeeding

6-24 mo: Complementary

feeding and continued BF

WINDOWS OF OPPORTUNITY




Fifteen ideal IYCF practices include:

1. All infants are breastfed for the first time within the first hour after birth.

2. No infants are given prelacteals before BF.

3. All infants are fed colostrum.

4. All infants and young children are breastfed on demand, during the day and night.

5. All infants are exclusively breastfed for the first 6 months.

6. No children are weaned before 24 months of age.

7. Children are not fed with a bottle and pacifiers.

8. All infants are fed complementary food after the first six months (180 days).

9. All infants and young children are fed the recommended number of meals daily.

10. All infants and young children meet their recommended daily energy requirements.

11. All infants and young children are fed nutrient- and energy-dense food.

12. Children are given diverse food (with four food groups or more).

13. Children are given iron-rich food or an iron supplement daily.

14. All infants and young children are fed meat, fish, or poultry daily.

15. All the children are supported and motivated to eat to satiety during meal times.

WHO age calculation

Zero-month-old baby: children from the time of delivery until 29 days old.

One- month-old baby: children from 30 to 59 days old.

Five- month-old baby: children from five months to five months and 29 days old.

Children under six months: children under 180 days old.

Thus, EBF in the first six months means in the first 179 days.

Session 4: Current situation of IYCF in Viet Nam


SESSION 4: CURRENT SITUATION OF IYCF IN VIET NAM

Objectives:


• Point out IYCF problems in Viet Nam in general and in provinces selected by A&T.

Current situation of IYCF in Viet Nam

Though Viet Nam has been recognized as a country that has experienced significant economic devel-

opment in the past years, child malnutrition still exists.

• More than 7 million children under 5 years old*.

• One in five children: underweight (18.9%)#.

• One in three children: stunted (31.9%)#.

Despite:

• Food security.

• 90% literacy*.

Source: * Health Statistics Yearbook (2009), # NIN Surveillance: 10 A&T provinces (2009)

Antenatal care and postnatal care (ANC & PNC)

• More than 90% of women receive ANC but no/little counseling on BF.

• 80-90% of women have a skilled attendant at birth but no/few have support at delivery for the

initiation of BF.

• No PNC visits except for complications.

BF

Ideal Practice 1: Initiate BF within an hour of birth

• Only 55% of children are breastfed within the first hour after birth.

• The rate is highest in mountain areas (70%), lowest in urban areas (30%).

• The rate is higher for community health centers (CHCs) (70%) compared to hospitals and private

clinics (40%).



Ideal Practice 2: No prelacteals

• Two out of three mothers (60%) give something beside breastmilk during first three days.

• One out of three mothers (30%) bring formula to the health facility for delivery (in Hanoi as manyas 87% mothers bring formula with them).

Ideal Practice 3: Give colostrum

• Almost one out of three mothers (27%) squeeze out some colostrum.

• In some provinces this rate is as high as 90%.

Ideal Practice 4: BF on demand, day and night

• 85% mothers breastfeed on demand.

Ideal Practice 5: EBF tills 6 months

• 10% EBF up to 6 months of age.

• Only of 50% of mothers and 30% of pregnant women know what EBF means.

• Most health workers know what EBF means but believe EBF is required for only four months.

Ideal Practice 6: BF up to 24 months of age

• 60 - 90% of mothers BF up to 12 months.

• On average most mothers stop BF at 15 -18 months.

Ideal Practice 7: No feeding with bottles and pacifiers

• 75% of children are not fed with bottles and pacifiers (0-24 months).

Barriers to BF

• Perception of insufficient milk quality and quantity.

• Separation of mother and child.

• Perception that water is needed to clean a baby’s mouth and quench thirst.

• Availability of formula milk.

• Maternity-leave policy.

• Lack of appropriate information and support.



CF indicators

Indicator

Ideal practice 8: Children aged 6-8 months given complementary food 90%

Ideal practice 9: Children given the recommended number of meals per day No data

Ideal practice 10: Children meet the recommended daily energy requirements Yes, if BF

Ideal practice 11: Children fed nutrient- and energy-dense food No data

Ideal practice 12: Children 6-23 months given diverse food 50%

Ideal practice 13: Children given iron-rich food 79%

Ideal practice 14: Children fed meat, fish, or poultry daily 3-4 times/week

Ideal practice 15: Children supported and motivated to eat Yes

CF

• Complementary food is given as early as 2-3 months (urban: 4-5 months).

• Consistency and quality of complementary food is an issue.

• Diets are highly iron-deficient.

Communication findings

• The rate of TV, radio, and mobile ownership is high, but very few called/used a hotline. In urban

areas, computer ownership is more than 60%, access to the Internet 26%. Less than 25% of moth-

ers read newspapers.

• Only 30% of mothers attended group sessions on nutrition counseling.

• 75% are willing to pay for effective nutrition counseling – on average 30,000- 50,000 VND.

Session 5: Introduction of A&T and the Social-Franchise Model on Infant and Young Child Nutrition Counseling


SESSION 5: INTRODUCTION OF A&T AND THE

SOCIAL - FRANCHISE MODEL ON INFANT AND

YOUNG CHILD NUTRITION COUNSELING

Objectives:


1. Clarify the main content of the A&T project.

2. State the concept of the franchise model on IYCF.

A&T project

• Five-year initiative (2009-2013).

• Bangladesh, Ethiopia, and Viet Nam

• Improving BF and CF policies and practices at scale and preventing child deaths.

• Funded by the Bill & Melinda Gates Foundation.

International partners

• Academy for Educational Development – Lead, Communications, Private Sector.

• GMMB – Policy and PR.

• International Food Policy Research Institute – M&E, Operations Research.

• Save the Children – Community interventions.

• University of California, Davis – Small-grants program.

Vietnamese partners

• MoH– Department of Maternal and Child Health.

• NIN.

• Provincial Department of Health.

• Viet Nam Women’s Union.

• UN Agencies.

• NGOs – Marie Stopes International, Plan International, World Vision, etc.



Program areas

• North: Hanoi, Hai Phong, Thai Nguyen, Thanh Hoa.

• Central: Danang, Quang Tri, Quang Ngai, Quang Nam, Quang Binh.

• South: Khanh Hoa (Nha Trang), Vinh Long, Tien Giang, Ca Mau, Dak Lak, Dak Nong.

Project objectives

1. Double EBF rates (0 - 6 months) by the end of the project.

2. Improve CF practices (6-24 months) in both quality and quantity by the end of the project.

3. Reduce the stunting rate for children under 2 years old by at least 2% per year.

Intervention strategies

• Improve the policy and regulatory environment to support IYCF interventions.

• Shape, create, and support demand for IYCF through the franchise model on IYCF.

• Increase supply and demand and encourage the use of fortified complementary food through co-

operation with the private sector.

Franchise model

Overview of franchising

“Franchising” is a business model that enables rapid and effective expansion of a product and/or service

of a specified standard by transferring daily management responsibility for other independent

enterprises.

In the commercial sector, franchising is used to expand a franchisor’s business with the aim of quickly

increasing profits. For society, social franchising is used to expand a “business” but for the purpose of

increasing the impact of a social initiative as opposed to generating revenues for the franchisors.

Benefits of social franchising

FRANCHISOR FRANCHISEE

• Rapid growth of service through a network offranchisees

• Increasing access to services for people

• Quality assurance

• Enhanced reputation with certificates of servicequality and brand name

• Supported in marketing services

• Supervised to support service quality

• Updated technical expertise

• Increased number of clients and revenue

Social welfare

• Public receives a high-quality service with appropriate price

• In the health sector, it is able to manage service quality and improve income for staff

• Health indicators are improved



• National franchisors are A&T and NIN: Their role is to select, train, develop systems and materials,

monitor, and create demand.

• Provincial franchisor is the Department of Health or reproductive-health centers (RHCs): Their role

is to select, supervise, monitor, and report to the national franchisor.

• Franchisees are health facilities: these facilities will directly provide IYCF counseling services and

report to the provincial franchisor.

• Clients of A&T franchise include fathers, mothers, and caregivers. When using the services, clients

will have to pay for services.

Standard social franchising in the health sector is the type of franchising that supplies specific service

packages (such as family planning) through health facilities, which already supply diverse treatment

and prevention services. This is called “partly” franchising and is the model applied to the franchise on

IYCF in Viet Nam.

The product of A&T social franchise is a high-quality IYCF counseling service. Time duration is from

pregnancy until 24 months of age with a total of 15 contacts.

A&T franchise model on IYCF

NATIONAL

FRANCHISOR

PROVINCIALFRANCHISOR

FRANCHISEE

CLIENT

A&T & NIN

DoH/RHC

HEALTH FACILITIES

MOTHERS,FATHERS,

CAREGIVERS

Select, train, develop systems & materials,

monitor & create demand

Select, supervise, monitor, report to franchisor

Provide IYCF Counseling services Report to

sub-franchisor

Use and pay for services

FIELD FORCE COMMUNITY-BASED WORKERS

Generate demand




• In the community, the CBWs include village health workers, nutrition collaborators, and members

of village WU : their role is to generate demand for services.

Components of a franchise

• High-quality standardized service.

• Fee for services.

• Franchise-branded commodities.

• Operator-owned outlets.

A&T franchise model

• Standardized service:

Good-quality IYCF counseling services.

9-15 contacts over 27 months (3rd trimester pregnancy –24 months).

• Fee for services:

To be established by provinces.

Dependent on level of facility.

• Brand:

Easily identifiable, gains equity over time.

Recognized.

• Ownership:

Public Health facilities (province, district, commune).

Private Health facilities.



A&T brand

A&T FRANCHISE BRAND


• Professional

• Trustworthy

• High quality

• Functional

• Welcoming

• Child-friendly

The logo set is composed of three elements:

• The logo: The beaming sun both symbolizes a blooming sunflower as well as a smiling child in

good care. The sun represents vitality while the two leaves stand for nurturing hands. The overall

meaning is caring for a healthy, happy child and for the future generation.

• The clinic name: The clinic name “Mat troi be tho” is synonymous with the above meaning and

emphasizes “child” as the prime target of the clinic. The clinic name is short and easy to remember

and understand. It is highly indicative of the nature of the project as well as its target.

• The project slogan: “Nutrition today, health tomorrow” – The slogan emphasizes the importance

of appropriate nutrition for babies to create a foundation for their future development, and for the

future of Viet Nam.

Value of the brand name:

• Professional

• Trustworthy

• High-quality

• Functional

• Welcoming

• Child-friendly

Session 6: IYCF Franchise Services: Opportunities of Individual and Group Contacts


SESSION 6: IYCF FRANCHISE SERVICES: OPPORTUNITIES

OF INDIVIDUAL AND GROUP CONTACTS

Objectives:


1. State IYCF Service Packages provided at a health facility

2. Point out proper timing to access mothers for IYCF counseling

The A&T Model is a social-franchise model and its product is “High-quality IYCF counseling services”.

Full IYCF service package

SERVICE METHOD TIME

1) Package 1 (G1): EBF promotion (as pregnancy)

1 group/class counseling 3rd trimester of pregnancy

2 individual counseling 3rd trimester of pregnancy

2) Package 2 (G2): EBF support (at delivery)

Individual support At delivery

3) Package 3 (G3): EBF management

2 (the first two) individualcounseling

1 week after birth

2 weeks after birth

2 Group/class counseling 1-6 months after birth

4) Package 4 (G4): CF education

1 individual counseling 4-6 months after birth

5) Package 5 (G5): CF management

Combination of individual- and group-coun-seling sessions, totaling 6 contacts

One between 6-8 months

One between 9-12 months

Four between 12-24 months



Service packages depending on types of health facility:

In general, these components will be available at health facilities as follows:

TYPES OF HEALTH FACILITY FRANCHISE SERVICE PACKAGE

Commune Health Centers

EBF promotion

EBF support (for CHCs that do deliveries)

EBF management

CF education

CF management

Provincial Reproductive-Health-Care Centers

EBF promotion

EBF management

CF education

CF management

Hospital (where deliveries occur)EBF promotion

EBF support

Paediatric facilities

EBF management

CF education

CF management



IYCF service-delivery flow chart for clients from the third trimester of pregnancy throughto 6 months post-partum until child is 24 months of age

Register new IYCF client (assign code and create client file)

Create individualized IYCF package for client (depending upon timingof first visit, payment preferences, recommended and desired serv-

ices – content and format such as individual counseling or class, etc.)

Collect payment from client if paying upfront for the entire servicepackage. Otherwise fees can be collected as clients use the service.

Deliver EBF Promotion 1 Schedule follow-up appointment for EBF promotion 2

Complete client record

Client knows and understandsbenefits of EBF and costs of NOTexclusively breastfeeding

Client is knowledgeable abouthow to properly breastfeed andbelieves that breastfeeding isbest choice for her and her baby,and that she is capable of EBF

Client makes decision to exclusively breastfeed

Client successfully initiates EBF

Client continues exclusivebreastfeeding



Client introduces appropriatecomplementary foods at 6months and continues optimalfeeding practices up to 24 months

Deliver EBF Promotion 2 Schedule follow-up appointment for EBF promotion 3


3rd trimesterof pregnancy

3rd trimesterof pregnancy

Time of Delivery

Post-partum1 week

Post-partum2 weeks

Post-partum3 -6 months

Infant age 6 - 24 months

Deliver EBF Promotion 3 Schedule follow-up appointment and/or referral for EBF support


Deliver EBF Support Schedule follow-up appointment and/or referral for EBF

management 1Complete client record

Deliver EBF Management 1 Schedule follow-up appointment for EBF Management 2


Deliver EBF Management 2 Schedule follow-up appointment for EBF Management 3

Complete client record.

Deliver EBF Management 3 and 4 and CF education 1 Schedule follow-up appointment for CF management


Deliver CF management 1-6Schedule follow-up appointments for CF management & support

as desiredComplete client records

3rdtrimester

of preg-nancy

TIMING IYCF SERVICE PROVISION GOAL

Session 7: Behavior Change Communication


• There is behavior that is good for health and there is behavior that is not good for health.

Examples of healthy behavior in IYCF:

• Useful healthy behavior

Eat and drink sufficiently when pregnant.

Consume iron tablets according to a health worker instruction.

Feed your baby colostrum.

Exclusively breastfeed for the first 6 months.

Appropriate CF.

Provide Vitamin A for babies.

Monitor the child’s weight.

Increase BF if the baby is ill.

Wash your hands with soap before feeding children.

Etc.

SESSION 7: BEHAVIOR CHANGE COMMUNICATION

Objectives:


1. Identify basic concepts of behavior and BCC.

2. Explain the steps of behavior change.

3. Describe BCC interventions and strategies at different levels.

1. Definition of healthy behavior:

• Healthy behavior is a daily practice or action that is positive to health.

• Healthy behavior is affected by ecological, environmental, social, economic, cultural, and political

elements.

• Behavior consists of the following sections: knowledge, attitude, belief, and practice.

BEHAVIOR = KNOWLEDGE + ATTITUDE + BELIEF + PRACTICE



• Harmful behaviors (risky behaviors)

Squeezing out colostrum.

Feeding children with liquorices right after birth.

Giving complementary food to children under 6 months of age.

Letting babies go on a diet when they get diarrhea.

• Behaviors that are not good but not harmful for child health:

Putting a silver ring on a child’s wrist.

2. What is BCC?

Behavior change communication is comprised of communication activities that are planned to create

sustainable behavior of individuals and the community based on the understanding of practices among

the community, sharing appropriate information to help an individual and the community develop new

skills or beliefs and encouraging them to overcome difficulties to practice and maintain new behavior.

BCC on IYCF aims to change/create new community norms on IYCF.

For example: BCC on IYCF will help pregnant women and mothers feeding children under 2 years

old practice and maintain behaviors such as: coming to a health facility to be counseled on IYCF,

practicing right IYCF behaviors (feeding children with colostrum, EBF for the first sixth months, appro-priate CF...)

The aim of any BCC activity is not just to improve knowledge but to ensure that the knowledge

becomes an action – i.e., behavior changes and is maintained. It is also important that most people in

the community (70-80%) start practicing the behavior so that it becomes a norm or standard

practice in the community. Only then can we consider behavior change communication successful.

3. Process of behavior change

Behaviors of person can be changed, sometimes quickly, sometimes slowly and due to many reasons.

The behavior of a person is complicated, so it’s very difficult to change it. However, to accept practicing

and maintaining a good behavior compared to a harmful behavior, a person needs to experience a

process of the five summarized steps:

Step 1: Pre-awareness

Step 2: Awareness

Step 3: Intention

Step 4: Trials - Assessment

Step 5: Maintenance / Relapse



4. Stages of behavior change communication

BCC of IYCF includes four stages: the household stage, the community stage, the health-facility stage,

and the policy stage. For each stage, there is different access to IYCF behavior change communication

but the messages should be consistent at all levels.

• In the household: negotiate behavior change with individuals

Health workers, village heath staff, Viet Nam women’s union... (generally called communicators)will counsel, encourage, and convince mothers and family members to change inappropriate IYCF

behaviors and to practice appropriate ones.

STEPS OF BEHAVIOR-CHANGE PROCESS AND INTERVENTIONS BY

COMMUNITY-BASED WORKERS

3. Provide basic information

2. Explain/analyze the positive/negative effects of the behavior

1. Identify knowledge, belief and practice

9. Provide/support resources needed

8. Support to address barriers

7. Discuss implementation and analyze barriers /motivators

6. Encourage and motivate

5. Give examples of positive deviants

4. Provide knowledge and skills

Pre-awareness

Awareness

Intention

Trials - Assessment

Maintenance Relapse

11. Follow up, support, and encourage maintenance

10. Discuss experience and make a decision

Community-based workers’ interventions



• In the community: changing community norms and problem solve

The communicators in the community can organize group sessions and clubs, combining with

community meetings to carry out group counseling on IYCF. In group-counseling sessions,

communicators will help local people recognize harmful behavior and customs, and then prioritize

issues to influence and gradually change old practices related to IYCF and accept and practice

new behaviors.

• In the health facility: training and building capacity for health workers

When health workers are trained and their capacity to train others on IYCF improved, they will start

group and individual counseling, open IYCF classes for mothers, and help and support mothers to

change IYCF behaviors. In cases that exceed the health facility’s capacity, health workers will refer

mothers and babies to appropriate health facilities to be given appropriate counseling and care.

Research has indicated that mothers usually believe, and want to receive information from, health

workers. Therefore, counseling and training activities for mothers at health facilities will urge them

to change behaviors.

• Policies: advocacy

Authorities receive information in many ways, such as through documents, newspapers, confer-

ences, meetings, or the mass media. If they accept IYCF information, leaders and policy makers

will issue policies creating a favorable environment or promoting practical actions to support and

to raise concerns about IYCF. For example, actions such as: regulations about maternity leave for

mothers to take care and breastfeed their children; arrangements for mothers to work near home;

putting malnutrition prevention into the socio-economic development targets of each locality;

strengthening economic development and hunger eradication; poverty reduction; and supporting

communication on IYCF in each community, etc.



BCC INTERVENTIONS AT DIFFERENT LEVELS

Home

Community

Negotiate individualbehavior change

Change communitynorms & problem solve

Training &capacity building

AdvocacyPolicy

Healthcenter/PVO


The stages of BCC are shown by BCC Pyramid below:

Session 8: Good communication skills


SESSION 8: GOOD COMMUNICATION SKILLS

PART 1 – LISTENING, LEARNING, AND OBSERVING

Objectives:


1. List basic skills in interpersonal communication on IYCF.

2. Practice the skills of listening and learning and observing.

1. Listening and learning skills

• Listen carefully to get information on mothers’ IYCF practices

Show appropriate gestures, eyes, smile, facial expression, and posture (sitting, standing,

moving…).

Remove barricades between communicators and mothers.

Maintain eye contact and use non-verbal communication effectively.

Sit in line with participants. Keep a proper distance between communicators and mothers.

Do not appear in a hurry.

Do not grumble, sigh, or yawn.

• Pay attention and encourage mothers to share their thoughts and feelings

Look at the participant, nod, smile, or use simple words such as “well”, “yeah”, “really”...

Do not argue or interrupt mothers if it is unnecessary.

Do not do personalize things as mothers are talking.

Minimize factors causing distraction (TV, phone, noise...).

• Ask questions on unclear points or repeat the key points that mothers have just discussed

using similar language but also to briefly check whether you understand mothers or not. If you mis-

understand them, you can correct them again. For example: you can repeat “Is that what youmean...”, “In other words,...”

• Use non-verbal communication effectively.

• Avoid judging words such as: not right, wrong, not good, bad... If you use these words when

discussing with mothers, you will make them feel that they have made mistakes or something is

wrong, and therefore they will be afraid to open up to you.

• Maintain eye-contact.

• Use a lot of open-ended questions.

Essentially, there are three types of questions:

• A closed-ended question:

A closed-ended question is the type of question that limits the answer content to one wordsuch as “yes” or “no”, “right” or “wrong”, “already” or “not yet”, etc...

For example: Question: “Did you go for a pregnancy test?”

The mother will answer: “Yes” or “No”.

The answer is short and provides little information, so you need to ask more questions. Limitthe use of closed-ended questions in the communicating process.

• An open-ended question:

An open-ended question is a type of question that requires mothers to think and to give an an-swer with more information.

An open-ended question usually starts with words such as: Why? When? How? What?Where?... You should use a lot of open-ended questions in the communicating process togather more information.

For example: What difficulties do you have when BF?

• An oriented question (leading question).

A leading question is a type of question where the communicator orients the trainees to givethe answer he wants. Avoid using this type of question in the communicating process.

For example: “You understand that breastmilk is very important to children, don’t you?”

How to ask questions:

• Ask one question at a time.

• Ask short and clear questions.

• Ask relevant questions.

• Use open-ended questions to help trainees talk about their emotional states, conditions, and

behaviors (to understand what they know, trust, and do).

• Avoid leading questions.

2. Observation skills

How to observe

• Observe all aspects carefully: facial expression, gestures, responses, behaviors, context, a baby’s

status, etc.





• Choose an appropriate position.

• Observation is carried out in a sensitive way, politely, continuously, and with a motivating and

encouraging attitude.

• Observe objectively, do not judge subjectively.

Don’ts during observation

• Observe with neglect, indifference, or lack of concentration.

• Scrutinize with unsympathetic and insensitive eyes.

• Use disrespectful and impolite non-verbal language.



SESSION 9: GOOD COMMUNICATION SKILLS

PART 2 - BUILDING CONFIDENCE AND GIVING SUPPORT.

HOW TO USE COUNSELING CARDS

Objectives:


1. Describe the skills of providing information; building confidence and giving support.

2. Describe how to use counseling cards.

1. Providing information skills

• Provide specific and relevant information.

• Use simple words that are easy to understand.

• Speak clearly and concisely.

• Make one to two recommendations only – recommendations should be practical.

• Use counseling cards as a support.

• Demonstrate the skill/recommendation if required.

• Ask the mother to repeat/demonstrate recommendations to ensure she completely understands.

• Negotiate and ensure that the mother agrees to try out the recommendations.

• Arrange follow-ups if needed.

2. Skills for building confidence and providing support

• Accept what mothers think and feel, avoid being judgmental: Sometimes you can not be sat-

isfied with what mothers tell you but if you show your disagreement or do not want to listen, they

will feel hurt, sad, uncomfortable, unconfident, and not want to tell to you anything else. Do not

oppose and criticize, but accept what they tell you neutrally (neither agree nor oppose).

• Empathize with the mother and let her know how you feel.

• Identify and compliment good practices, praise the mothers: When people are praised about

what they did, they will be confident and encouraged to try other things. We learn how to identify

an issue and what mothers do wrong, then help them correct it. However, it is also necessary to

identify what mothers do well to compliment them.



• Provide practical help: Showing your support will help mothers feel confident in the things they

are doing and continue maintaining those good behaviors. Your support is shown through many

aspects such as: providing appropriate information and arranging follow-ups to practice new

behavior.

• Encourage mothers to ask questions and clarify any doubts.

• Use non-verbal communication effectively.

• Create a friendly and reliable atmosphere.

3. Use counselling cards

Purposes of using counseling cards in communication sessions on IYCF

• Counseling cards are tools that support interpersonal communication and counseling.

• Counseling cards consist of many pictures, therefore:

They are attractive and draw the mother’s attention.

They help mothers to easily remember for a long time, especially for mothers who have low

literacy.

They help mothers better understand what they were verbally instructed to do.

• It is necessary to know how to use counseling cards during behavior change communication on

IYCF to achieve a high level of efficiency.

How to use counseling cards

• Counseling cards are only used with individuals or small groups (6-10 persons).

• Health workers should select cards and review them in advance. In each session, communicators/

counselors should choose two to three cards only.

• When providing information, it is necessary to hold the cards so that the mothers can see them

clearly.

• Let mothers view the cards and share what they see in the cards.

• Discuss the content of the cards and ask mothers to relate them to their situation.

• Explain and provide additional information if required. Health workers may refer to information from

text pages.

• Summarize and come to an agreement on recommendations that the mothers should try.

• At the end of the session, place the cards back in order and check to be sure the set is complete.

Session 10: Individual counseling for mothers and caregivers


SESSION 10: INDIVIDUAL COUNSELING FOR MOTHERS

AND CAREGIVERS

Objectives:


1. Explain how to apply communication skills to counseling.

2. Describe steps of individual counseling on IYCF.

How to give counseling to mothers and caregivers to help them change old practices, accept and maintain new behavior on IYCF and to help their children grow well? This is the question that is posedhere for health workers and communicators.

To help mothers change IYCF behaviors, health workers and communicators need to have good communication skills (listening and learning skills, observation skills, information-provision skills, andskills on building confidence and giving support) to apply in counseling steps.

Six steps of individual counseling

Step 1: Introduce – create a warm and friendly atmosphere

• Greet mother.

• Introduce yourself.

• Make eye contact.

• Smile.

• Show respect.

Step 2: Identify current problems/issues

• Listen.

• Be non-judgmental.

• Ask open-ended questions to learn about current situation/issue.

• Accept what a mother says.

Step 3: Analyze and assess


• Identify the problem / issue.

• Respond to the mother’s questions.



Step 4: Make practical recommendations

• Provide relevant information (use simple language).

• Build confidence.

• Make one to two practical recommendations.


Step 5: Negotiate behavior – get commitment

• Discuss different solutions - small practical solutions.

• Let mothers choose the solution.

• Get commitment to try one to two recommendations.

• Use simple language and be non-judgmental.

Step 6: Summarize – closing

• Ask the mother to repeat the recommendation.

• Correct the recommendation if required.

• Arrange follow-ups with mothers.

• Praise and thank the mothers.

Notes: In order to help counselors at the franchise “M t tr i bé th ” comply with these six steps of

individual counseling and apply appropriate skills for each step, the following checklist will help:

• The counselor to self-check when providing the counseling services.

• The manager and supervisor to use when evaluating counseling skills of health

Checklist of individual - counseling skills on IYCF



PROCEDURE ACTIVITIESNOT

DONENOT DONE

WELLWELL-DONE

1

Introduction,create a warmand friendly environment

Greet mothers

Introduce yourself

Make eye contact

Smile

Show respect

2

Identifycurrent

situation/issue

Ask open and closed questions

Listen

Be non-judgmental

Accept what a mother says

3 Analyze andassess

Identify the problem, issue

Be non- judgmental

Response to mother’s question

4

Makepractical

recommenda-tions

Provide relevant information

Use simple words

Build confidence

Make 1-2 practical recommendations

Be non- judgmental

5Negotiate be-havior - getcommitment

Discuss different solutions with mothers

Let mothers choose the solution

Get a mother’s commitment to try one to tworecommendations

6 Summarizeand close

Ask a mother to repeat recommendation

Correct a recommendation if required

Arrange follow-up with mother

Praise and thank mother

Session 11: Group counseling for mothers on IYCF


SESSION 11: GROUP COUNSELING FOR

MOTHERS ON IYCF

Objectives:


1. Describe what preparation is needed for organizing a group-counseling session.

2. escribe steps for conducting a group-counseling session on IYCF.

Why group counseling is needed

• Access to a greater number of clients than that of individual counseling.

• Clients have an opportunity to learn from each other and support each other.

• Provide information and instruction on new behaviors and discuss how to solve problems

on IYCF.

• Identify client difficulties and encourage clients to come for individual counseling and

better care.

When to conduct a group-counseling session

• Communicator may organize a group-counseling session for pregnant women or mothers in the

village, usually once a month in the communes where the health facility has no “franchise modelon IYCF”.

• May integrate with community meetings, including women’s and village meetings etc.

• May integrate with club activities.

Prepare for a group-counseling session

• Review time that clients need to receive counseling on IYCF to identify the appropriate participants

for the counseling session

• Select topic of the counseling session, prepare appropriate information and counseling cards

• Identify appropriate time and location for counseling session (no more than 60 minutes from startto finish).

• Invite participants.

• The counselor should come early to check seats, drinks, etc.

Steps of conducting a counseling session for a group

Step 1: Introduction

• Greet mothers.

• Introduce yourself.

• Ask mothers to introduce themselves.

• Introduce the topic.

• Do a quick warm-up to create a friendly atmosphere and attract participation (sing songs, warm-up games, etc.).

Step 2: Identify attitudes, understanding, and practices of mothers on a counseling topic

• Use open-ended questions to find out what mothers know, believe, do, and are interested in.

• Listen carefully to what mothers share.

• Accept what mothers think and do.

• Identify and praise what mothers understand and do right.

Step 3: Analyze and assess

• Identify difficulties mothers are having in practicing the current topic.

Step 4: Provide information and negotiate change

• Provide information related to the counseling topic.

• Use relevant counseling cards to help mothers understand and remember information.

• Discuss solutions to overcome difficulties.

• Make practical recommendations on what mothers can do.

• Encourage and negotiate with mothers to select one to two actions to try.

• Come to an agreement on practicing new behavior and get commitment from mothers.

• Ask one to two mothers to repeat the recommendations.

• Correct the recommendations if required.

• Inform mothers that they can be counseled privately at CHCs.

Step 5: Summarize and closing

• Summarize main points of the counseling session

• Identify the need for individual home visits if required

• Agree on a plan of the next counseling session

• Thank mothers

The checklist of group counseling skills on IYCF is a tool that helps:

• The counselor to self-check whether s/he provided appropriate counseling services.

• The manager and supervisor to use when evaluating counseling skills of health staff.





Checklist of individual - counseling skills on IYCF

PROCESS ACTIVITYNOT YET

DONENOT DONE

WELLWELL-DONE


Greet mothers

Introduce yourself

Mothers introduce themselves

Introduce the topic

Warm-up to a create happy atmosphere involvingtrainee participation (singing, games…)

Step 2: Identify atti-

tudes, under-standing, andpractices ofmothers onthe counsel-

ing topic

Use open-ended questions to see what mothersknow, believe, do, and are interested in

Listen to mothers sharing

Accept what mothers think and do

Identify and praise what mothers understand anddo right

Step 3: Analyze and

assess

Identify the mothers’ difficulties in practicing thecurrent topic

Step 4: Provide infor-

mation andnegotiatechange

Give information that is relevant to the counselingtopic

Use the counseling card properly to help the mothers understand and remember information

Discuss solutions to overcome difficulties

Make practical suggestions on what mothers can do

Encourage and negotiate with each mother to select one to two actions to try

Come to an agreement on implementing new behavior

Inform mothers that they can be counseled privately at CHCs

Step 5: Summarize –get commit-

ment

Summarize main points of the counseling session

Agree on the plan for the next meeting

Arrange a follow-up about the mother practicingthe new behavior

Say “thank you” to the mothers.

Notes: Each franchise will be provided with BCC materials to support counseling sessions. Detailed

list of BCC materials provided is as follows:



JOB AIDS /COUNSELING MATERIAL


At village level:

• Invitation card

• Loudspeaker scripts

At franchise:

• Counseling cards

• Posters; Leaflet

• Mother-and-child booklet

• Franchise promotional items

• Educational CD/DVDs

In which:

• Invitation cards: are designed as leaflets and contain IYCF messages. The invitation cards are

managed by community-based workers (CBWs). As pregnant women and mothers who are eligible

for franchise services are identified, community-based workers are required to give them invitation

cards and motivate them to go to the franchise “M t tr i bé th ” to receive the services.

• Loudspeaker scripts: every 2-3 months, CBWs will be given a CD with messages to be played on

the village loudspeakers.

• Mother-and-child booklet: is designed as a health book and contains information on IYCF practices.

During the first visit to the “M t tr i bé th ” franchise, pregnant women/mothers will be registered

and given a mother-child book. CBWs must ensure that the pregnant women/mothers keep these

books safe and use them.

• Counseling cards: are a set of cards illustrating IYCF messages. Each franchise will get two to

three sets that can be used by health-facility workers for individual and group-counseling sessions.

• Posters, leaflets: during visits to the “M t tr i bé th ” franchise, pregnant women/mothers, fathers,

and caregivers will be given leaflets on a variety of topics. Once they return to the village, they

may consult CBWs on the content of these leaflets.

Session 12: Health and nutrition care for pregnant women and lactating mothers


SESSION 12: HEALTH AND NUTRITION CARE

FOR PREGNANT WOMEN AND LACTATING MOTHERS

Objectives:


1. Present the importance of nutrition care for pregnant women and lactating mothers.

2. State the proper dietary requirements for mothers during pregnancy and lactation.

3. Point out necessary health care for women during pregnancy and lactation (breast care, immu-nization, supplementation of iron, hygiene, working and resting routines, mental support, etc.).

4. List out the types of food and appropriate dishes for pregnant women and lactating mothers at

their localities.

Importance of nutrition

• Meet demand for the body’s activities and the mother’s physiological changes such as metabolism

transformation, fat accumulation, weight gain, increased uterus volume, fetus growth, and milk pro-

duction later on.

• Inappropriate nutrition for pregnant women will affect infant’s development later on:

Undernutrition in the first period of pregnancy: newborn is not underweight but is at high riskof obesity and cardiovascular diseases later.

Undernutrition in the last period of pregnancy: newborn is at high risk of underweight and diabetes.

You need to understand the importance of nutrition for pregnant women to meet the demands of the

fetus’s development as well as mother’s nutrition needs during pregnancy and lactation.

Changes in mother’s body during pregnancy

• Body-weight changes (mother and fetus’s weight gain) during pregnancy:

AMOUNT OF WEIGHTGAIN

1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

Mother 1000 gram 4000 – 5000 gram 5000 – 6000 gram

Fetus 100 gram 1000 gram 2000 gram

• Based on nutritional status (body mass index: BMI) before pregnancy, the recommended amount

of weight gain is as follows:

Good nutritional status (BMI: 18.5-22.9): Amount of weight gain should be equal to 20% ofbody weight before pregnancy.

Poor nutritional status (BMI<18.5): Amount of weight gain should be equal to 25% of bodyweight before pregnancy and

Overweight-obese (BMI>=23): Amount of weight gain should be equal to 15% of body weightbefore pregnancy.

• According to the international standard (FAO), mean weight gain of Asian women should range from

10-12 kg, including 4kg of fat, which is equal to 36000kcal. This is a resource for milk production.

Nutritional demand of pregnant women and lactating mothers

Pregnant women have higher demand on energy and nutrients compared to before pregnancy

• Energy: According to FAO/WHO’s recommendations for Southeast Asia in 2005:



Weight

(height)2(

kg

m2)BMI =

• Protein: is especially essential for forming and building internal organs such as heart, liver, lung

and particularly neurological cells.

• Lipid: accounts for 20-25% of the total energy, i.e., about 60g lipid/day (from oil, fat, and cheese).Lipid is needed in meals for mothers because it has the role of providing energy and also dissolves

Vitamins A, D, E, and K necessary for both mother and baby. Lipid builds cells in the body,

especially mental cells.

Nutritiondemand/day

Normal womenPregnant women – extra needed

Lactating mothers– extra needed

1st + 2nd trimester 3rd trimester

Energy 2200-2600 kcal360 kcal

(equally 1 full bowl of rice)

475 kcal (equally 2 bowls

of rice)

505 – 675 kcal *(Equally 2-3 bowls

of rice)

Protein 55 gram 15 gram 18 gram 28 gram

Lipid 60 gram 0 20 gram 20 gram

Iron 39.2 mg 20mg **

Vitamin A 500mcg 300 mcg 350 mcg



• Vitamins, minerals, and micro-nutrients:

Vitamins and minerals are necessary for the body’s normal metabolism and building internal organs.

In addition to its increasing eyesight and immune resistance, Vitamin A creates long bones forinfants, helping them to potentially reach optimal height.

Vitamin D supports absorption and metabolism of calcium, forming a child’s skeleton.

Vitamin C increases resistance to infection and supports iron absorption.

Acid folic helps produce blood and neurological tubes.

Other vitamins support the body’s ability to absorb nutrients and strengthen the body’s functions.

Iron helps to produce blood, and is available in solid blood, red-colored meat, soy beans, anddark-green leaves.

Calcium helps in forming the skeleton.

Zinc increases an infant’s height during pregnancy and an infant’s immune system.

Nutrients are available in food consumed daily. However, each type of food will contain more of some

nutrients than others. Therefore, food diversification is needed to receive sufficient nutrients.

Appropriate diet for mothers during the pregnancy period

A meal for a pregnant woman should provide sufficient nutrients by providing all four food groups; her

meal should contain more food than before pregnancy. In this way the mother receives:

• Sufficient energy by consuming rice, noodles, corn, sweet potato, cassava, and its processed

products.

• Protein: from animal-source food such as meat, fish, egg, and milk containing precious protein.

Also, she should eat more beans, peas, sesames, peanuts, and plant oils to provide more protein.

• Lipid: provided from oil, fat, peanuts, sesames, etc.

• Vitamins and minerals by eating green vegetables and fruit (popular vegetables available in VietNam such as spinach, “rau ngot”, “rau cai xoong”, “rau den”, etc. are rich in Vitamin C, carotene,B12, B2, iron, folic acid, etc.) Ripe fruit such as banana, papaya, orange, mango, etc. are also es-

sential for mothers. She should eat ripe fruit daily if possible.

Foods and drinks that should be limited

• Do not use stimulating beverages/food such as alcohol, coffee, cigarettes, and thick tea.

• Reduce condiments such as chili, pepper, and garlic.

• Reduce salty food, especially for edematous mothers, to diminish edema and avoid problems

at birth.

Other health care

• Antenatal care: every three months in three trimesters during pregnancy

Purposes:

1st trimester: identify pregnancy and receive counseling on nutrition, consume an iron tablet,and monitor weight.

2nd trimester: monitor the fetus’s development, receive a tetanus vaccine, monitor the amountof weight gain, and receive counseling on nutrition.

3rd trimester: monitor the fetus’ development, receive tetanus vaccine, monitor the amount ofweight gain, receive counseling on nutrition, and make prognosis of delivery.

• Consume an iron tablet to prevent iron-deficiency anemia as instructed by health staff.

• Breast care: Breast care, especially nipple sanitation, is very important to ensure that the lactiferous

duct is unblocked after delivery. Gently cleaning during bathing is recommended.

Advice to mothers during breast sanitation:

Do not continuously rub a dry milk drop, clean and gently get it out.

In case of flat or inverted nipples: stretching nipples is only allowed for full-term pregnancy(from 38 weeks of pregnancy) because early stretching leads to uterus contraction, affectingthe development of the fetus.

• Appropriate schedule of work and rest:

Do not work hard during pregnancy, to avoid miscarriage and premature delivery.

Do moderate exercises for smooth circulation, but do not participate in extreme sports or athletics.

Relaxation is necessary for mother and unborn baby; however only relaxing and not workingmakes a mother unhealthy and she will have difficulty delivering her baby. The last month isthe period of greatest weight gain, resulting in the mother having difficulty moving. Therefore,stopping work one month before delivery is helpful to both mother and baby

Mental factors are very important to the pregnant mother and fetus’s development. A happyfamily and a well-cared-for mother will help the fetus develop well, prepare for a smooth delivery, and enable sufficient milk production.



Session 13: The significance of BF


SESSION 13: THE SIGNIFICANCE OF BF

Objectives:

After finishing this session, trainees will be able to:

1. State the concept and definition of EBF.

2. Point out the benefits of early and EBF.

3. State the components of breastmilk.

4. Describe major differences between breastmilk and other milk.

1. Definition of EBF:

EBF means giving a baby only breastmilk, and no other liquids or solids, not even water. Drops or

syrups consisting of vitamins, mineral supplements, or medicines are permitted.

2. Benefits of BF

Benefits of BF – for infants

• Provides a superior source of nutrients, meets all of the baby’s demands for the first 6 months.

• Promotes optimum growth and development.

• Stimulates optimum development of the brain.

• Protects against infections, especially diarrhea and respiratory infections.

• Easy to digest and effectively used.

• Provides adequate water for the baby in the first 6 months.

• Ensures nutrition, especially in emergencies (natural disaster, war, etc.).

• Clean, always ready, and of appropriate temperature.

Benefits of BF – for mothers

• Helps expel placenta and reduces the risk of bleeding.

• BF stimulates good uterus contraction.

• Early and frequent BF stimulates breastmilk production.

• Prevents engorgement (early and frequent BF).

• Provides good economic benefit (cost-effective).

FURTHER READING

Protecting a baby against infections

• Breastmilk contains white blood cells and a number of anti-infection factors, which help

to protect a baby against infections. Breastmilk helps the baby fight against infections

such as diarrhea, respiratory infection, otitis, meningitis, and urinary infections.

• This diagram shows that: when the mother develops an infection (1), white blood cells

• Promotes bonding and motherhood.

• Good for a mother’s health (decreases ovarian cancer, breast cancer, and cervical cancer).

• Improves nutrition metabolism for mothers.

• Delays a new pregnancy and menstruation.

Benefits of BF – for the family

• Reduces illness.

• Reduces health expenses.

• Prevents the mother from getting pregnant again soon after birth.

3. Disadvantages of artificial feeding

• For babies:

Interferes with bonding between mothers and babies.

More diarrhea and persistent diarrhea.

More frequent respiratory infections.

Malnutrition and Vitamin A deficiency.

More allergies and milk intolerance.

Increased risk of some chronic diseases.

Obesity.

Lower IQ.

• For mothers:

Mothers may become pregnant sooner.

Increased risk of anemia, ovarian cancer, and breast cancer for mothers.



4. Composition of breastmilk

Differences between colostrum and mature milk

• Colostrum is the special breastmilk that is available in the mother’s breast from the 14th to 16th

week of pregnancy and is produced in the first one to three days after delivery. Colostrum is thick

and yellowish or clear in color. It contains more protein than mature milk.

in her body become active and make antibodies against infections to protect her; (2)

some of these white blood cells go to her breasts and make antibodies; and (3) these

are secreted into breastmilk to protect her baby.

• Therefore a baby should not be separated from his mother when she has an infection

because her breastmilk also protects him against infection.

Psychological benefits of BF

• BF has important psychological benefits for both mothers and babies. Close contact im-

mediately after delivery helps the mother and baby to bond and helps the mother to feel

emotionally satisfied.

• The child who is breastfed tends to cry less and may be more emotionally secure. Some

studies suggest that BF may help a child develop intellectually. Low-birth-weight babies

fed breastmilk during the first weeks of life perform better on intelligence tests in later

childhood than children who are formula-fed.



COLOSTRUM

Property Importance

• Antibody-rich • Protects against allergies and infection

• Many white cells • Protects against infection

• Mild purgative effect• Clears meconium

• Helps to prevent jaundice

• Growth factors• Helps intestine to mature

• Prevents allergies and food intolerance

• Rich in Vitamin A • Reduces severity of infection

• Mature milk:

After three to seven days, colostrum changes into transitional milk and after seven to ten days, transi-

tional milk completely changes into mature milk. There is a greater amount of milk, and the breasts

feel full, hard, and heavy. Some people call this the milk “coming in”. Mature milk exists until the child

is weaned and it is made up of two parts:

Foremilk is the milk that is produced early in a feed. Foremilk is greenish, produced in large

amounts, and provides plenty of protein, lactose, water, and other nutrients. Babies do not

need other drinks of water before they are six months old, even in a hot climate. If babies are

provided with water when they are hungry, they will suckle less.

Hindmilk is the milk that is produced later in a feed. Hindmilk is white milk and contains more

fat than foremilk. This fat provides much of the energy of a breastfeed, which is why it is

important to let babies finish hindmilk, and not to let them discard a breast too quickly.



DIFFERENCES BETWEEN COLOSTRUM AND MATURE MILK

Source: WHO/UNICEF (2006) Infant and Young Child Feeding Counseling: An Integrated Course

Fat

Protein

Lactose

Foremilk

Hindmilk

Colostrum

Mature milk


FURTHER READING:

• Colostrum contains more antibodies and other anti-infective protein than mature milk.

This is part of the reason why colostrum contains more protein than mature milk. It also

contains more white blood cells than mature milk. Colostrum helps to prevent bacterial

infections that are a danger to newborn babies and provides the first immunization

against many of the diseases that a baby meets after delivery.

In conclusion: EBF can meet the baby’s nutrient and water demand for the first six months. All infants

who are under six months and exclusively breastfed do not need any water – even if it is hot – because

88% of breastmilk is water.

5. Major differences between human and animal milk



NUTRIENTS IN HUMAN AND ANIMAL MILKS


Fat

Protein

Lactose

Human Cow Goat


• Colostrum has a mild purgative effect, which helps to clear meconium (the first darkstools). This clears bilirubin from the gut, and helps to prevent jaundice from becoming

severe.

• Colostrum contains many growth factors that help a baby’s immature intestine to

develop after birth. This helps to prevent babies from developing allergies and intoler-

ance to other foods.

• Colostrum is rich in Vitamin A, which helps to reduce the severity of any infections that

the baby might have.

• It is very important for babies to be fed colostrum for their first few feeds. Colostrum is

ready in the breasts when a baby is born. Babies should not be given any drinks or foods

before they start BF. Artificial feeds given before a baby has colostrum are likely to cause

allergies and infection.

• All infants under six months need only breastmilk without being given extra water even

if it is hot because giving water will make the baby breastfeed less.

• This chart shows that much of the protein in cow's milk is casein. Casein forms thick, indigestible

curds in a baby’s stomach.

• Human milk contains more whey proteins. The whey proteins contain anti-infective proteins, which

help to protect a baby against infection.

• Artificially fed babies may develop intolerance to protein from animal milk. They may develop di-

arrhea, abdominal pain, rashes, and other symptoms when they have feeds that contain the differ-

ent kinds of protein.

• Formula milk is made from a variety of products, including animal milk, soybeans, and vegetable

oil. Although they have been adjusted so that they are more like human milk, they are still far from

perfect for babies.

• In order to understand the composition of formula milk, we need to understand the differences

between animal and human milk and how to produce formula milk from animal milk.

• This chart compares the nutrients in breastmilk with the nutrients in fresh cow and goat milk.

• All the milks contain fat, which provides energy, protein for growth, and a milk sugar called lactose,

which also provides energy.

• Animal milk contains more protein than human milk. It is difficult for a baby's immature kidneys to

excrete the extra waste from the protein in animal milk.

• Human milk also contains essential fatty acids that are needed for a baby's growing brain and

eyes, and for healthy blood vessels. These fatty acids are not present in animal milk, but may have

been added to formula milk.

Differences in the quality of proteins in different milks



DIFFERENCES IN THE QUALITY OF PROTEINS IN DIFFERENT MILKS

35%Casein

80%Casein

Cow’s milkHuman milk

Whey protein

Curds

Anti-infectiveproteins

Easy to digest Difficult to digest





FURTHER READING: TEN STEPS FOR SUCCESSFUL BF

Every facility providing maternity services and care for newborn infants should:

1. Have a written BF policy that is routinely communicated to all health-care staff.

2. Train all health-care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of BF.

4. Help mothers initiate BF within half an hour of birth.

5. Show mothers how to breastfeed and how to maintain lactation even if they are separated from

their infants.

6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.

7. Practice rooming-in – allow mothers and infants to remain together 24 hours a day.

8. Encourage BF on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to BF infants.

10. Foster the establishment of BF support groups and refer mothers to them upon discharge from

the hospital or clinic.

SESSION 14: NUTRIENT DEMANDS OF CHILDREN

UNDER SIX MONTHS

Objective:

After this session, trainees will be able to:

1. Describe the size of a baby’s stomach.

2. Describe the nutrient demands of a BF baby.

3. State frequency and duration of BF.

1. Size of baby’s stomach

Parents often worry about whether their babies eat sufficiently or not. With bottle-fed babies, it is easy

to quantify compared to BF babies; the amount of breastmilk they eat is unknown. To know if babies

suckle sufficiently or not, we should study the size of baby’s stomach, especially in the first few weeks.

Day 1 and 2: the size of a small grape

Mothers still ask themselves why colostrum is too little. It is simple: a newly born baby’s stomach only

can store a liquid amount equivalent to a small grape. In addition, in the first two days, a baby’s stomach

is not able to stretch to store more than that. Mothers see that if babies are fed too much, they will

burp. Burping in children is due to many reasons, among which the small size of baby’s stomach is a

common one.

At this time, a baby’s stomach only can store about 5 to 7 ml. Therefore, a mother’s body only produces

the amount of colostrum that a baby’s stomach can store. The size of a baby’s stomach and the amount

of colostrum and suckling frequency (about 10 to 12 times per day) all combine to ensure that the baby

gets enough colostrum on day 1 and day 2.

Day 3: the size of a lemon

A baby’s stomach expands in the first three days until it reaches the size of a lemon (22 to 27 ml). Until

the third day, babies should be breastfed 8 to 12 times/day.

Breastfeeding a baby frequently is better than BF large amounts infrequently. This is because a baby’s

stomach cannot store much. In addition, a long breastfeed can cause nipple pain. Long BF periods

should only be applied later when baby’s stomach is big enough to store more milk.

Day 10: the size of a big egg

Until breastmilk is “coming in” around the tenth day of BF, a baby’s stomach can only store an amount

equivalent with 60 to 81 ml and equal in size to a big egg.

Session 14: Nutrient Demands of Children under Six Months


Sufficient is only relative

So, what does “sufficient is only relative” mean? The human body is naturally created with evolution:

mothers deliver babies and can feed them with breastmilk sufficient to baby’s demand right after birth

(colostrum) and then later (mature milk). The mother is gradually able to produce more milk and the

baby is gradually able to take in more milk.



SIZE OF A NEWBORN BABY’S STOMACH

5 - 7 ml = a grape

1 - 2 days 3 - 4 days 10 days

22 - 27 ml = a lemon

60 - 80 = an egg


2. Nutrient demands of BF babies

The energy demands of full-term babies of normal weight from a normal delivery are generally satisfied

by breastmilk for the first six months if the mothers have good nutritional status. See the table below:

Table: Comparison of a baby’s energy needs and breastmilk satisfaction rate

AgeEnergy need Breastmilk

(kcal/day) g/day Energy (Kcal/day)

0-2 months 404 714 493

3-5 months 505 784 540

• On this graph, each column represents the total amount of energy needed at that age. The taller

columns indicate that more energy is needed as the child becomes older, bigger, and more active.

The dark part shows how much of this energy is supplied by breastmilk.

• This graph shows that breastmilk supplies sufficient energy and nutrients for the baby for the first

six months. In this period, the child’s digestive system is not mature enough to manage formula

milk or complementary food. Breastmilk helps the child’s digestive system to mature.

• From the age of six months, breastmilk is no longer sufficient by itself. In addition to breastmilk, all

babies need complementary food from six months of age.

• However, breastmilk continues to be an important source of energy and high-quality nutrients be-

yond six months of age. From 6-12 months, breastmilk still continues to provide more than half of

the child’s energy needs. From 12 – 24 months, breastmilk continues to provide about one third of

the child’s energy needs. Breastmilk also helps to complete the child’s brain development and

provides antibodies. No food or formula can serve as a substitute. Hence, we must encourage and

support mothers to continue to breastfeed up to 24 months or beyond.

Milk production of mothers is adjusted appropriately according to a baby’s demand. This is clearly

shown in mothers who have twins or triplets and still practice EBF for the first six months or more.

When a baby’s demand increases, breastmilk production also increases within a few days, even in a

few hours. See the chart below to see more about a baby’s energy demands and the nutrient supply

from breastmilk.



00-2 m 3-5 m 6-8 m 9-11 m 12-23 m

200

400

600

800

1000 Energy Gap

Energy frombreast milk

Energ

y (k

cal/d

ay)

ENERGY REQUIRED BY AGE AND THEAMOUNT SUPPLIED FROM BREAST MILK

Age (months)


Source: WHO/UNICEF, IYCF Counseling: An Integrated Course (2006)

3. Frequency and duration of BF

• BF on demand:

Signs that a baby wants to suckle (turns over, opens its mouth and turns its head from oneside to another, moving its tongue in and out, sucking its fingers or fist).

Continue BF until the baby comes off the breast itself, at least 15-20 minutes each breast.

• Finish one breast before shifting to another.

• BF both day and night, that is, 8-12 times/24 hours.

• Frequent suckling maintains breastmilk production.

• A baby gets enough milk when s/he passes urine at least six times/day.

• BF up to 24 months or beyond.



FURTHER READING:

Practice frequent BF and BF on demand during the day and night

• Babies need to be breastfed on demand and frequently, both during the day and night.

The frequency of suckling is about 8-12 times within 24 hours. The gap between each

feed may be more or less two to three hours.

• A baby’s stomach is small and needs frequent feeds. Breastmilk amounts are totally ap-

propriate with that size, breastmilkis easy to digest.

• Babies should be fed before they cry. Crying is a sign of being hungry.

• Each feeding time should last until the baby wants to stop and come off the breast

him/herself. If the feeding duration lasts for more than half an hour or two successive

feeds are too close (the gap between each time is only 1-1.5 hours), it shows that babies

do not attach well to the breast and suckle ineffectively, so mothers should double check.

• Frequent BF maintains milk secretion, delays a new pregnancy, and provides

immune substances in each feed. Frequent BF also helps to prevent breast problems

like engorgement that make mothers feel uncomfortable and not want to continue

BF their baby.

• If babies urinate at least six times within 24 hours, it is a sign of sufficient BF (in the firsttwo days when babies drink colostrum, mothers may only need one to two nappies/day).If not, babies should be breastfed more or mothers need to check their BF technique

again.

• The dark skin, which surrounds the nipple, is called the areola. In the areola there are small glands

called Montgomery's glands, which secrete an oily fluid to keep the skin healthy. Inside the breast

are the alveoli, which are very small sacs made of milk-secreting cells. There are millions of alveoli

the diagram shows only a few. The box shows three of the alveoli enlarged. A hormone called

prolactin makes these cells produce milk.

• Around the alveoli are muscle cells, which contract and squeeze out the milk. A hormone called

oxytocin makes the muscle cells contract. Small tubes, or ducts, carry milk from the alveoli to the

outside. Milk is stored in the alveoli and small ducts between feeds. The larger ducts beneath the

areola dilate and hold the breastmilk temporarily during the feed.

SESSION 15: BREASTMILK PRODUCTION

Objectives:

After completing this lesson, trainees will be able to:

1. Name the main parts of the breast and describe their function.

2. Describe the hormonal control of breastmilk production and ejection.

1. Anatomy of the breast

Session 15: Breastmilk production


Supportingtissue and fat

Alveoli

Montgomery’s glands

Areola

Nipple

Larger ducts

Ducts

Milk-secreling cells Prolactin makesthem secrete milk{

Muscle cellsOxytocin makesthem contract{

ANATOMY OF THE BREAST

• The secretory alveoli and ducts are surrounded by supporting tissue and fat. It is this fat and other

tissue that give the breast its shape and that makes most of the difference between large and small

breasts. Small breasts and large breasts both contain about the same amount of gland tissue, so

they can both make plenty of milk.

2. Prolactin reflex



Prolactin in blood

Baby suckling

Sensory impulses fromnipples

More prolactinsecreted at night

Suppresses ovulation

Secreted during and after feed to produce next feed

• When a baby suckles at the breast, sensory impulses go from the nipple to the brain. In response,

the pituitary gland at the base of the brain secretes prolactin. Prolactin goes in the blood to the

breast and makes the milk-secreting cells produce milk.

• Most of the prolactin is in the blood about 30 minutes after the feed, so it makes the breast produce

milk for the next feed. For this feed, the baby takes the milk that is already in the breast.

PROLACTIN REFLEX

• When a baby suckles, sensory impulses go from the nipple to the brain and stimulate the pituitary

gland at the base of the brain that secretes the hormone oxytocin. Oxytocin goes in the blood to

the breast, and makes the muscle cells around the alveoli contract.

• Contracted alveoli make the milk that has collected in the alveoli flow along the ducts to the larger

ducts beneath the areola. This is the oxytocin reflex, the milk-ejection reflex or the “let-down” reflex.

• Oxytocin is produced more quickly than prolactin. It makes the milk in the breast flow for this feed.

Oxytocin can start working before a baby suckles, when a mother learns to expect a feed.

• If the oxytocin reflex does not work well, the baby may have difficulty in getting the milk. In this

situation, the breasts are producing milk, but the milk is not flowing out.

• Another important point about oxytocin is that it makes a mother's uterus contract after delivery.

This helps to reduce bleeding, but it sometimes causes uterine pain and a rush of blood during a

feed for the first few days.

4. Helping and hindering of oxytocin reflex

The oxytocin reflex is easily affected by a mother's thoughts and feelings. For example, feeling pleased

with her baby, or thinking lovingly of him, or feeling confident that her milk is the best for him can help

the oxytocin reflex to work. Sensations such as touching or seeing her baby, or hearing him cry, can

also help the reflex. But negative feelings, such as pain or worry or doubt that she has enough milk,

can hinder the reflex and stop her milk from flowing. Fortunately, this effect is usually temporary.

3. Oxytocin Reflex



Oxytocin in blood

Baby suckling

Sensory impulses fromnipples

Works before or during feed to make milk flow

Makes uterus contract

OXYTOCIN REFLEX



These help reflex These hinder reflex

Thinks lovingly of baby

Sounds of baby

Sight of baby

Touches baby

Confidence

Worry

Stress

Pain

Doubt

FURTHER READING: SIGNS AND SENSATIONS OF AN ACTIVE OXYTOCIN REFLEX

A mother may notice:

• A squeezing or tingling sensation in her breasts just before she feeds her baby or during a feed.

• Milk flowing from her breasts when she thinks of her baby or hears him crying.

• Milk dripping from her other breast when her baby is suckling.

• Milk flowing from her breasts in fine streams if her baby comes off the breast during a feed.

• Pain from uterine contractions, sometimes with a rush of blood, during feeds in the first week.

• Slow deep sucks and swallowing by the baby, which show that breastmilk is flowing well into his

mouth.

HELPING AND HINDERING OF OXYTOCIN REFLEX

5. Inhibitor in breastmilk

• While counseling, you may be asked why one breast sometimes stops making milk, while the other

breast continues even though oxytocin and prolactin go equally to both breasts. This diagram

shows why.



INHIBITOR IN BREAST MILK

If breast rem ainsfull of milk,

secretion stops

Inhibitor

• There is a substance in breastmilk that can reduce or inhibit milk production. If a lot of milk is left

in a breast, the inhibitor stops the cells from secreting any more. This helps to protect the breast

from the harmful effects of being too full. It is obviously necessary if a baby dies or stops BF for

some other reason. If breastmilk is removed, by suckling or expression, the inhibitor is also

removed. Then the breast makes more milk.

• This helps you to understand why if a baby stops suckling from one breast, that breast stops making

milk. If a baby suckles more from one breast, that breast makes more milk and becomes larger

than the other.

• It also helps you to understand why the milk must be removed for a breast to continue making

milk. If a baby cannot suckle from one or both breasts, the breastmilk must be removed by

expression to enable production to continue.

SESSION 16: IN-CLASSROOM PRACTICE - INDIVIDUAL

COUNSELING ON BF

Objectives:


1. Practice individual BF-counseling skills.

2. Apply knowledge on BF into counseling practice for mothers.

• Read carefully “the case studies on BF individual counseling” below and determine:

Who are the clients? What are their problems?

Which behaviors need to be changed?

What are the difficulties when practicing new behaviors?

Which information is necessary during the counseling session?

Which counseling cards should be used?

• Use the checklist of individual counseling on IYCF as a self-observing and monitoring tool to see

if the counseling session provides enough information.

Session 16: In-classroom practice - Individual Counseling on BF


CASE STUDIES ON BF INDIVIDUAL COUNSELING

AT A HEALTH FACILITY

Case study 1: Ms. Phuong is in the seventh month of pregnancy. This is her first child. When

talking to her, you learn that her mother-in-law does not let her eat crabs, shellfish, and buf-

falo meat because she said that this food could make the baby get diarrhea easily. Please

counsel her mother-in-law.

Case study 2: You are in the ninth month of pregnancy, this is your first time. You intend to

breastfeed your baby but many people say that breastmilk often comes in late so you should

bring formula milk when coming to the hospital for delivery. You don’t want to feed your baby

formula milk but are afraid that he will be hungry when he is born.

You can start the conversation with: “I don’t know whether I should bring formula milk whencoming to hospital for delivery.”



Case study 3: Ms. Huong gave birth to her first baby two days ago and she does not know

how to breastfeed her baby properly. She hears that if she does not breastfeed properly, her

baby may not be able to suckle and will get hungry. Please counsel her on how to attach the

baby to her breast and how to breastfeed properly.

Case study 4: Ms. Nhung delivered a baby two months ago. You visit her house and see

her breastfeed her baby but there is still a tin of milk powder for babies and a feeding bottle,

teat, etc. Ms. Nhung says that she has a lot of breastmilk but she hears that feeding infants

with powdered milk will make them chubbier. Therefore, she is going to feed her baby with

powdered milk next week. Please counsel her.

Case study 5: Ms. Ngan is BF her baby who is three months old. She feels that she does

not have enough milk to breastfeed her baby exclusively. She would like to start giving her

child other food as she feels her child is hungry all the time. Please counsel her.

Case study 6: Ms. Chung is BF her baby who is four months old. However, she is going to

return to work in a few weeks. She wants to start giving her child half a bowl of bot (ricegruel) twice a day. Please counsel her.



SKILLS ACTIVITIESNOT

DONENOT DONE

WELLWELL-DONE

1

Introduction – a create warmand friendly environment

Greet mothers

Introduce yourself

Make eye contact

Smile

Show respect

2Identify

current prob-lems /issues

Listen

Be non-Judgmental

Ask open-ended questions


3 Analyze/assess


Identify priority if there is more than one problems

Ask more open-ended questions to identify barriers

Respond to mother’s question

4Make practicalrecommenda-

tion


Build confidence


Use counseling cards/ materials

5Negotiate

behavior – getcommitment


Let mothers decide the solution

Get mother’s commitment to try 1-2 recommendations

6 Summary -Closing

Ask mother to repeat recommendation

Correct recommendation as appropriate

Arrange follow-up with mothers

Praise and thank mothers

CHECKLIST OF INDIVIDUAL COUNSELING SKILLS ON IYCF

Session 17: In-classroom practice Group-counseling practice on BF


SESSION 17: IN-CLASSROOM PRACTICE

GROUP - COUNSELING PRACTICE ON BF

Objectives:


1. Practice group-counseling skills on BF.

2. Apply knowledge on BF in counseling practice for mothers.

• Read carefully “the case studies for BF group counseling” below and determine:

Who are the clients? What are their problems?

Which behaviors need to be changed?

What are the difficulties when practicing new behaviors?

Which information is necessary during the counseling session?

Which counseling cards should be used?

Case studies for BF group counseling

Case study 1: In your village, local residents live far from the health station. They live hardlives. Mothers often work hard and do not receive nutrition care during the pregnancy andBF period. Organize a group discussion with pregnant women on nutrition care for pregnantwomen.

Case study 2: You have organized a group-counseling session for pregnant women. Youraim is to talk about the immediate initiation of BF. As you discuss this with the mothers, youlearn that in this community they believe that the first few drops of colostrum are not goodfor the baby. Please conduct the counseling session.

Case study 3: You have organized a group-counseling session on EBF for mothers of children aged 3-4 months. Some mothers say that they have to go to work and so they haveto give their children some other food besides breastmilk. Please conduct the counseling session.

Case study 4: It is the summer season and you receive feedback from the village healthworkers that many mothers are giving water to their children because they believe the chil-dren will get dehydrated. You organize a counseling session for mothers to talk about EBF.

• Use the checklist of group counseling on IYCF as a self-observing and monitoring tool to see if thecounseling session provides enough information

Session 17: In-classroom practice Group-counseling practice on BF


CHECKLIST OF GROUP COUNSELING ON IYCF

PROCESS ACTIVITYNOT YET

DONENOT WELL

DONEWELLDONE


Greet mothers

introduce yourself

Mothers introduce themselves

Introduce the topic

Warm-up to create happy atmosphere, involvingtrainee’s participation (singing, games…)

Step 2: Identify atti-

tudes, under-standing, andpractices ofmothers onthe counsel-

ing topic

Use open-ended questions to know what mothersknow, believe, do and are interested in

Listen to mothers’ sharing

Accept what mothers think and do

Identify and praise what mothers understand anddo right

Step 3: Analyze and

assess

Identify mothers’ difficulties in practicing the current topic

Step 4: Provide infor-

mation andnegotiatechange

Give information that is relevant to the counselingtopic

Use counseling cards properly to help mothers understand and remember information

Discuss solutions to overcome difficulties

Make practical suggestions on what mothers can do

Encourage and negotiate with each mother to select one to two actions to try

Come to an agreement on implementing new behavior

Inform mothers that they can be counseled privately at CHCs

Step 5: Summarize –get commit-

ment

Summarize main points of the counseling session

Agree on the plan for the next meeting.

Arrange follow-up on mothers’ practicing new behavior

Say “thank you” to mothers

Session 18: Positioning and attachment


SESSION 18: POSITIONING AND ATTACHMENT

Objectives:

After completing this lesson trainees will be able to

1. Explain the four key points of positioning.

2. Describe how a mother should support her breast for feeding.

3. Help a mother to position her baby at the breast.

4. Help the baby to attach to the breast.

5. Demonstrate the main positions – sitting, lying, underarm, and across.

Note:

• Always assess a mother BF before you help her. Take time to observe what she does so that you

can understand her situation clearly. Do not rush to make her do something different.

• Give a mother help only if she has difficulty. Some mothers and babies breastfeed satisfactorily in

positions that would be difficult for others. This is especially true with babies more than about two

months old. There is no point trying to change a baby’s position if he is getting breastmilk effectively,

and his mother is comfortable.

• Let the mother do as much as possible herself. Be careful not to ‘take over’ from her. Explain what

you want her to do. If possible, demonstrate on your own body to show her what you mean.

• Make sure that she understands what you do so that she can do it herself. Your aim is to help her

to position her own baby. It does not help if you can get a baby to suckle but his mother cannot do

it on her own.

Help a mother who is sitting to position her baby

• Greet the mother, introduce yourself, and ask for the mother and baby’s name. Ask how the mother

feels and one to two more open-ended questions on BF.

• Assess a breastfeed. Ask if you may see how baby breastfeeds and ask the mother to put him to

the breast in her usual way. (If the baby has just been breastfed many times, arrange a time tocome back.) Observe the breastfeed.

• If you identify that the mother needs help to improve the baby’s attachment at the breast, say some-

thing encouraging like: “He really wants your breastmilk, doesn’t he?”

• Then explain what to do to help and ask if the mother agrees or not. For example, say: “BF might



be less painful if (child’s name) took a larger mouthful of breast when he suckles. Would you likeme to show you how?” If she agrees, you can start to help her.

• Make sure the mother is sitting in a comfortable and relaxed position. Sit down yourself, so that

you are also comfortable and relaxed, and in a convenient position to help.

Explain to mothers how to hold her baby and show her if necessary.

Explain the four key points of positioning a baby at the breast:

• The baby’s head and body are in line.

• The baby is held close to the mother’s body.

• The baby approaches the mother’s breast, nose to nipple.

• The baby’s whole body is supported.

Show a mother how to support her breast with her hand to feed her baby:

• She should place her four fingers flat on her chest wall under her breast, so that her first finger

supports the base of the breast.

• The mother can use her thumb to press the top of her breast slightly. This can improve the shape

of the breast so that it is easier for her baby to attach well.

• The mother should not put her fingers too near to the nipple.

Explain to the mother how to touch her nipple to the baby’s lips to make his mouth open wide. Explain

that she should wait until her baby’s mouth is open wide before she moves him onto her breast. His

mouth needs to be wide open to take a large mouthful of breast.

Explain or show her how to quickly move her baby to her breast, when he is opening his mouth wide.

She should bring her baby to her breast. She should not move herself or her breast to her baby. As

she brings the baby to her breast, she should aim for her baby's lower lip to be below her nipple.

Notice how the mother responds. Does she feel pain? Does she say “oh, much better”? If the mother

does not say anything, ask her how the suckling feels. Looking for signs of good attachment.

Show how a mother who is lying down breastfeeds

Help the mother to lie down in a relaxed and comfortable position. The mother should not lie down

propped on her elbow, as it makes it difficult for the baby to attach to the breast.

Show the mother how to hold her baby. It is important for a mother who is lying down to apply four keypoints. She can support her baby with her lower arm. She can support her breast if necessary with

her upper arm.

Other positions of BF: the mother can breastfeed her baby in various positions such as:

• Underarm position.

• With the arm opposite the breast.

Figure 18.1 A mother holding her baby in theunderarm position

Useful for:

• Twins

• Blocked duct

• Difficulty attaching the breast

Figure 18.3 A mother BF her baby lying down

Figure 18.2 A mother holding her baby with herarm opposite the breast

Useful for:

• Small babies

• Sick babies



In case of a blocked duct, difficulty attaching the breast and a sick baby, trying different positions is

just a suggestion to make the baby easily attach to the breast.

HELPING A MOTHER TO POSITION HER BABY

• Greet the mother and ask how BF is going.

• Explain what might help, and ask if she would like you to show her.

• Make sure that she is comfortable and relaxed.

• Sit yourself down in a comfortable and convenient position.

• Explain how to hold the baby and show her if necessary.

The four key points are:

The baby’s head and body in line.

The baby is held close to the mother’s body.

The baby’s face approaches the breast, nose to nipple.

The baby’s head, shoulders, and bottom held.

Show her how to support her breast:

With her fingers against her chest wall below her breast.

With her first finger supporting the breast.

With her thumb above her breast.

Her fingers should not be too near to the nipple.

• Explain or show her how to help the baby to attach:

Touch her baby's lips with her nipple.

Wait until her baby's mouth is wide open.

Move her baby quickly onto her breast, aiming his lower lip below the nipple.

• Notice how she responds and ask her how she feels when her baby is suckling.

• Look for signs of good attachment. If the attachment is not good, try again.



Attachment

Look at pictures on attachment from the inside and outside and explain with picture one “correct attachment” and picture two “incorrect attachment”.

Good and poor attachment

What differences do you see?

Attachment (outside appearance)

What differences do you see?

1 2 1 2

Four signs of correct attachment

1. More of the areola is visible above the baby’s top lip than below the lower lip.

2. The baby’s mouth is wide open.

3. The baby’s lower lip is curled outwards.

4. The baby’s chin is touching or almost touching the breast.

Causes of poor attachment

1. Use of a feeding bottle – nipple confusion.

2. Inexperienced mother – first baby, bottle feeding.

3. Functional difficulty – small/weak babies, poorly protractile nipple/underlying tissues, engorged

breasts, BF delay.

4. Lack of skilled support –from the community, experienced women, birth attendants, etc.

Result of poor attachment

If a baby is poorly attached, and he ‘nipple sucks’, it is painful for his mother. Poor attachment is the

most important cause of sore nipples. As the baby sucks hard to try to get milk he pulls the nipple in

and out. This makes the nipple skin rub against his mouth. If a baby continues to suck this way, he can

damage the nipple skin and cause cracks (also known as fissures). As the baby does not drink breast-

milk effectively the breasts may become engorged. As s/he does not get enough breastmilk, s/he may

be unsatisfied and cry a lot. He may want to feed often or for a very long time at each feed. Eventually

if breastmilk is not removed, the breasts may make less milk. A baby may fail to gain weight and the

mother may feel she is failing at BF.

To prevent this from happening all mothers need help to position and attach their babies. Also babies

should not be given feeding bottles. If a baby feeds from a bottle before BF is established, he may

have difficulty suckling effectively.





How to attach a baby at the breast

Position baby’s nose level to the nipples. Use a

finger or nipple to lightly touch the baby’s lips

so that the baby opens his mouth.

Wait until the baby’s mouth is wide open, then

bring the nipple right onto his mouth.

Ensure that the baby takes a mouthful of breast,

nearly covering all of the areola.

When a baby is attached well• More areola is seen above baby’s upper

lip• Baby’s mouth is wide open • Lower lip is turned outwards• Baby’s chin is touching the mother’s

breast

When the baby is full, hold him tightly in your

arms.

When finished, BF will bring a satisfactory

feeling to both mother and baby.

Session 19: Assessing a Breastfeed


SESSION 19: ASSESSING A BREASTFEED

Objectives:


1. Explain the content of and the use of the Breastfeed Observation Job Aid

2. Assess a breastfeed by observing a mother and baby.

3. Recognize signs of good and poor attachment and positioning.

Assessing a breastfeed helps you to decide if a mother needs help or not, and how to help her. Before

asking questions, you can learn a lot about how well or badly BF is going just by observing. There are

some signs you can observe when a baby is not BF. However, there are signs you can only observe

when a baby is BF.



BREASTFEED OBSERVATION JOB AID

Mother's name ________________ Date ______________

Baby's name ___________________ Baby's age ________

Signs that breastfeeding is going well:

GENERAL

Mother:

¨ Healthy

¨ Relaxed and comfortable

¨ Signs of bonding between mother and baby

Signs of possible difficulty:

Mother:

¨ Ill or depressed

¨ Tense and uncomfortable

¨ No mother/baby contact

Baby:

¨ Healthy

¨ Calm and relaxed

¨ Reaches or moves for breast if hungry

Baby:

¨ Sleepy or ill

¨ Restless or crying

¨ Does not reach or root

BREASTS

¨ Healthy

¨ No pain or discomfort

¨ Breast well supported with fingers away from nipple

¨ Breasts look red, swollen, or sore

¨ Breast or nipple painful

¨ Breasts held with fingers on areola

BABY’S POSITION

¨ Baby’s head and body in line

¨ Baby held close to mother’s body

¨ Baby’s head and neck supported

¨ Baby approaches breast, nose to nipple

¨ Baby’s neck and head twisted to feed

¨ Baby not held close

¨ Baby not supported

¨ Baby approaches breast, lower lip/chin to nipple

BABY’S ATTACHMENT

¨ More areola seen above baby’s top lip

¨ Baby’s mouth open wide

¨ Lower lip turned outwards

¨ Baby’s chin touches breast

¨ More areola seen below bottom lip

¨ Baby’s mouth not open wide

¨ Lips pointing forward or turned in

¨ Baby’s chin not touching breast

SUCKLING

¨ Slow, deep sucks with pauses

¨ Cheeks round when suckling

¨ Baby releases breast when finished

¨ Mother notices signs of oxytocin reflex

¨ Rapid shallow sucks

¨ Cheeks pulled in when suckling

¨ Mother takes baby off the breast

¨ No signs of oxytocin reflex noticed



Figure 19.1 Positioning a baby

a. Baby’s body is approaching the mother’s,

to the mother’s breast; the mother is looking

at her baby lovingly. (Good)

b. Baby’s body is not approaching the

mother’s, the baby’s neck is twisted, and the

mother is not looking at her baby. (Poor)

Figure 19.2 How to hold breasts

a. Hand attached to chest wall,

breast held by first finger. (Good)

b. Nipple held closely by fingers. (Poor)

Figure 19.3 Attachment to the breast

a. Good attachment to the breast. b. Poor attachment to the breast



Exercise: Using the Breastfeed Observation Job Aid

In this exercise, you will practice identifying signs of good and poor attachment through some slides

showing a baby suckling. In some pictures, you will also see signs of correct and wrong positioning.

• If you see a sign on the slide, make a in the box next to the sign.

• If you do not see a sign, leave the box empty.

BREASTFEED OBSERVATION JOB AID

Mother's name ________________ Date ______________

Baby's name ___________________ Baby's age ________

Signs that breastfeeding is going well:GENERALMother:

¨ Healthy

¨ Relaxed and comfortable

¨ Signs of bonding between mother and baby

Signs of possible difficulty:

Mother:¨ Ill or depressed

¨ Tense and uncomfortable

¨ No mother/baby contact

Baby:¨ Healthy

¨ Calm and relaxed

¨ Reaches or moves for breast if hungry

Baby:¨ Sleepy or ill

¨ Restless or crying

¨ Does not reach or root

BREASTS¨ Healthy

¨ No pain or discomfort

¨ Breast well supported with fingers away from nipple

¨ Breasts look red, swollen, or sore

¨ Breast or nipple painful

¨ Breasts held with fingers on areola

BABY’S POSITION¨ Baby’s head and body in line

¨ Baby held close to mother’s body

¨ Baby’s head and neck supported

¨ Baby approaches breast, nose to nipple

¨ Baby’s neck and head twisted to feed

¨ Baby not held close

¨ Baby not supported

¨ Baby approaches breast, lower lip/chin to nipple

BABY’S ATTACHMENT¨ More areola seen above baby’s top lip

¨ Baby’s mouth open wide

¨ Lower lip turned outwards

¨ Baby’s chin touches breast

¨ More areola seen below bottom lip

¨ Baby’s mouth not open wide

¨ Lips pointing forward or turned in

¨ Baby’s chin not touching breast

SUCKLING¨ Slow, deep sucks with pauses

¨ Cheeks round when suckling

¨ Baby releases breast when finished

¨ Mother notices signs of oxytocin reflex

¨ Rapid shallow sucks

¨ Cheeks pulled in when suckling

¨ Mother takes baby off the breast

¨ No signs of oxytocin reflex noticed

Session 20: Expressing and storing breastmilk


SESSION 20: EXPRESSING AND STORING BREASTMILK

Objectives:


1. List the situations when expressing breastmilk is needed.

2. Explain and practice ways to stimulate the oxytocin reflex.

3. Explain to a mother the steps of expressing breastmilk by hand.

4. Introduce some other tools for expressing milk.

5. Explain how to store breastmilk.

Introduction

• There are many situations in which expressing breastmilk is necessary and important to enable a

mother to initiate or to continue BF.

Expressing milk is needed to:

Leave breastmilk for a baby when the mother goes out or goes to work.

Feed a low-birth-weight baby who cannot breastfeed.

Feed a sick baby, who cannot suckle enough.

Keep up the supply of breastmilk when a mother or baby is ill.

Prevent leaking when a mother is away from her baby.

Help a baby to attach to a full breast.

Help with breast-health conditions, e.g., engorgement.

Facilitate the transition to another method of feeding or to heat-treat breastmilk.

• All mothers should learn how to express their milk, so that they know what to do if the need arises.

All maternal-health workers should be able to teach mothers how to express their milk.

• Many mothers are able to express plenty of breastmilk using their own techniques. If a mother's

technique works for her, let her continue. But if a mother is having difficulty expressing milk, teach

her a more effective technique.



Stimulate the oxytocin reflex

The oxytocin reflex may work well if a mother expresses breastmilk as it does when a baby suckles. A

mother needs to know how to facilitate her oxytocin reflex, or she may find it difficult to express

her milk.

HOW TO STIMULATE THE OXYTOCIN REFLEX

1. Help the mother psychologically:

• Build her confidence.

• Try to reduce any sources of pain or anxiety.

• Help her to have good thoughts and feelings about the baby.

2. Help the mother practically. Help or advise her to:

• Sit quietly and privately or with a supportive friend.

• Some mothers can express easily in a group of other mothers who are also expressing for their babies.

• Hold her baby with skin-to-skin contact if possible:

She can hold her baby on her lap while she expresses. If this is not possible, she can look at the babyor a photograph of her baby.

• Warm her breasts

She can apply a warm compress, or warm water, or have a warm shower.

• Stimulate her nipples

She can gently pull or roll her nipples with her fingers.

• Massage or stroke her breasts lightly

Some women find that it helps if they stroke the breast gently with their finger tips or with a comb.

Some women find that it helps to gently roll their closed fist over the breast towards the nipple.

• Ask a helper to rub her back.

Figure 20.1 A helper rubbing a mother's back to stimulate the oxytocin reflex

How to express breastmilk by hand

• Hand expression is the most useful way to express milk. It needs no appliance, so a woman can

do it anywhere, at any time.

• A woman should express her own breastmilk. The breasts are easily hurt if another person tries.

• If you are showing a woman how to express, show her on your own body as much as possible,

while she copies you. If you need to touch her to show her exactly where to press her breast, be

very gentle.



HOW TO PREPARE A CONTAINER FOR EXPRESSED BREASTMILK

• Choose a container for expressed breastmilk such as a cup, glass, jug, or jar with a wide mouth.

• Wash the cup with soap and water (she can do this the day before).

• Pour boiling water into the cup, and leave it for a few minutes. Boiling water will kill most of the germs.

• When ready to express milk, pour the water out of the cup.

HOW TO EXPRESS MILK BY HAND

• Teach a mother to do this herself. Do not express her milk for her. Touch her only to show her what todo, and be gentle.

• The mother should wash her hands thoroughly.

• Sit or stand comfortably, and hold the container near her breast.

• Put her thumb on her breast ABOVE the nipple and areola, and her first finger on the breast BELOWthe nipple and areola, opposite the thumb. She supports the breast with her other fingers (see figure20.2).

• Press her thumb and first finger slightly inwards towards the chest wall. She should avoid pressing toofar or she may block the milk ducts.

• Press her breast behind the nipple and areola between her fingers and thumb. She should press on thelarger ducts beneath the areola. Sometimes in a lactating breast it is possible to feel the ducts. Theyare like pods, or peanuts. If she can feel them, she can press on them.

• Press and release, press and release. This should not hurt -- if it hurts, the technique is wrong. At firstno milk may come, but after pressing a few times, milk starts to drip out. It may flow in streams if theoxytocin reflex is active.

• Press the areola in the same way from the SIDES, to make sure that milk is expressed from all segmentsof the breast.

• Avoid rubbing or sliding her fingers along the skin. The movement of the fingers should be more like arolling action.

• Avoid pressing on the nipple itself. Pressing or pulling the nipple cannot express the milk. It is the sameas the baby sucking only the nipple.

• Express one breast for at least three to five minutes until the flow slows. Express the other side andthen repeat both sides. She can use either hand for either breast, and change when they tire.

• Explain that to express breastmilk adequately takes 20-30 minutes, especially in the first few days whenonly a little milk may be produced. It is important not to try to express in a shorter time.



How often should a mother express her breastmilk?

It depends on the reason for expressing the milk, but usually as often as the baby would breastfeed.

To establish lactation, to feed a low-birth-weight (LBW) or a sick newborn she should start to

express milk on the first day, as soon as possible after delivery. She may only express a few drops of

colostrum at first, but it helps breastmilk production to begin, in the same way that a baby suckling

soon after delivery helps breastmilk production to begin.

She should express as much as she can as often as her baby would breastfeed. This should be at

least every three hours, including during the night. If she expresses only a few times, or if there are

long intervals between expressions, she may not be able to produce enough milk.

To keep up her milk supply to feed a sick baby: she should express at least every three hours.

To build up her milk supply, if it seems to be decreasing after a few weeks: express very often for

a few days (every two hours or even every hour), and at least every three hours during the night.

To leave milk for a baby while she is out at work: express as much as possible before she goes to

work, to leave for her baby. It is also very important to express while at work to help keep up her

supply.

Figure 20.2 How to express breastmilk

a. Place a finger and thumb each side of the areola and press inwards towards the chest wall.

b. Press behind the nipple and areola between your finger and thumb.

c. Press from the sides to empty all segments.

a b

c

To relieve symptoms, such as engorgement, or leaking at work: express only as much as is

necessary.

How to store breastmilk



STORAGE PLACE TEMPERA-

TUREDURATION

THE BEST OPTIONS FOR STORINGHUMAN MILK:

At room temperature 19-26°C 4 hours (ideal), up to 6-8 hours (acceptable)

• Glass or hard-sided plastic containerswith well-fitting tops.

• Containers should not be filled to thetop – leave an inch of space to allowthe milk to expand as it freezes.

• Put only 60 to 120 ml (two to fourounces) of milk in the container (theamount your baby is likely to eat in asingle feeding) to avoid waste.

• Do not bring temperature of milk toboiling point and do not use a mi-crowave oven to heat human milk.

• Place breastmilk container in a bowl ofhot water or run hot water over thebreastmilk container to warm storedbreastmilk.

In a refrigerator <4°C 3 days (ideal), up to 8days (acceptable)

In a freezer -18 to -20°C6 months (ideal), up to12 months (accept-able)

Session 21: Common BF difficulties


SESSION 21: COMMON BF DIFFICULTIES

Objectives:


1. Identify symptoms and causes of common BF difficulties and know how to support mothers in treatment and prevention.

Introduction:

• In previous sessions we have discussed ways to help mothers with BF.

• When helping mothers with difficulties you will need to use all the skills you have learned so far.Counselors and community health workers have important roles to support mothers through thesedifficulties, as mothers may not visit a health facility to seek help.

• The most commonly encountered BF difficulties include:

Insufficient milk.

Flat and inverted nipple.

Cracked nipple.

Engorgement.

Mastitis.

Crying baby – breast refusal.

Difficulty one: At a mother’s side

1. Not enough milk

SIGNS WHAT TO DO PREVENTION

Reliable signs

• Poor weight gain: less than500 grams per month

• Small amount of concen-trated urine: less than 6times per day

Possible signs

• Baby not satisfied afterbreastfeeds and cries often

• Very frequent breastfeeds

For mothers who really do not have enough milk

• Use your counseling skills to compile a goodfeeding history.

• Observe and assess a breastfeed to check po-sitioning and attachment

• Listen to the mother and family to identify if thereis any psychological problem or wrong belief.

• Solutions that you suggest to the mother mustdepend upon the cause of the insufficient milk.

• If possible, visit the mother and baby daily untilthe baby is gaining weight

• Disseminate andeducate motherson BF from preg-nancy.

• Skin-to-skin con-tact with motherto start BF withinan hour after birth

• Support motherwith correct posi-tioning right fromthe first breast-

2. Breast conditions



SIGNS WHAT TO DO PREVENTION

• Baby refuses to breastfeedor has very long breastfeeds

• Baby has hard, dry, or greenstools

• No milk comes out when themother expresses

• Breasts did not enlarge dur-ing pregnancy

• Milk did not ‘come in’ afterdelivery

For mothers who perceive that their babies donot get enough milk but in fact, they do getenough.

• Signs of the child: no signs detected as identifiedin the left column. The child gains weight well,passes urine regularly, and does not cry often.

• Identify the reasons why the mother doubts herability to produce enough milk.

• Based on what is being identified, provide appro-priate solutions and support.

• Arrange follow-ups with mothers as soon as pos-sible and provide more support to prevent moth-ers from giving complementary foods.

feed.

• Breastfeed exclu-sively on demandduring the dayand night.

• Encourage agood diet for themother from preg-nancy and duringthe BF period.

PROBLEMS - SIGNS WHAT TO DO PREVENTION

Flat and inverted nipple • Build confidence for the mother by explainingthat a baby suckles from the breast – not fromthe nipple; that the mother should breastfeedmore because, when the baby breastfeeds, hewill stretch her nipple out.

• Encourage the mother to position the baby atthe breast early after delivery, and urge her tobe patient before the milk comes in and herbreasts are full.

• Show the mother how to make the nipple stretchout by herself before a feed; this will help a babyto attach better.

• Show the mother how to shape the breast bysupporting her breast from underneath with herfingers, and press the top of the breast gentlywith her thumb; this will help the areola and nipple to stretch out so that the baby can attachbetter.

• If the breasts are full of milk: express breastmilkand feed it to the baby with a cup. Continue tobreastfeed the baby until the breasts are released (the baby attaches better and nipplecondition is improved).

• In complicated cases, use the syringe method(cut through the barrel of the syringe at the nozzle end, place the plunger in the cut end, restthe uncut end on top of the nipple and pull theplunger to protract your nipple).

Before delivery:

• If inverted nipple is iden-tified early during preg-nancy, instruct mothershow to stretch the nippleor wear nipple shells.

• Most nipples improvearound the time of deliv-ery without any treat-ment.

• Help a mother to initiateBF early after delivery.



PROBLEMS - SIGNS WHAT TO DO PREVENTION

Sore or cracked nipple

• Cracks across top of nipple or around base

• Occasional bleeding• May become infected

• Do not stop BF.• Improve attachment. Begin to breastfeed on the

side that hurts less.• Vary BF positions.• Let the baby come and attach to the breast by

him/herself.• Apply drops of breastmilk to nipples and allow

them to air dry.• Do not use soap or cream on nipples.• Do not wait until the breast is full to breastfeed.• Continue to breastfeed the baby and do not use

bottles.

• Good attachment. • Do not use feeding

bottles (suckling from abottle is easier than suck-ling from a mother’sbreasts so the baby mayrefuse the breast).

• Do not let the breasts gettoo full.

• Do not use soap orcreams on nipples.

Engorgement – blocked duct

Symptoms:• Swelling

• Warmth

• Slight redness

• Pain

• Skin shiny and tight andnipple flattened

• Usually begins on the 3rd-4th day after birth

• Apply cold compresses to breasts to reduceswelling.

• Breastfeed more frequently and offer bothbreasts.

• Improve attachment.• Gentle stroking of breasts helps to stimulate milk

flow (in the community, mothers often use acomb and gently comb the breast towards thenipple).

• Press around the areola to reduce edema andto help baby to attach.

• Express milk to relieve pressure until baby cansuckle.

• Help the baby to attachwell in the first breast-feed.

• Put the baby skin-to-skinwith the mother and startBF within an hour of birth.

• Breastfeed frequently ondemand/cue both dayand night: 10 -12 timesper 24 hours.

• Express unused breast-milk after each breast-feed.

Plugged Ducts and Mastitis

Symptoms of Mastitis• Hard lump, severe pain,

redness in one area,swelling, and no fever.

Symptoms of pluggedducts• Hard swelling. • Severe pain. • Redness in one area.• Generally not feeling well. • Fever.

• Continue BF (if breastmilk is not near the ab-scess let the baby feed more frequently and asoften as s/he will).

• Apply a warm compress (if mastitis is not de-tected).

• Hold the baby in different positions, so that thebaby’s tongue/chin is close to the site of theplugged duct/mastitis (the reddish area). Thetongue/chin will massage the breast and releasethe milk from that part of the breast.

• Ensure good attachment.• Apply gentle pressure to the breast with the

palm of your hand, rolling fingers towards nipple.Then express milk or let the baby feed every twoto three hours day and night.

• Rest (mother).• Drink more liquids (mother).• If there is no improvement in 24 hours, refer the

mother to a health facility.

• Ensure good attachment.• Breastfeed on demand/

cue, and let infants finish/come off the breastby him/herself.

• Avoid tight clothing. • Get support from the fam-

ily to perform non-infant-care chores so that themother has more timewith her baby – ensurethat the baby is breastfedon demand.

• Avoid holding the breastwith a scissors hold be-cause this will preventmilk flow.

Difficulty two: A crying baby

• We will discuss another common reason for a mother to stop BF – a crying baby. Many mothersgive complementary food or fluid because their baby cries. This additional food and drink oftendoes not make a baby cry less. Sometimes a baby cries more.

• A baby who cries a lot can upset the relationship between him/her and his/her mother, and causestension among other members of the family.

• An important way to help a BF mother is to counsel her on this problem.



REASONS WHY BABY CRIES

Discomfort (Dirty, hot, cold)

Tiredness (Too many visitors)

Illness or pain (Changed pattern of crying)

Hunger (Not getting enough milk, growth spurt)

BF refusal

Colic

Reasons why a baby cries

• Hunger due to a growth spurt: a baby seems very hungry for a few days, possibly because heis growing faster than before. He demands to be fed very often. This is most common at the agesof about two weeks, six weeks, and three months, but can occur at other times. If he suckles oftenfor a few days, the breastmilk supply increases, and he breastfeeds less often.

• Mother's food: sometimes a mother notices that her baby is upset when she eats a particularfood. This is because substances from the food pass into her milk. It can happen with any food,and there are no special foods to advise mothers to avoid, unless she notices a problem.

• Colic: some babies cry a lot without one of the above causes. Sometimes the crying has a clearpattern. The baby cries continuously at certain times of day, often in the evening. He may pull uphis legs as if he has abdominal pain. He may appear to want to suckle, but it is very difficult tocomfort him. Babies who cry in this way may have a very active gut, or wind, but the cause is notclear. This is called ‘colic’. Colicky babies usually grow well, and the crying usually becomes lessafter the baby is three months old.

• “High needs” babies: some babies cry more than others, and they need to be held and carriedmore. In communities where mothers carry their babies with them, crying is less common than incommunities where mothers like to put their babies down to leave them, or where they put themto sleep in separate cots.



a. Holding the baby along

your forearm.

b. Holding the baby on

your lap. Embrace his

abdomen.

c. Father holding the baby

against his chest.

How to help mothers whose babies cry a lot

• As with “not enough” milk, you have to try to find the cause of the crying so that you can help themother. Use your counseling skills to compile a good history. Help the mother to talk about howshe feels and empathize with her. She may be tired, frustrated, and angry.

• Accept her ideas about the cause of the problem and how she feels about the baby. Try to learnabout pressures from other people and what they think is the cause of the crying.

• Assess a breastfeed to check the baby’s position, attachment and the length of a feed.

• Make sure the baby is not ill or in pain. Check the growth and refer if necessary. Where relevant,tell the mother that her baby is growing well and is not ill, bad, or naughty.

• Demonstrate ways to carry and comfort a crying baby. Give relevant information to the mother.

• Avoid using a bottle, teat, or pacifiers.

• Talk to other family members to decrease the pressure so that mother doesn’t have to give unnec-essary complementary foods.

• Advise the mother to breastfeed the baby more often to increase the production of breastmilk tomeet the baby’s demand.

Some different ways to hold a colicky baby



FURTHER READING:

Breast refusal

• In some communities breast refusal is a common reason for stopping BF. However, it need notlead to the complete cessation of BF, and can often be overcome. Refusal can cause great distress to the baby's mother. She may feel she has failed at BF.

• There are different kinds of refusals as follows:

Sometimes a baby attaches to the breast, but then does not suckle, or suckles very weakly.

Sometimes a baby cries and fights at the breast, when his mother tries to breastfeed him.

Sometimes a baby suckles for a minute and then comes off the breast crying. He may dothis several times during a single feed.

Sometimes a baby takes one breast, but refuses the other.

• You need to know why a baby is refusing to breastfeed, before you can help the mother andbaby to enjoy BF again.

• Reasons why babies refuse to breastfeed:

The baby is ill, sedated, or in pain.

Difficulty with BF technique.

Changes which upset the baby.

Apparent, not real, refusal.



CAUSES OF BREAST REFUSAL

Illness, pain, or sedation

Infection

Brain damage

Pain from bruising (vacuum, forceps)

Blocked nose

Sore mouth (thrush, teething)

Difficulty with BF technique

Use of bottles and pacifiers while BF

Not getting enough milk (e.g., poor attachment)

Pressure on the back of the head when positioning

A mother shaking her breast

Restricting the number of feeds

Difficulty coordinating the breastfeed

Change that upsets the baby(especially when aged 3-12months)

Separation from her mother (e.g., if mother returns to work)

New caregiver or too many caregivers

Change in the family routine

Mother is ill

Mother has a breast problem – e.g., mastitis

Mother is menstruating

Change in the smell of the mother

Apparent refusal

Newborn – rooting

Age 4-8 months – distraction

Above one year – self-weaning

How to help mothers whose babies refuse the breast



HELPING A MOTHER AND BABY TO BREASTFEED AGAIN

Help the mother to do these things:

• Keep her baby close – no other caregivers: Give plenty of skin-to-skin contact at all times, not just at feeding times.

Sleep with her baby.

Ask other people to help with housework.

• Offer her breast whenever her baby is willing to suckle:When her baby is sleepy, or after a cup-feed.

When she has time.

• Help her baby to take the breast using the following ways:Express breastmilk into his mouth.

Position him so that he can attach easily to the breast – try different positions.

• Feed her baby by cup:Give her own expressed breastmilk if possible. If necessary, give artificial feeds.

Avoid using bottles, teats, or pacifiers.

Other situations that can affect BF

1. The mother is sick:

• When a mother has a headache, pain in her back, a flu, diarrhea, or other common diseases(malaria, anemia, cholera, etc.), she SHOULD CONTINUE BF.

• The mother should relax and drink more water to help her body recover.

• If there is no improvement, she should go for a health check and tell the health staff that she is BF.

2. Light-weight baby:

• The mother needs to help her baby attach well to the breast and hold her baby.

• How to breastfeed: breastfeed long and slowly, keep the baby near the breast.

• In the first few weeks, the baby may not be able to suckle directly from mother’s breast so themother is encouraged to express breastmilk and feed her baby by cup and spoon

• If the baby sleeps too much, pick him up gently in order to wake him up for BF.

• Crying is the last sign of hunger. Early signs of hunger include the combination of the followingthings: alertness and restless, mouth open and head moving, tongue turning outwards and inwards,sucking his/her fingers. If there is only one of these signals, it is not certain that the baby is hungry.

3. The mother has malnutrition:

• She should eat more to get better (the mother eats to breastfeed her baby).



• She needs vitamin A within six weeks after delivery and micronutrient supplements daily if available.

• The mother secretes more breastmilk if she breastfeeds her baby frequently.

4. Twins:

• The mother can exclusively breastfeed both babies if they are frequently breastfed and well attached to the breast.

• The more the baby suckles, the more breastmilk is secreted.

• Twins need early BF after delivery, if the babies are unable to latch on immediately, help the motherto express her breastmilk and feed them by a cup. Try to stimulate breastmilk production early tomake sure the breasts can secrete enough milk for both babies.

5. The mother becomes pregnant again:

• In most countries, when a mother gets pregnant again, she often stops BF her baby. She usuallythinks that BF during the pregnancy period can affect one of the two babies. Sometimes, a mother’snipple is sensitive when she is pregnant. However, BF both babies is completely safe and has noharm to them and the mother has enough breastmilk for both of them.

• If the baby is under one year old, continued BF is good for him/her in order to maintain good health,growth, and development.

• The mother is encouraged to eat more meals per day to have good health, support BF and nurturethe fetus.

6. The mother is stressed

• The quality of breastmilk is not affected and milk secretion is not reduced if the mother is stressed.However, breastmilk can temporarily come in infrequently.

• If she continues BF, milk flow will recover.

• Often keep the mother and baby together if the mother agrees

• Comfort and encourage the mother, enable her to talk, and provide spiritual and practical support.

• She should rest and breastfeed her baby.

• She should drink warm water to relax and support breastmilk secretion.

7. Mother is away from the baby

• When the mother is not at home, she should express and store breastmilk to feed her baby at timeof a normal breastfeed.

• Instruct the caregiver to feed the baby with safely expressed breastmilk

• The mother should sleep with her baby in order to frequently BF at night when she is at home

• If the mother can take her baby to her work place, continue BF frequently.

Session 22: Field practice


SESSION 22: FIELD PRACTICE

Objectives:


1. Use appropriate listening and learning skills when counseling mothers on IYCF.

2. Assess a breastfeed with a Breastfeed Observation Job Aid.

3. Illustrate how to help a mother with good positioning and attachment.

The following notes summarize the instructions for your tasks in a field practice that the trainer will tell

you about. Try to spend some time reading these notes to remind youself of what you have to do during

the practice. In the field practice, you will work in a small group and take turns talking to mothers while

the others observe.

Trainees should bring:

• Four Breastfeed Observation Job Aids.

• Four counseling-skills checklists.

• Pencils, notebooks.

• No books.

If you are the one who talks to the mother:

• Introduce yourself and ask for the mother’s permission to talk to her. Introduce your group and

explain to the mother that you are interested in child feeding. Find a chair to sit down. You can sit

on mother’s bed if needed and if allowed.

• If the baby is suckling, ask the mother to continue BF. If not, ask the mother to breastfeed as usual

whenever the baby wants to suckle. Ask for the mother’s permission so that the whole group can

observe a breastfeed.

• Before or after a breastfeed, you should ask the mother several open-ended questions to start

such as: how the mother feels, how the baby is, how a breastfeed works. Encourage the mother

to talk about herself and her baby. Praise two things that the mother and baby do right. Provide

two necessary bits of information relevant to her situation. Practice counseling skills as much as

possible.

• Helping the mother to position her baby and to overcome difficulties is an important part of field

practice. Usually, the baby feels sleepy. In case that a baby is sleeping, you can say that “I knowthat your baby is sleepy but can we talk about how to hold a baby until he wakes up?” Then show



Summary

Remember all skills learned so that you can help mothers in different situations: listening and learning,

building confidence and giving support, assessing a breastfeed, helping a mother with positioning and

attachment, and taking details of feeding history.

In many cases, there is no treatment. Therefore, it is important that you give appropriate suggestions

and information to help mothers.

the mother four key points of positioning. By doing so, the baby may wake up and want to suckle

when his nose touches the mother’s breast.

If you are an observer:

• Stand and keep quiet. Try to be as quiet as possible. Give no comments and do not talk.

• Generally observe the mother and baby. Pay attention to: is the mother happy? Does she have

formula milk or is she bottle-feeding? Generally observe the conversation between the mother and

the trainee. Pay attention to: who talks the most? Is the mother comfortable and interested?

• Specifically observe the counseling skills of the trainee who is practicing, including non-verbal com-

munication. Mark with a ( ) in the checklist of counseling skills if any skill is in use in order to help

the discussion. Notice if the trainee makes any mistakes – for example, using judging words or

asking a lot of closed-ended questions that the mother can only answer with “yes” or “no”.

• Keep quiet while observing the mother and baby during a breastfeed. When observing, make

notes in the Breastfeed Observation Job Aid. Write the mother and baby’s names, mark a ( ) beside

each sign that you see and note down the duration of the breastfeed.

• Thank the mother after the conversation and say something to praise and support her.

MISTAKES TO AVOID

Do not tell her that you are paying attention to her BF

The mother’s behavior may change and she may feel uncomfortable if she feeds her baby formula milk.You should say that you are interested in “child feeding” or “child- feeding techniques”.

Be careful not to turn forms into barriers

While talking to the mother, do not note down anything. Trainees should use forms to remind themselvesof what to do and to record later what they want to remember. Trainees who are observing are allowed tonote things down.

CHECKLIST OF INDIVIDUAL-COUNSELING SKILLS ON IYCF



SKILLS ACTIVITIESNOT

DONENOT DONE

WELLWELL-DONE

1

Introduction–

a createwarm andfriendly

environment

Greet mothers

Introduce yourself

Make eye contact

Smile

Show respect

2Identify

current prob-lems /issues

Listen

Be non-Judgmental

Ask open-ended questions


3 Analyze/assess


Identify priority if there is more than one problems

Ask more open-ended questions to identify barriers

Respond to mother’s question

4

Makepractical

recommen-dation


Build confidence


Use counseling cards/ materials

5

Negotiatebehavior –

get commit-ment


Let mothers decide the solution

Get mother’s commitment to try 1-2 recommen-dations

6 Summary -Closing

Ask mother to repeat recommendation

Correct recommendation as appropriate

Arrange follow-up with mothers

Praise and thank mothers

SESSION 23. IMPORTANCE OF CF

Objectives:


1. Explain the importance of continued breastfeeding.

2. Define complementary feeding (CF).

3. Explain why there is an optimal age for children to start CF.

Definition of CF

• CF means giving other soft, semi-solid, or solid foods in addition to breastmilk.

• These foods are called complementary foods.

Note: Powdered milk (formula) and other fruit juice are not considered to be complementary foods.

• These additional foods and liquids are called complementary foods, because they are complemen-

tary to breastmilk and do not totally replace breastmilk. Complementary foods must be nutritious

and in adequate supply so the child can continue to grow.

• During the CF period, the young child gradually becomes accustomed to eating family foods. Feed-

ing includes more than just the foods provided for the child. How the child is fed can be as important

as what the child is fed.

The optimal age to start CF

• Our body uses food for energy to keep it alive, to grow, to fight infection, to move around, and to

be active. Food is like the wood for the fire – if we do not have enough good wood, the fire does

not provide good heat or energy. In the same way, if young children do not have enough good

food, they will not have the energy to grow and to be active.

• The following chart demonstrates the daily energy demands of a child by age.

Session 23. Importance of CF


• After six months, babies need to learn to eat semi-solid soup or mashed foods. These foods fill the

energy gap more than liquids do.

• The following signs show that the baby is ready for complementary food:

Reaching for food when others are eating.

Putting something to his/her mouth.

Can control their tongue better to move food around their mouth.

Starting to chew and move his/her jaw up and down.

• In addition, at this age, a baby’s digestive system is mature enough to begin to digest a range of

foods.

• Most babies need CF at 6 months of age. Therefore, the mother should be counseled on how to

prepare complementary food and how to feed the child in the first feed when the baby is about five

months of age. This will help the mother to have sufficient information and the skills to practice CF

when the baby is six months old.

• On this graph, each column represents the total energy needed at that age. The columns become

taller to indicate that more energy is needed as the child becomes older, bigger, and more active.

The dark part shows how much of this energy is supplied by breastmilk.

• From about six months onwards there is a gap between the total energy needs and the energy

provided by breastmilk. The gap increases as the child gets bigger. Therefore, for most babies, six

months of age is a good time to start complementary foods.



00-2 m 3-5 m 6-8 m 9-11 m 12-23 m

200

400

600

800

1000 Energy Gap

Energy frombreast milk

Energ

y (k

cal/d

ay)

ENERGY REQUIRED BY AGE AND THEAMOUNT SUPPLIED FROM BREAST MILK

Age (months)

Starting complementary foods in addition to breastmilk at 6 months

helps a child to grow well

• If the baby is not breastfed, continue to use appropriate breastmilk substitutes until the child is 6

months of age; do not be in a hurry when feeding him/her complementary foods.

Risks of starting CF too soon

Adding complementary foods too early may:

• Make the baby breastfeed less, which will reduce the precious source of nutrients, especially vita-

min A and minerals.

• Increase the risk of illness due to the lack of protective factors found in breastmilk.

• Increase the risk of diarrhea because complementary food is not as clean or easy to digest as

breastmilk.

• Increase the risk of allergies because the baby cannot digest proteins from complementary food.

• Increase the mother’s risk of another pregnancy because the baby breastfeeds less.

Risk of starting complementary foods too late

Adding foods too late is also a risk because:

• The child does not receive the necessary nutrients to fill the nutrient gap from breastmilk, especially

the iron gap.

• The child grows slowly.

Note: we still need to breastfeed the baby until at least 24 months because at this age, breastmilk stillprovides about 50% of the energy required for the baby, and also continues to be an important sourceof energy, vitamins, and minerals such as vitamin A.

See the chart below to understand why the baby needs to be breastfed up to 24 months of age.



Gap

Provided by550mlbreast milk

0%

25%

50%

75%

100%

Pe

rce

nta

ge

of

da

ily n

ee

ds

Energy Protein Iron Vitamin A

Nutrient

BREAST MILK IN SECOND YEAR OF LIFE


Continued BF

• Babies should be exclusively breastfed for the first 6 months.

• From 6-12 months, BF continues to provide half or more of the child’s nutritional needs, and from

12-24 months, at least one-third of their nutritional needs. In addition, breastmilk continues to

provide protection for the child against many illnesses and provides more than 50% of the total

amount of vitamin A that a child needs each day.



BF for two years or longer helps a child to develop and to grow

strong and healthy

Summarize the lesson

• A baby’s nutritional status affects his/her health. A baby’s health condition includes not only devel-

opment and growth but also the baby’s ability to fight against diseases and recover after illness.

• In order to ensure that a baby is always healthy and grows well, the mother needs to ensure:

All infants are breastfed for the first six months.

All infants and young children are given complementary food at six months.

All young children continue to be breastfed up to 24 months.

SESSION 24: CF - QUANTITY AND QUALITY

Objectives:


1. Present the quantity of complementary foods, including frequency and amount.

2. Explain reasons for using foods of a thick consistency.

3. Describe ways to enrich foods.

4. Explain the importance of using a variety of foods, including iron- and vitamin A- rich foods.

1. Principles of CF

• Start giving complementary food at an appropriate age (start at 6 months – 180 days), not too early

or too late. Continue BF as much as possible.

• Start with liquid food and move to solid food, from a little to bigger amounts, and help the baby get

acquainted with new food (not providing diluted food for more than two weeks).

• Number of meals should increase according to the child’s age. Ensure that the food suits the baby’s

appetite.

• Make the food tender for easy eating and swallowing.

• Prepare mixed food rich in nutrients using locally available food. Add different food to the baby’s

semi-solid soup and porridge to make the food colorful, delicious, attractive, and sufficient in

nutrients. For example, add egg yolk for a yellow color, add vegetables for a green color, add meat,shrimp, or crab for a brown color. You should not give the baby the same food more than once ina day.

• Thicken the complementary food. Add oils, fat, sesame, or peanut in the complementary foods to

provide more energy, helping the baby to grow fast or add micronutrient powder.

• The cooking tools must be clean and hands must be washed before preparing meals and feeding

the child.

• Give the child more complementary food during and after the child’s illness and give the child more

liquid food/drink especially after a bout of diarrhea or a high temperature.

• You should not give MSG to a child; MSG is not nutritious.

• Do not give the child confectionery sugars or soft drinks before meals because the sweetness will

increase blood sugar, inhibiting the extracting enzyme so that child lose his/her appetite and skips

the meal or takes less food.

Session 24: CF - Quantity and Quality


3. Consistency of complementary food to fill energy gap

• All foods provide some energy. However, each locality has different types of staples available (soup,porridge, etc.). In general, all staples provide protein and other nutrients, but they cannot provide

all the nutrients needed on their own. The staple must be eaten with other food (meat, fish, veg-etables, etc.) for a child to get enough nutrients.

• It is important that you know and use the food available in your area to prepare complementary

food that is appropriate for your children by their age.

As the child gets older, the amount of food offered increases. Give as much as the child will eat with

active encouragement.

2. Quantity of complementary food: frequency and amount

When a child starts to eat complementary food, he/she needs time to get accustomed to that food. The

child needs to learn how to eat and the family should accustom the child to gradually increased

amounts of food, starting with two to three small spoonfuls of the food twice a day.



AMOUNT OF FOOD

Age Texture Number of meals/day Amount of food at each meal

6- 8 months Mashed family food 2-3 meals + 1-2 snacks +

frequent BF

Start with 2-3 tablespoons perfeed Increasing gradually to 1/2

of a 250 ml-sized bowl

9 -11months

Finely chopped food,mashed food, and foodthat a baby can pick up

3-4 meals + 1-2 snack + BF 1/2 of a 250 ml-sized bowl

12-23months

Family food, mashed orchopped if necessary

3-4 meals + 1-2 snacks + BF ¾ to one 250 ml-sized bowl

The amount of food above is given for the BF child. If the child is no longer given breastmilk, give an additional1-2 cups of milk/day and 1-2 extra meals/day.

All infants (6-24 months) are fed the recommended

number of meals daily

• The child’s stomach is very small. At the age of 8 months, a baby’s stomach can hold about 200

ml at one time. Liquid and diluted foods quickly fill up the baby’s stomach so that the baby does

not receive enough nutrients. This explains why consistency of complementary food is of concern.

• Thickness of food makes a big difference in meeting a baby’s energy needs.



FOOD WITH APPROPRIATE CONSISTENCY PROVIDES MORE

ENERGY FOR BABIES

Rightconsistency Too thin

Ways to enrich a child’s food

Food can be made more energy- and nutrient-rich in a number of ways:

• For a porridge or other staple:

Prepare with less water and make a thicker porridge as we just saw. Do not make the foodthin and runny.

Toast cereal grains before grinding them into flour. Toasted flour does not thicken so much, soless water is needed to make porridge

• For beans, vegetables, meat, and fish: mash/chop into a thick puree and feed to the child insteadof the liquid part of the soup.

• Add energy- or nutrient-rich food to the porridge or semi-solid soup:

Replace some (or all) of the cooking water with fresh or soured milk or coconut milk.

Add a spoonful of milk powder after cooking.

Mix legumes, pulses, or bean flour with the staple flour before cooking.

Make it thick with peanut or sesame flour.

Add a spoonful of margarine, fat, or oil.

FURTHER READING:

Fats and oils

• Oils and fats are concentrated sources of energy. A little oil or fat, such as one-half

teaspoon, added to the child’s bowl of food, gives extra energy in a small volume. The

addition of fatty/oily foods also makes thicker porridge or other staples softer and

easier to eat.

• Fats and oils can also be used for frying foods, or spreading on foods such as bread.

The fat or oil should be fresh because fats and oils can go bad when stored.

• If a large amount of oil is added, the child may become full before he has eaten all of

the food. This means the child may get the energy from the oil but less of the other

nutrients because the child eats less food overall.

• If a child is growing well, extra oil is usually not needed. A child who eats too much oil

or fried foods can become overweight.

• Sugar and honey are also energy-rich and can be added to foods in small quantities

to increase the energy concentration. However, these foods do not contain any other

nutrients.

• Caregivers need to watch that sugary foods do not replace other foods in the diet. For

example, sweets, sweet biscuits, and sugary drinks should never be used instead of

a meal for a young child.

• Essential fatty acids are needed for a child’s growing brain and eyes, and for healthy

blood vessels. These essential fatty acids are present in breastmilk.

• For children over six months old, who are not breastfed, good sources of essential

fatty acids are fish, seeds, and vegetable oil. Animal-source foods also provide

essential fatty acids.

Fermented or germinated flour

• Fermented porridge can be made in two ways – the grain can be mixed with water

and set to ferment overnight or longer before cooking, or the grain and water are

cooked into porridge and then fermented. Sometimes some of a previous batch of the

fermented porridge is added to speed up the process of fermentation. Porridge made

from germinated grain can also be fermented.

• The advantages of using fermented porridge are:



It is less thick than plain porridge so more grain/flour can be used with the same

amount of water. This means each cupful of porridge contains more energy and

nutrients than plain (unfermented) porridge.

Children may prefer the taste of “sour” porridge and therefore eat more.

The absorption of iron and some other minerals is better from fermented porridge.

It is more difficult for harmful bacteria to grow in fermented porridge, so it can be

kept for a day or two.

• Grain is also fermented to make alcohol. However, the short fermentation period talked

about here to make fermented porridge will not make alcohol or make the child drunk!

Germinated or sprouted flour

• Cereal or legume seeds are soaked in water and then left to sprout. The grains are

then dried (sometimes toasted) and ground into flour. A family can do this at home but

it is more common to buy flour already germinated.

• Mixed flours that include germinated flour in addition to the main flour may be available

in the store.

• If families in your area use germinated flour, the following ways can make a thicker

and more nutritious semi-solid soup:

Use this germinated flour to make semi-solid soup. This type of flour does not

thicken much during cooking so less water can be used.

Add a pinch of the germinated flour to cooked thick semi-solid soup that has

cooled a little bit. Semi-solid soup should be boiled again for a few minutes after

adding the germinated flour. This addition will make the semi-solid soup softer and

easier for the child to eat.

• Germinated flour also helps more iron absorption.



4. Components of complementary food

To ensure that all children receive diverse foods, each complementary feed should include the following

food groups:

• Basic food: include food that provides the main calories in the diet. In our country, rice, corn, and

sweet potato are often made into paste for the child to eat.

• Food rich in protein:

Animal-source food: rich in nutrients, including eggs, milk, meat, shrimp, crab, eel, pupa, and

organs such as liver. Pork, beef, chicken, not necessarily lean meat, can be given to a baby

but it is better to give children both lean and fat meat.

Food from plants: including all kinds of pulses such as black beans, green beans, soy beans,

etc., of which soy beans are the richest in protein and lipid. When these foods are mixed with

cereals, they become as nutrient-rich as animal-source foods – but are cheaper.

• Food rich in energy: including oil, butter, fat, sugar, etc. Oil and fat provides energy for the child’s

meal. They also make food softer and easy to swallow. In addition to animal fat, a child should be

given more peanut oil, sesame oil, soya oil, and so on. Oil contains more unsaturated fatty acids

than fat does so it is easily absorbed. Feeding a child with fat and oil helps him easily absorb vita-

mins saturated in oil such as vitamin A, E, D, K, etc.

• Food rich in vitamins, minerals, and fiber: Green vegetables and ripe fruit have a significantly

abundant supply of vitamins and minerals. This is a very good source of food for children. Dark-

green leaves such as “rau ngot”, “rau muong”, “rau den”, “mong toi”, “rau cai”, etc. are all rich in

vitamin C and micronutrients like beta-caroten (pre-vitamin A) and iron, preventing a baby from

having dry eyes and anemia. Ripe fruit (papaya, mango, banana, orange, mandarine, sapodilla...)is rich in micro-nutrients, which are not lost because no cooking is needed.

Food selection and substitution

For areas with disadvantaged economic conditions such as remote and mountainous areas, compo-

nents of complementary food for babies can be replaced as follows:

• Rice replaced by corn or sweet potato.

• In protein-rich foods: meat and eggs replaced by shrimps, crabs, fish, and cow milk replaced with

soya milk.

• Animal-protein substitution: protein from meat, eggs, milk, shrimps, crabs, or fish can replaced by

protein from plants: soy-beans, green beans, black beans, sesame, or peanuts.

• Oil replaced by fat.

5. Importance of using diverse foods

• Most adults and older children eat a mixture or a variety of foods at mealtimes. In the same way,

it is important for young children to eat a mix of good complementary foods.

• To give more energy to children, snacks can be given to them in addition to meals. Good snacks

– such as yoghurt and other milk products, bread or biscuits spread with butter, margarine, nut

paste or honey, fruit, bean cakes and cooked potatoes, etc. –provide both energy and nutrients.

Note: snacks should not be confused with junk food such as sweets, fried potatoes, or other products.



• Dark-green vegetables or orange-colored fruits or vegetables and animal-source food should be

given to children daily in addition to the staple food. Animal foods are special foods for children.

These foods should be eaten every day, or as often as possible. The gaps in iron and energy may

be the hardest to fill. If cooked food fortified with iron is available, this could be used to help fill the

iron gap.

• If an iron-rich food is not available, health staff need to motivate the family to give iron or micronu-

trient supplements to their children.



All children are given diverse foods (with four food groups or more)

6. Foods to fill gaps for Iron

Why the iron gap needs to be filled in the child’s diet

• Young children need iron to make new blood, to assist in growth and development, and to help the

body to fight infections.

Abso

rbed ir

on

(mg/d

ay)

0

0-2 m 3-5 m 6-8 m 9-11 m 12-23 m

0.4

0.8

1.2

Age (months)

Iron gap

Iron frombirth stores

Iron frombreast milk

GAP FOR IRONABSORBED IRON NEEDED AND AMOUNT PROVIDED

• In this graph:

The top of each column represents the amount of absorbed iron that is needed per day by

children.

The plaid area is the amount of stored iron from birth (enough for the first six months).

FURTHER READING:

Iron absorption: The amount of iron that a child absorbs from food depends on:

• The amount of iron in the food.

• The type of iron (iron from meat and fish is better absorbed than iron from plants).

• The types of other food present in the same meal (some increase iron absorption andothers reduce absorption).

• Whether the child has anemia (more iron is absorbed if anemic).

Eating these foods at the same meal increases the amount of iron absorbed from eggsand plant foods such as cereals, pulses, seeds, and vegetables:

• Food rich in vitamin C such as tomato, broccoli, guava, mango, pineapple, papaya,orange, lemon, and other citrus fruit.

• Small amounts of the flesh or organs/offal of animals, birds, fish, and other sea foods.

Iron absorption is decreased by:

• Drinking tea and coffee.

• Eating food high in fiber.

The black area along the bottom of the columns shows the iron provided by breastmilk (thebaby must be breastfed).

The white area illustrates the iron gap that needs to be filled with complementary food.

• A full-term baby is born with good stores of iron to cover his needs for the first 6 months.

• The young child grows faster in the first year than in the second year. This is why the need for iron

is higher when the child is younger.

• The iron store is gradually used up over the first 6 months. So after that time we see a gap between

the child’s needs and the iron they receive from breastmilk.

• Zinc is another nutrient that helps children to grow and stay healthy. It is usually found in the same

foods as iron, so we assume that if they are eating food rich in iron they are also receiving zinc.

Health workers’ aims are:

• To identify locally available food that is rich in iron.

• To instruct families to use these iron-rich foods to complement the food for their young children.

Iron absorption

Pulses and dark-green leaves are sources of iron. However, it is not enough that a food has iron in it.

The iron must also be in a form that the child can absorb and use.





7. Foods that can fill Vitamin A gap

Another important nutrient is vitamin A, which is needed for healthy eyes and, skin and to help the body

fight infections.

Vit

amin

A (

g R

E/da

y)

0

0-2 m 3-5 m 6-8 m 9-11 m 12-13 m

100

200

300

400

Age (months)

Vitamin Agap

Vitamin Afrom birthstores

Vitamin Afrom breastmilk

GAP FOR VITAMIN AVITAMIN A NEEDED AND AMOUNT PROVIDED

• The top of each column in this graph represents the amount of vitamin A needed by a child each

day. Breastmilk supplies a large part of the vitamin A required, provided the child continues to

receive breastmilk and the mother’s diet is not deficient in vitamin A. As a young child grows, vitamin

A intake must be bolstered with complementary foods

• Good vitamin A-rich foods include dark-green leaves, yellow-colored vegetables, and fruit. Other

sources of vitamin A already mentioned include:

Organ foods/offal (liver) from animals.

Milk and food made from milk such as butter, cheese, and yoghurt.

Egg yolks.

Margarine, dried milk powder, and other foods fortified with vitamin A.

• Vitamin A can be stored in a child’s body for a few months, but encouraging families to consume

vitamin A-rich food as often as possible is ideal, preferably every day. A variety of vegetables and

fruit in the child’s diet help to meet many nutrient needs.

• It is important to remember that breastmilk provides a significant amount of vitamin A for a child. If

the baby is not breastfed, s/he especially needs a vitamin A-rich diet.

• Health workers should notice the availability of local foods.

• If health workers know about these foods, they can discuss using these foods for children with

families.

Dark-green leaves and yellow-colored vegetables help the baby to have

healthy eyes and fight against infections

FURTHER READING:

The importance of animal-source foods

• Foods from animals, meat, and organs such as liver, heart, and blood, as well as milk,yoghurt, cheese, and eggs are rich sources of many nutrients.

• The meat and organs of animals, birds, and fish (including shell fish and tinned fish),as well as blood-source foods, are rich in iron and zinc. Liver is not only a good sourceof iron but also of vitamin A.

• Animal-source foods should be eaten daily or as often as possible. This is especiallyimportant for the non-breastfed child.

• Foods from animals such as milk and eggs are good for children because they arehigh in protein and other nutrients. However, milk and milk products, such as cheeseand yoghurt, are not good sources of iron.

• Milk fat contains vitamin A. Therefore, foods made from whole milk are good sourcesof vitamin A.

• Foods made from milk (whole milk, skim milk, or powdered milk) and any food containing bones, such as pounded dried fish, are good sources of calcium to helpbones grow strong.

• Egg yolk is another source of nutrients and rich in vitamin A.

• Only animal-source foods can provide enough iron needs for children. Foods suchas flour, pasta, and instant cereals are also a good iron source for children. Some children may need supplements if they do not eat enough food containing iron, or ifthey have particularly high iron needs.

• Ideal practice: All infants and young children are fed meat, fish, or poultry daily. Allchildren are given iron-rich food and iron supplements daily.

The importance of legumes

Legumes or pulses such as beans, peas, and lentils, as well as nuts and seeds, are goodsources of protein. Legumes are a source of iron as well. Beans, peas, lentils, nuts, orseeds are all good for children.

Some ways these foods could be prepared that would be easier for the child to eat and digest are:

• Soak beans before cooking and throw away the water.



• Remove skins by soaking raw seeds and then rub the skins off before cooking them.

• Boil beans, then sieve to remove coarse skin.

• Toast or roast nuts and seeds and then pound them into a paste.

• Add beans/lentils to soups or stews.

• Mash cooked beans.

Eating a variety of foods in the same meal can improve the way the body uses the nutrients. For example, combining a cereal with a pulse (e.g., rice and beans), or addinga milk product to a cereal or grain (maize meal with milk).

Foods fortified with micro-nutrients

In some countries, there are fortified complementary foods available cheaply – e.g., flouror a cereal product with added iron and zinc for children. These products are convenientto use and provide nutrients that families may be interested in.

Note: when discussing fortified complementary foods with caregivers, there are somepoints to consider:

• What are the main ingredients?

• Is the product fortified with micronutrients such as iron, vitamin A, or other vitamins?

• Does the product contain ingredients such as sugar and/or oil to add energy?

• What is the cost compared to similar home-produced foods?

• Does the label or other marketing imply that the product should be used for childrenof a specific age or how to use it? Does it have an expiry date?

• Do not use products that have written on them “a breast-milk substitute” or “for childrenunder six months only”.



8. Fluid needs of the young child

• A baby who is exclusively breastfeeding receives all the liquid he/she needs. However, he/she

needs extra water when given complementary food. Likewise, a baby who is under six months of

age and only receiving replacement milk does not need extra water.

• Offer a drink when the child seems thirsty. Extra fluid is needed if the child has a fever or diarrhea.



FLUID NEEDS OF THE YOUNG CHILD

• Water is good for thirst. A variety of pure fruit juices can also be used.

Note: Too much fruit juice may cause diarrhea and may reduce the child’s appetite.

• Drinks that contain a lot of sugar may actually make the child thirstier as his body has to

deal with the extra sugar. Fizzy drinks (sodas) are not suitable for young children.

• Sometimes a child is thirsty during a meal. A small drink will quench the thirst and they

may then eat more.

• Remember that children who are not receiving breastmilk need special attention and

special recommendations. A non-breastfed child aged 6-24 months of age needs

Approximately two to three cups of water per day (1 cup = 250ml) in a moderate

climate.

Four to six cups of water per day in a hot climate.

This water can be incorporated into porridge or stews, but clean water should also be

offered to the child several times a day to ensure that the infant’s thirst is satisfied.

SESSION 25: FEEDING TECHNIQUE

Objectives:

After completing this lesson trainees will be able to:

1. Describe feeding patterns and influences on children’s feeding activity

2. Explain to family members how to encourage the children to eat

• A child needs to be fed, to be taken care of, and to have good health in order to grow and develop

well. Even when food is limited, good care can help make the best use of these limited resources.

• Good care here refers to the behavior and practice of caregivers and family members who provide

food, health care, stimulation, and emotional support necessary for the child’s growth and

development.

• An important time to use good care practices is at meal times – when helping young children

to eat.

• A child needs to learn how to eat, to try new foods (not breastmilk), to chew, to move food around

the mouth, and to swallow food. A child needs to learn how to get food effectively into his/her mouth,

how to use a spoon, how to drink, and to hold a spoon and a cup.

• Therefore, it is very important to show how a mother can encourage her child and to feed him. This

can help families to enjoy a happy atmosphere at mealtimes.

• Feeding needs to occur in response to the child’s cues or signals using encouragement and praise.

Session 25: Feeding technique


RESPONSIVE FEEDING TECHNIQUES

• Respond positively to the child with smiles, eye-to-eye contact, and encouraging words.

• Feed the child slowly and patiently with love.

• Try to feed a variety of food to encourage eating.

• Cease temporarily when the child stops eating, and then continue later on

• Give the child finger food that the child can feed him/herself.

• Minimize distractions in the meal.

• Stay with the child through the meal and be attentive.

Talk to the child with eye-to-eye contact during feeding

Mealtime is when children learn to eat and they will eat more if a happy and comfortable atmosphere

is created. Feed the child when he is alert and happy. If the child is sleepy, upset, or over-hungry, he

may not eat well. Regular mealtimes and the focus on eating may also help a child learn to eat.

Session 25: Feeding technique


All infants and young children (6-24 months) are supported and

motivated to eat to satiety during meal times

SESSION 26: IN-CLASSROOM PRACTICE APPROPRIATE

CF PROMOTION AND MANAGEMENT

Objectives:


1. Apply counseling skills to the promotion and management of appropriate CF.

1. Instructions for food demonstration

The trainer needs to prepare:

• Essential cooking utensils: Gas cooker, three pots, bowls, chopsticks, plates, spoons (5 ml), knife,

cutting board, clean towel, fresh water, etc.

• Food: adequate to prepare three different types of CF (first processed, cleaned)

• Cooking process

• Age-appropriate CF recipes

• Get food and utensils ready

Food demonstration:

• The trainer practices first: prepare CF for seven-month-old children and explain to mothers what

s/he is doing:

How to measure water, “bot” exactly?

What is the right order of food?

Add rice flour (Starch) + meat/shrimp/fish (Protein) + water and stir until they are well-cooked,

then add vegetables, fish sauce and oil at last.

Ensure hygiene and food safety while preparing food and store dry food (“bot”) after use

• Ensure hygiene and food safety while preparing complementary food (four “clean”)

• Demonstrate and give further explanation:

A seven month-old child needs how many calories? How much food does he need? Etc.

Energy demand by age?

How to check the consistency of food?

Session 26: In-classroom practice Appropriate CF Promotion and Management


How to reduce the consistency of “bot”/”chao”?

How to increase the density of food?

What to note while preparing food for sick children?

• When the food is ready: ask the mothers to taste and give comments

• Ask if the mothers have any questions

2. Apply the skills that you have learned to counsel mothers in the following case studies

• Greet the “caregiver” and introduce yourself. Ask his/her name and use his/her name during the

conversation.

• Ask one or two open-ended questions to start the conversation and identify why he/she needs

counseling.

• Use the skills that you have learned to encourage the “caregiver” to talk to you.

Case studies on CF:

Your baby is 6 months of age and grows well. This is your second baby. You come to the health facility

to enquire about how to feed your baby.

Some of your friends advise you to bottle feed because you can put the watery food into a bottle and

your baby can eat him/herself.

You are not sure whether this is good or bad.

You can start the conversation with:

“I wonder if I could give my baby thin semi-solid soup by bottle so that he can eat on his own?”

Case study two:

You come to the health facility because you think your baby grows slowly and often gets sick. Your

baby is 8 months of age. This is your first baby.

You are confused from the different information you have heard. You do not know what to follow. You

do some things that you think are correct and some things that your husband and mother-in-law advise

you to.

You do not give your baby meat and mashed vegetables but only use the water after you boil these

foods because you think it is too early to give him these foods.


“I do not give my baby mashed vegetables or meat – my mother-in-law said that they are not good foryoung children.”



Case study three:

You come to the health facility for a regular weight check-up. Your baby is 18 months of age and grows

very slowly. You are very worried, anxious, and tired. This is your first child.

You feed your baby diverse foods (semi-solid soup, mashed fruit, vegetables, and beans) but he only

eats a bit and then cries and throws it away. You feed him daily and do not breastfeed him.


"Why my baby is not gaining weight?"

"I try to feed my baby but he refuses"

"Please tell me what I should do to make my baby eat".

Case study four:

Your baby is 7 months of age. This is your first child. Your friends advise you to come to a health facility

to receive counseling on CF. You are surprised because you think your baby is too young – less than

one year old – for complementary food.

Your baby is breastfed and growing well. You do not particularly care, but are curious and want to know.


“I haven’t thought of giving my baby complementary foods; he does not need that until he is one yearold. Is that right?”



SESSION 27. PREPARING A HYGIENE MEAL AND FOOD SAFETY

Objectives:


• Explain the ways to keep a child’s meal hygienic and safe.

Requirements for clean and safe feeds

A baby who is not breastfed is at increased risk of illness for two reasons:

Replacement feeds may be contaminated with organisms that can cause infection.

The baby lacks the protection provided by the breastmilk.

• After six months (180 days) of age all children require complementary food. Clean and safe prepa-ration and feeding of complementary food is essential to reducing the risk of infection and itscauses.

• The main points to remember for clean and safe preparation of food are:

Clean hands.

Clean utensils.

Clean food and water.

Safe storage

Clean hands

Session 27. Preparing a hygiene meal and food safety


CLEAN HANDS

Wash hands with soap andwater

• Before holding food andreguarly when preparing a meal

• After using the toilet, cleaning ababy’s bottom, or holding pets/animals

• Wash hands and the child’shands before feeding


• You must regularly wash your hands after using the toilet, after washing the baby, after disposing

of the baby’s stools and changing the nappies, and after preparing food because your hands may

be easily contaminated with organisms such as: raw meat, poultry. Also after touching animals,

before preparing or serving food and before eating and feeding the baby.

• It is important to wash your hands with soap, running water, or clean water, washing the palms,

the space between the fingers and nails, and the back of the hands. Let the hands dry naturally or

wipe the hands with a clean towel. Do not wipe your hands on the clothes you are wearing or a

towel you share with others.

Clean utensils



CLEAN UTENSILS

• Keep knives, chopping boards,containers, and the kitchenclean

• Wash all the surface and uten-sils for cooking and food con-tainer before and after usingthem

• Use clean utensils and coveredcontainers for the baby

• Separate raw meat, poultry,and sea food from other food

• Use separate containers andchopping board for cooked foodand raw food

• Use covered containers tostore food


• You should keep clean all the utensils and the surfaces used for preparing food. If possible, use

a soft brush to reach all the corners. Use covered utensils to avoid insects and dust. Use a clean

spoon to feed the baby semi-solid soup and a clean cup to give the baby milk or fruit juice. The

caregiver needs to use another spoon when tasting the baby food.

• Bring the water to a rolling boil before using it. This will kill most harmful micro-organisms. A rolling

boil is when the surface of the water is moving vigorously for a second or two. The water can cool

down naturally in a clean covered container. The best kind of container has a narrow top, and a

tap through which the water comes out. This prevents people from dipping cups and hands into

the water, which can make it unsafe. If the water has been stored for more than 48 hours it is better

to use it for something else, for example, cooking or give it to older children to drink.

Safe storage

Safe water and food



SAFE FOOD AND WATER

Water

• Use clean or filtered water

• Give the baby boiled water

Food

• Use fresh food

• Do not use expired/old food

• Wash and clean the raw foodbefore cooking

• Cook food well

• Eat immediately affter cooking

• Stored food needs to be re-heated


SAFE STORAGE

• Keep the food in a coveredcontainer

• Keep food in dry, clean places

• Preserve dry food carefully

• Use cooked food within onehour


FURTHER READING:

Cleaning a cup: A cup does not need to be boiled. To clean a cup, wash it and scrub it

with hot soapy water each time it is used. If possible, dip the cup into boiling water, or pour

boiling water over it just before use, but this is not essential. An open, smooth surfaced

cup is easiest to clean. Avoid tight spouts, lids, or rough surfaces where milk could stick

and allow bacteria to grow.

Five key points for safe food

Keep clean

• Wash your hands before handling food and often during food preparation.

• Wash your hands after going to the toilet, changing the baby, or coming in contact

with animals.

• Wash all surfaces and equipment used for food preparation or serving.

• Protect kitchen areas and food from insects, pests, and other animals.

Separate raw and cooked food

• Separate raw meat, poultry, and seafood from other food.

• Use separate equipment and utensils such as knives and cutting boards for han-

dling raw food.

• Store food in covered containers to avoid contact between raw and prepared food.

Cook thoroughly

• Cook food thoroughly, especially meat, poultry, eggs, and seafood.

• Bring food like soups and stews to a boil. For meat and poultry, make sure juices

are clear, not pink.

• Reheat cooked food thoroughly. Bring to a boil or heat until it is too hot to touch.

Stir while re-heating.

Keep food at safe temperatures

• Do not leave cooked food at room temperature for more than two hours.

• Do not store food too long, even in a refrigerator.



• Do not thaw frozen food at room temperature; thaw in a refrigerator.

• Food for infants and young children should ideally be freshly prepared and not

stored at all after cooking.

Use safe water and raw materials

• Use safe water or treat it to make it safe.

• Choose fresh and wholesome foods.

• Use pasteurized milk.

• Wash fruit and vegetables in safe water, especially if eaten raw.

• Do not use food beyond its expiry date.



SESSION 28: FEEDING ILL (SICK) CHILDREN AND

CHILDREN WITH HIV-INFECTED MOTHERS

Objectives:


1. Explain the importance of feeding children during illness.

2. Present how to feed the child during illness and recovery and how to feed a child with an

HIV-infected mother.

3. State the danger signs in young children and how to handle them.

Introduction

• During infections, the child needs more energy and nutrients to fight the infection. If they do not

get extra food, their fat and muscle tissue is used as fuel. This is why they lose weight, look thin,

and stop growing.

• The goal in feeding a child during and after illness is to help him to return to the weight he had

before he was ill.

Session 28: Feeding ill (sick) children and children with HIV-infected mothers


Encourage children to drink and eat during illness and provide

extra food after illness to help them recover quickly

1. Feeding a child during illness

A child who is ill needs extra food. In this period, the child normally only wants breastmilk and no other

food. Although the child does not want to eat, you should not restrict his food.

FEEDING A SICK CHILD

For children < 6 months

• Continue to breastfeed.

• Breastfeed more frequently.

For children > 6 months

• Continue to breastfeed.

• Encourage the child to drink and eat – with lots of patience.

• Feed them small amounts frequently.

• Give food that the child likes.

• Give a variety of nutrient-rich food.

• The food should be tender and easily digestible.

2. Some guidance for feeding child having diarrhea and infection

When a child is sick, it is important to take care of and feed him/her properly - in addition to getting

medical treatment to help him/her recover quickly from illness. Common diseases among young chil-

dren are diarrhea and respiratory infection. In this section, we focus on introducing care and on feeding

a child who has diarrhea and a high fever. These are also common principles of feeding a child during

any illness.

Diet for a child who has diarrhea

• To treat diarrhea, the most important thing is to prevent dehydration; quickly handle dehydration if

it occurs and monitor the child’s diet.

• Prevent dehydration at home by giving the child more clean water than usual or an oral rehydration

salts (ORS) drink along with liquid made from food like porridge, salted porridge water, roasted

rice water, and rice water.

• In case of dehydration, take the child to health staff or health stations for treatment. The best way

to deal with dehydration is to give an ORS drink and liquid from cooking food.

• The common principle is to give the child more to drink than usual whenever he wants and to

continue providing the child with something to drink until he no longer has diarrhea. For children

under two years old, they cannot ask for water themselves so they express their thirst by stimulation

and looking uncomfortable. Therefore, you should bring water to him/her to see whether s/he is

thirsty and wants to drink or not. When s/he does not want more to drink, it means that s/he is

getting enough water to compensate lost liquid.

• How to give a child a drink: do not bottle-feed. Feed him/her by spoon every 1-2 minutes and use

a cup for older children. If the child vomits, stop giving him anything to drink for ten minutes, then

• During illness, a child has little appetite even though the family tries to encourage him to eat. The

child’s appetite usually increases after the illness so it is important to continue to pay extra attention

to feeding after the illness. This is a good time for families to give the child extra food so that lost

weight is quickly regained.

• Young children need extra food until they have regained all their lost weight and are growing at a

healthy rate.



FEEDING DURING RECOVERY

• Give extra breastfeeds.

• Feed an extra meal.

• Give an extra amount.

• Use extra-rich food.

• Feed with extra patience and love.

continue, but more slowly, for example, a spoon every 2-3 minutes. The amount of water a child

needs after going to toilet is:

Children under 2 years old: 50-100 ml

Children from 2-10 years old: 100-200 ml

Children over 10 years old and adults: drink on demand

• Take the child to a health worker or health facility for treatment if there is sign of severe

dehydration.



FURTHER READING:

Types of drinks used in diarrhea treatment:

a) ORS: is the best drink to treat dehydration

• How to prepare an ORS drink: wash your hands with soap and clean water before

preparing it.

• Pour the powder from the package into a clean jar or pot. Get a liter of clean water (or

suitable amount of water for each package used). Cooling boiled water is the best,

but if it is not available, use the cleanest water. Pour the water into the container and

stir carefully until the powder is completely dissolved. Cover the jar and give it to the

child within 24 hours. If all the ORS has not been used up within 24 hours, throw it

away and prepare a new batch.

b) How to prepare salted porridge: Cook a handful of rice with a pinch of salt and clean

water, and then filter it though a closely woven basket to get the water for the child to

gradually drink .

c) Water from rice roasted with salt and sugar: 50g rice (one handful) roasted until it

turns yellow and water. Cook them together, then filter the mixture though a closely

woven basket and add eight teaspoons of sugar, one teaspoon of salt, then boil it

again. When it is cool the child can drink it gradually.

d) Banana water or sapodilla water: grind or smash five bananas or sapodillas with one

liter of cooling boiled water and one teaspoon of salt, for the child to drink gradually.

e) Carrot soup with salt and sugar: 500g of carrot, one teaspoon of salt, eight spoon-

fuls of sugar. Rub well-cooked carrot in a closely woven basket or mash in a blender,

add salt and sugar, then boil it again.

Diet of a child with diarrhea:

• Feeding a child who has diarrhea is very important to prevent weight loss and possible

malnutrition.

• A child under 6 months old who is breastfed: continue BF with increased frequency of breastfeeds.

• A child over 6 months old: Foods that are recommended for a child who has diarrhea include: rice

(rice flour), potato, lean chicken, lean pork, soya milk, oil, carrot, sapodilla, and banana.

• In addition, feed the child more often, little by little, with other nutrient-rich foods such as meat,

egg, milk, fish, etc. and add oil or fat to enrich the energy of the food. The food should be tender,

well cooked, thinner than usual, and fed to the child right after cooking to ensure hygiene and

reduce risk of infection. If only processed food is available, re-cook it before feeding the baby. A

baby should be given ripe fruit or ripe fruit juice such as banana, orange, lemon, mango, papaya,

etc. to increase the amount of potassium. Avoid giving them soft drinks because they may lead to

more serious diarrhea.

Avoid using high-fiber or nutrient-poor food such as high-fiber vegetables, grain starch (corns,beans, etc.); they are difficult to digest.

Avoid using food containing too much sugar, which may cause more serious diarrhea.

The amount of food: encourage the child to eat as much as possible, six times a day or morefor younger children.

After the diarrhea is over, a child should be given one more meal per day for two weeks inorder to help him quickly recover and prevent malnutrition. A child with prolonged diarrheashould be given one more meal per day for at least one month.

When to take a child to health facility

After two to three days treated at home without improvement or if the following symptoms are noticed,

a child should be taken to health facility:

• Urinating many times with watery stools.

• Continuous and multiple vomiting.

• Increased signals of thirst.

• Fever.

• Eating and drinking less than usual.

• Blood in stools.

Prevention of diarrhea

• A child should be exclusively breastfed in the first six months and continued to be breastfed until

the child is two years old.



• A child should be given complementary food from the seventh month. Porridge for the child should

be prepared with colorful food of all four food groups, especially oil. The food should be well cooked,

mashed, and served right after cooking.

• The food must be clean.

• Use a clean bowl, cup, and spoon to feed the child.

• Family members need to wash their hands after going to the toilet and before cooking and feeding

the child.

• Use a hygienic toilet. Let the child use a chamber pot and throw stools into the toilet.

• Give the child all scheduled vaccinations. Give the child the measles vaccination when he is nine

months old.

3. Diet for a child who has a high fever after developing infections

When children develop an infection, they often have a high fever, increased basic metabolism of ten

percent in accordance with one increased degree of fever. Therefore; demand for fluid, energy, protein,

vitamins, and minerals rise significantly. High fever often makes digestive enzymes become inhibited,

leading to the child losing appetite, which is why the child should be given food that is easy to digest.

Foods recommended for a child having high fever due to infection: ripe fruit, especially fruit rich

in vitamin C, such as orange, lemon, mandarin, grapefruit, etc. and food rich in protein, such as breast-

milk, cow milk, soya milk, egg, meat, and fish

Diet for a child who has a high fever due to infection

• A young child who is still breastfed: continue to breastfeed with increased frequency. If the child

cannot suckle, feed him expressed breastmilk with a spoon.

• An older child who is eating complementary food: give him tender, various, and easily digestible

food and divide this food into many small meals such as semi-solid soup and, porridge, thinner

soup cooked with meat, egg, fish, vegetable, and oil. Feed the child his favorite foods to encourage

him to eat more.

• Give the child more fruit, drinks, and fruit juices to compensate fluids lost due to fever and to provide

him with more vitamins.

• After the child recovers from illness, give him one extra meal per day and feed him food rich in nu-

trients to help him recover quickly .

4. For children of an HIV-infected mother

• Most mothers with HIV are appropriately counseled by specially trained health workers. Therefore,

franchise staff only need to note that mothers should not practice mixed feeding, that is, should

not give breastmilk and other food at the same time.



Replacement feeding is the process of feeding a child who is not breastfed with a diet that provides

all the nutrients the child needs until the child is fully fed with family food.

The five requirements include:

1. Acceptable: the mother perceives no barrier to replacement feeding. Barriers may have cul-

tural or social reasons, or be due to fear of stigma or discrimination.

2. Feasible: the mother (or family) has adequate time, knowledge, skills, hours, and resources

to prepare the replacement food and feed the infant up to 12 times in 24 hours.

3. Affordable: the mother and family, with community or health-system support if necessary, can

pay for the cost of purchasing/producing, preparing, and using replacement food, including all

ingredients, fuel, clean water, soap, and equipment, without compromising the health and nu-

trition of the family.

4. Sustainable: availability of a continuous and uninterrupted supply and a dependable system

of distribution for all ingredients and products needed for safe replacement feeding, for as long

as the infants need, up to one year of age or longer.

5. Safe: replacement food is correctly and hygienically prepared, stored, and fed in nutritionally

adequate quantities with clean hands and using clean utensils, preferably by cup.



Options for feeding 0-6 month old babies

Replacement feeding (milkpowder, home-modified ani-mal milk with a micronutrientsupplement) if 5 requirementsare met

5 requirements

- Acceptable

- Feasible

- Affordable

- Sustainable

- Safe

Early cessation as replacementfood meets 5 requirements

Exclusive breastfeeding

5. Danger signs in children

When a child is sick, the family should pay more attention to recognize danger signals. When a

caregiver sees the child having one of the following danger signs, it is necessary to bring him to the

health facility for treatment:

• A baby cannot breastfeed.

• A baby has diarrhea and is thirsty.

• A baby cannot drink or has difficulty drinking.

• A baby vomits a lot.

• A baby’s stool is mixed with blood.

• A baby has a fever (high temperature, higher than 380C).

• A baby has convulsions.

• A baby sleeps soundly and is hard to wake up.

• A baby has abnormal signs (fast breathing, difficultly breathing, sunken rib-cage).

• Hypothermia.



SESSION 29: ASSESSING NUTRITION STATUS

Objectives:


1. State the concept of nutrition status.

2. Categorize and assess nutrition status with anthropometrical methods.

3. Practice techniques of weighing with scales and height and arm- circumference measures.

4. Practice using a growth chart in counseling.

Definition:

Nutrition status is a set of functional, structural, and biochemical characteristics reflecting the satisfac-tion level of the body’s demands.

Nutrition status of individuals is the outcome of eating and using the body’s nutrients. Good nutrition

status reflects balance between food intake and health condition. When the body is in nutrient deficiency

or excess, it means the individual has health or nutrition problems.

Types of malnutrition

• Underweight: refers to humans who are considered to be under a healthy weight. The definition

is usually made with reference to the body mass index (BMI). (Weight-for-age Z score <-2).

• Stunting: is a reduced growth rate in human development. It is a primary manifestation of malnu-

trition in early childhood, including malnutrition during fetal development brought on by the

malnourished mother. (Height-for-age Z score <-2).

• Wasting: refers to the process by which a debilitating disease causes muscle and fat tissue to

"waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is believed that

episodes of wasting have a short duration, in contrast to stunting, which is regarded as chronic

malnutrition. (Weight-for-height Z score <-2).

Some methods to assess nutrition status

Major methods used include:

1. Anthropometry, using scales and tape measures

2. Survey of diet or eating customs.

3. Clinical check-up, paying particular attention to implicit or explicit symptoms of nutrient

deficiency.

Session 29: Assessing nutrition status


4. Tests, especially biochemical tests (blood, urine tests, etc.).

5. Function tests to identify functional disorders caused by nutrient deficiency.

6. Survey of sickness and fatality to study relations between sickness and nutrition status.

7. Assessment of ecological factors related to nutrition status and health.

Nutrition anthropometric method

Nutrition anthropometry is a technique to measure body size and structure and to assess nutritional

status. Nutritional status results from both hereditary and environmental factors, in which nutritional

factors play a critical role.

Anthropometric sizes can be classified into the following groups:

a) Body mass, characterized by weight

b) Length sizes, specifically lying length and standing height

c) Body structure, energy and protein storage via surface soft tissues: skin and muscle beneath fat

Techniques to collect anthropometric measures

Following is the WHO standards (1883) that are currently applied:

Month calculation (for babies under 5 years old):

• 0 month: from the time of delivery till before first completed month day (from day 1 to day 29).

• 1 month: from the first completed month until the day before the second completed month (fromday 30-day 59).

• 12 months: from 12 completed months until 12 months and 29 days.

Year calculation:

• 0 years or under 1 year: from the time of delivery until the day before the completed year (1st year).

• 1 year: from the day of first completed year until the day before the second birthday (2nd year).

When we say children under 5 years old, we mean children from 1-60 months.



Measuring technique

Note:

• When measuring height is impossible, measure him lying down and subtract 0.7 cm from the result.

• When a baby is 24 months old, s/he can both stand or lie down to be measured, but it should be

noted that if you measure the height, compare it to classification for height measuring and if you

measure his length, then compare it to classification for length measuring.

• When the child is 24 months old or over, measure height only.

Figure 29.2: Equipment and method for measuring the lying length of a child under 25 months old

Weighing technique

Figure 29.1: Weighing a baby



MEASURING PERSON

Using right handto pull the footboardagainst thechild’s feet

Left hand tohold the child’sknees

SUPPORTERUsing two handsto hold thechild’s head

The child lies straight along the board

Movablefootboard

Reading results Movableheadboard

Foldingdirection

Figure 29.3: Measuring the standing height of a child from 25 months old or over.



Measuring arm circumference: Poor development or muscular wasting is the main symptom of mal-

nutrition caused by protein and energy deficiency, especially in young children.

Height/age criteria (below -2SD) reflects prolonged malnutrition or malnutrition in the past.

3. Weight/height:

• Low weight/height that is below -2SD reflects malnutrition in the present – malnutrition that has

newly occurred and has stopped the child from gaining weight or made him lose weight. This is

called stunting.

• If weight/height rate excesses +2SD, the baby is overweight.

• When both height/age and weight/height criteria are below the recommended threshold (-2SD),the child is in coordinative malnutrition (acute and chronic) of both emaciation and stunting

malnutrition.

4. Mid Upper Arm Circumference (MUAC): recommended by WHO 2006

• Very severe acute malnutrition: MUAC <115mm (equal to <-3SD weight/height compared toWHO reference population).

• Severe acute malnutrition: MUAC 115mm - <125mm (equal to -3SD - < -2SD weight/heightcompared to WHO reference population).

Weight/age criterion only indicates malnutrition but cannot tell how it happened or if it is chronic.

2. Height/age:

A baby’s height is compared to the height of a baby of the same age and sex in reference the WHO

population. Classification is based on the following standard deviation:

Nutrition status assessment:

Three criteria: weight/age (W/A), height/age (H/A), and weight/height (W/H). Reference population of

WHO has been applied in Viet Nam since 2006.

1. Weight/age: this is the most common criterion

Threshold point below -2SD is considered underweight



LEVEL CLASSIFICATION THRESHOLD

Moderate malnutrition (level 1) From below -2SD to -3SD

Severe malnutrition (level 2) From below -3SD to -4SD

Very severe malnutrition (level 3) Below - 4SD

Normal - 2SD to + 2SD

Overweight Above +2SD

LEVEL CLASSIFICATION THRESHOLD

Normal - 2 SD or above

Malnutrition level 1 (stunting level I) below -2SD to - 3SD

Malnutrition level 2 (stunting level II) below -3SD

Practice using a growth chart in counseling

• Divide the class into small groups of three to four members: one member plays the role of a

counselor, one plays the role of the mother/ caregiver, the others observe and comment.

• Each group is given a growth chart and draws one of those situations.



Situation 1

Minh 3 months age, male

Birth weight: 3.4kg

1 month : 4.2 kg

2 months: 5 kg

3 months: 5.7 kg

Situation 2

Vân 6 months age, female

Birth weight: 3.1 kg

2 months: 4.5 kg

3 months: 4.7 kg

4 months: 4.7 kg

Situation 3

Nga 9 months age, female

Birth weight: 4 kg

6 months: 8 kg

7 months: 7.8 kg

9 months: 7.9 kg

Situation 4

Lan 13 months age, male


10 months: 9.3 kg

9 months: 9.6 kg

12 months: 10.1 kg

Situation 5

Hoa 15 months age, male


12 months: 12 kg

13 months: 12.5 kg

14 months: 13.5 kg

• Groups start the counseling role-play:

The person who plays the role of the mother: study the child’s weight gain to set up the situation(the diet, care, disease...).

The counselor completes the growth chart and uses it in counseling.

The observers use the Checklist of Counseling Skills to assess.

SESSION 30: DECREE 21

Objectives:


1. Point out the importance of Decree 21.

2. State the main points stated in Decree 21 related to health facilities and health workers.

What is Decree 21/2006/ND-CP?

Decree 21/2006/ND-CP (“Decree 21”), issued in 2006, aims to promote optimal IYCF practices by

restricting methods and scopes in which breastmilk substitutes are marketed.

Decree 21 stipulated that information and communication related to infant feeding should clearly state

that breastmilk is an optimal choice compared to breastmilk substitutes. The Decree indicated how

nutrition products can be marketed, where they can be sold and roles of major related target groups,

including product producers and traders, health facilities, and medical workers.

Scope of the Decree includes

Milk and food for infants under 6 months old

Milk for infants from 6 to 24 months of age

Feeding bottles

Pacifiers

Why Decree 21 is so important?

One consequence of poor nutrition for infants that can be clearly seen in Viet Nam is a high stunting

rate. Thirty-three percent of children under five are stunted. Good nutrition for babies from birth until

24 months is critical for his/her physical development. Appropriately nutritious diets in this period will

improve the child’s growth and physical development, learning achievements, and even future

economic conditions. Vice versa, poor nutrition in the first months of life will slow down the child’s

physical development to a point where poor growth becomes irreversible.

Research conducted by A&T has shown that the majority of children in Viet Nam do not receive

sufficient nutrition. Although there are many factors that influence what and how infants and young

children are fed, prevalent incorrect information about BF and the rampant advertisement of breast-

milk-substitutes is regarded as having huge impact on the nutrition decision of many families and the

consequent poor nutritional status of so many children.

Session 30: Decree 21


Conforming to Decree 21 will contribute to the promotion of optimal IYCF practices in Viet Nam. This

will help reduce malnutrition and stunting, which then increases national labor productivity through

reducing the burden of diseases and contributing to the abundance and vigor of the labor force.

Management and Implementation responsibility

The MoH is in charge of managing and implementing Decree 21, simultaneously coordinating with the

Ministry of Trade, Ministry of Culture and Information, Committee for Population, Family and Children,

and related Ministries and Departments.

• The food administration is responsible for screening and licensing advertisements related to formula

milk and nutrition products for young children in the mass media before these advertisements are

printed or broadcast.

• The Maternal and Child Health Department coordinates all programs targeting mothers with young

children.

• The Department of Health Inspection supervises the implementation of the Decree. Health

Inspectors cooperate with other departments in MoH to supervise and monitor the implementation of

this Decree nation-wide annually. (At the provincial level, the Health department is in charge of this).

Penalties given to violating milk companies are subject to Decree 45. This Decree was issued in 2005,

a year before Decree 21 was issued. As a result, the violations listed in Decree 21 do not necessarily

correspond to the penalties listed in Decree 45.

The government is currently considering revisions to these decrees.

Decree 21 and role of health facilities, physicians and medical workers

Health facilities and medical workers are responsible for encouraging and promoting optimal IYCF, and

can do this by conforming strictly to Decree 21:

Each health facility should:

• Encourage BF.

• Organize educational materials on BF.

• Enable mothers to breastfeed their babies within the first hour after delivery.

Health facilities should not:

• Sell or allow the selling of milk for infants less than 12 months of age or food for infants less than

6 months of age, except for drugstores at hospitals.

• Allow manufacturers and traders of nutrition products for infants to display products, except for

drugstores at hospitals.



Physicians and medical workers should:

• Encourage BF.

• Organize materials to promote BF.

• Instruct mothers and caregivers about correct usage of nutrition products for infants in those special

cases that require the use of these products.

Physicians and medical workers should not:

• Receive material benefits or products labeled with names or logos of milk products for infants less

than 12 months of age or food for infants less than 6 months of age.

• Help manufacturers and traders give sample products or presents related to nutrition products for

infants.

• Instruct or, counsel women in childbirth to use nutrition products for infants except in situations that

require the use of these products.

Information, education, and communication

Doctors and health workers at health facilities are the only channels to provide information and educa-

tional material on IYCF to pregnant women, mothers, and their families.

1. Information, education, and communication on the benefits of breastfeeding and on methods

of nurturing infants must be given priority in programs on information, education, and commu-

nication on the protection of mother and on child health, and on child-malnutrition prevention

and control.

2. Messages about the superiority of breastmilk must be clear and must point out the disadvan-

tages of not BF.

3. Information about BF and CF must be accurate and easy to understand.

Information, education, and communication documents on nurturing infants that have the following

content are prohibited:

1. Pictures or words to encourage bottle-feeding.

2. Discourage breastfeeding infants.

3. Comparisons of nutrition products for infants with breastmilk.

4. Names or logos of infant-nutrition products.

Decree 21 and the role of companies producing and distributing nutrition products forinfants:

Companies producing nutrition products for infants have an important role to play in ensuring the health

and development of young children. Establishments that produce or distribute nutrition products must

ensure that all products comply with relevant food safety, quality, and hygiene standards and that health

workers have information on how to properly use these products.



In regard to food for infants under 6 months old or milks for infants under 12 months old, or-

ganizations that produce or sell nutrition products for infants MAY NOT:

1. Use forms of sale promotion.

2. Contact mothers, pregnant women, or family members working in health facilities to promote

products.

3. Provide health workers or health facilities with food products for infants under 6 months old or

milk products for infants under 12 months old.

4. Provide health workers or health facilities with any material benefits, nor can the company

provide groups with items featuring the name or logo of products.

5. Grant scholarships or funds for research, training, counseling services, or other uses to

promote products.

6. Display products in health facilities. (The one exception where this is allowed is in a hospitaldrugstore)

Advertising

1. Advertising milk or food products for infants under 6 months old is prohibited.

2. Advertising of milk for children aged 12-24 months is allowed, but the first part of the

advertisement must state that breastmilk is the best food for the health and growth of infants.

3. All advertisements must be reviewed and approved by the MoH.

4. No advertisements may promote the abandonment of BF, promote bottle feeding, or compare

milk products with breastmilk.

Labeling of nutritious products for infants

1. Labels cannot imply that the product is equal to or better than breastmilk.

2. Labels must include the text: “breastmilk is the best food for the health and growth of infants.Antibacterial elements, especially antibodies, available in breastmilk only, help prevent andcontrol diarrhea, respiratory infections, and several other infectious diseases for infants”.

3. Labels must include the text: “Use this product only under physicians’ instructions. Strictlyfollow preparation instructions. Feed children with clean cups and spoons”.

4. Instructions on how to prepare the food should be in Vietnamese, be easy to follow, and be

accompanied by simple tables.

5. The age of the child that the product is designed for must be clearly indicated.

6. Product labels may not feature pictures or drawings of infants under the age of 12 months,

bottles, or dummies.



7. Laws on the labeling of products for domestic, imported, or exported goods must be adhered

to, and production and expiration dates must be included.

Labeling of Feeding Bottles and Dummies

1. Labels for bottles must include the text: “strictly following the instructions on hygiene and sterilization. The use of feeding-bottles may make children refuse breastfeeding, or cause diarrhea”.

2. Bottle labels must also include instructions on proper use and sterilization.

3. Packages or labels stuck on dummies must include the text: “using dummies will negativelyaffect BF”.

4. Labeling regulations for bottles and dummies also apply to products imported into Viet Nam.



THE GOVERNMENTSOCIALIST REPUBLIC OF VIET NAM

Independence – Freedom – Happiness

No.: 21/2006/ND-CP

Hanoi, February 27th 2006

Decree on the trading in and use of nutritious products for infants

THE GOVERNMENT

Pursuant to the December 25, 2001 Law on Organization of the Government;

Pursuant to the June 15, 2004 Law on Child Protection, Care and Education;

Pursuant to the June 14, 2005 Commercial Law;

Pursuant to the November 16, 2001 Ordinance on Advertisement;

Pursuant to the December 24, 1999 Ordinance on Goods Quality;

Pursuant to the July 26, 2003 Ordinance on Food Hygiene and Safety;

At the proposal of the Minister of Health,

DECREE:

Chapter I

GENERAL PROVISIONS

Article 1.- Scope of regulation and subjects of application

1. This Decree provides for information, education and communication on, advertisement for, trading

in, and use of, nutritious products for infants, feeding bottles and dummies.

2. This Decree applies to Vietnamese and foreign organizations and individuals in Viet Nam.

Article 2.- Interpretation of terms

In this Decree, the terms below are construed as follows:

1. Nutritious products for infants include milk and food produced by industrial methods, which are up

to the set standards and suitable to the special physiological conditions and each period of growth

of infants, including:

a) Milk and food of animal or plant origin, for under-6 month infants;

b) Milk for infants aged between 6 months and 24 months.



2. Supplementary food means food processed for additional use together with breastmilk, and milk

for infants aged between 6 months and 24 months.

3. Infants mean children who are from newborn to 24 months old.

4. Labels of nutritious products for infants means pictures, drawings or other illustrations; words,

prints or embossed images, affixed to or presented on packages of nutritious products for infants.

5. Giving of samples of nutritious products for infants means the free-of-charge supply of a small

quantity of nutritious products for infants.

6. Advertisement for nutritious products for infants means the introduction of nutritious products for

infants in any forms for profit-making purposes.

7. Medical examination and treatment establishments include general hospitals, obstetric or pediatric

hospitals, maternity homes; general clinics, obstetric or pediatric clinics; regional general clinics,

and commune, ward and township health stations.

8. Physicians and medical workers mean those who have medical professional qualifications, includ-

ing doctors, intermediate-level physicians, convalescence workers and midwives working at med-

ical examination and treatment establishments.

Chapter II

INFORMATION, EDUCATION, COMMUNICATION AND ADVERTISEMENT

Article 3.- Information, education and communication on the benefits of breastfeeding

1. Information, education and communication on the benefits of breastfeeding and on methods of

nurturing infants must be given priority in programs on information, education and communication

on the protection of mothers' and children's health, and on child malnutrition prevention and

control.

2. The MoH shall coordinate with the Ministry of Culture and Information, the Ministry of Trade, the

Ministry of Education and Training, the Committee for Population, Family and Children, the Central

Committee of the Viet Nam Fatherland Front, the Central Committee of the Viet Nam Women's

Union, the Central Committee of the Ho Chi Minh Communist Youth Union, the Central Committee

of the Viet Nam Peasants' Association, the Viet Nam Labor Confederation, and other agencies and

social organizations in communicating and educating about the superiority of breastmilk, the

importance of breastfeeding and the continuation of breastfeeding.

Article 4.- Information, education and communication documents on nurturing infants

1. Contents of information, education and communication documents on nurturing infants must be

clear, easy-to-read, easy-to-understand, objective and scientific.

2. Information, education and communication documents on nurturing infants must cover the following

contents:



a) Benefits and superiority of breastfeeding, affirming that breastmilk is the best food for the health

and all-sided growth of infants;

b) Instructions on exclusively breastfeeding infants until they are 6 months old and continuation

of breastfeeding until they are 24 months or older, rationally feeding them with supplementary

food from the time they are 6 months old;

c) Antibacterial elements, especially antibodies, available in breastmilk only, which help prevent

and control diarrhea, respiratory infections and other infectious diseases for infants;

d) Disadvantages of non-breastfeeding;

e) Adverse impacts of bottle-feeding, dummies, and supplementary food on infants of less than

6 months old;

f) Instructions on at-home processing, preservation and use of supplementary food for infants

by simple methods, ensuring hygiene, safety and proper nutrition with every day food.

3. Information, education and communication documents on nurturing infants which have the following

contents are prohibited:

a) Pictures or words to encourage bottle-feeding or discourage breastfeeding of infants;

b) Comparing nutritious products for infants as being equivalent or better than breastmilk;

c) Names or logos of nutritious products for infants, feeding bottles or dummies.

Article 5.- Information, education and communication documents on the use of nutritious prod-

ucts for infants

Contents of information, education and communication documents on the use of nutritious products

for infants must meet the following requirements:

1. Guiding proper ways of using nutritious products for infants.

2. Guiding ways of cleaning and sterilizing utensils used for feeding infants.

3. Guiding ways of feeding infants with clean cups and spoons.

4. Giving cautions about possible harms to infants' health caused by bottle-feeding.

5. Expenses of feeding infants with nutritious products.

Article 6.- Advertisement for nutritious products for infants

1. To strictly prohibit the advertisement for milk for under-12 month infants, food for under-6 month

infants, feeding bottles or dummies in any forms.

2. The advertisement for milk for infants aged between 12 months and 24 months must meet the fol-

lowing requirements:



a) The first part of the advertisement must have the content: "Breastmilk is the best food for thehealth and all-sided growth of infants";

b) Advertisement contents must comply with the provisions of Articles 4 and 5 of this Decree and

other provisions of law on advertisement.

3. Before putting advertisement for milk for infants aged between 12 months and 24 months, organ-

izations or individuals must send advertisement registration dossiers to the MoH according to the

provisions of law on advertisement.

Chapter III

TRADING IN NUTRITIOUS PRODUCTS FOR INFANTS

Article 7.- Publication of food quality, hygiene and safety standards

Nutritious products for infants, before being marketed, must have their quality, hygiene and safety stan-

dards published according to the provisions of law on goods quality and food hygiene and safety.

Article 8.- Regulations on labels of nutritious products for infants

1. Labels of nutritious products for infants must meet the following requirements:

a) There must be the words "CHU Y" (attention) (in upper case), followed by the words (in lowercase) with the following contents: "Breastmilk is the best food for the health and all-sided growthof infants. Antibacterial elements, especially antibodies, available in breastmilk only, help prevent and control diarrhea, respiratory infections and several other infectious diseases for infants." The height of letters must not be less than 2 mm;

b) There must be the words (in lower case): "Use this product only under physicians' instructions.Strictly follow preparation instructions. Feed children by clean cups and spoons." The height

of letters must not be less than 1.5 mm;

c) Infants' age groups suitable for use of the product must be clearly written;

d) Product labels must be printed with the number of the certificate of published food quality,

hygiene and safety standards.

2. Other contents of labels of nutritious products for infants shall comply with the provisions of law on

labeling of domestically circulated, imported or exported goods, and must meet the following

requirements:

a) Guiding proper ways of preparation, illustrated with simple and easy-to-understand tables in

Vietnamese;

b) Giving full and accurate introduction of origin, date of production, expiry date, ingredients, serial

number of the certificate of published food quality, hygiene and safety standards, and informa-

tion on nutritious value of the product;



c) Product labels must not contain pictures or drawings of infants of less than 12 months old,

feeding bottles or dummies; words or pictures implying that the product is equivalent or better

than breastmilk in quality.

Article 9.- Labels of feeding bottles and dummies

1. Labels of feeding bottles must meet the following requirements:

a) There must be the words (in lower case): "Strictly follow the instructions on hygiene and sterilization. The use of feeding-bottles may make children refuse breastfeeding, or cause diarrhea." The height of lower-case letters must not be less than 2 mm.

b) Guidance in proper ways of hygiene-keeping and sterilization.

c) Accurate names and addresses of producers and distributors.

2. Packages of or labels stuck on dummies must display the words (in lower case): "Using dummiesshall negatively affect breastfeeding." The height of lower-case letters must not be less than 2 mm.

3. The provisions on labels of feeding bottles and dummies specified in Clauses 1 and 2 of this Article

shall apply also to imported feeding bottles and dummies.

Article 10.- Responsibilities of heads of establishments producing and trading in nutritious

products for infants or of their representatives at law

1. Heads of production and business establishments or their representatives at law shall have the

responsibilities to:

a) Sell nutritious products for infants which meet the published food quality, hygiene and safety

standards;

b) Provide scientific information and proper ways of using nutritious products for infants to physi-

cians and medical workers.

2. Heads of production and business establishments or their representatives at law must not:

a) Produce or trade in nutritious products for infants which have their quality, hygiene and safety

standards not yet published or which fail to meet the published food quality, hygiene and safety

standards, or products with expired use duration or without labels or packages;

b) Appoint their employees to directly or indirectly contact mothers, pregnant women or members

of their families at medical examination and treatment establishments in order to promote or

sell milk for under-12 month infants or food for under-6 month infants;

c) Give physicians, medical workers or medical examination and treatment establishments milk

for under-12 month infants or food for under-6 month infants, material benefits or products in

other forms of expression displaying names or logos of milk for under-12 month infants or food

for under-6 infants;

d) Display milk for under-12 month infants or food for under-6 month infants at medical examina-



tion and treatment establishments, except hospital drugstores; or apply forms of sale promotion

to milk for under-12 month infants or food for under-6 month infants;

e) Grant scholarships, provide funds for scientific research, training courses, conferences, work-

shops, concerts, telephone counseling services or other forms in order to directly or indirectly

introduce products, aiming to promote the trading in or use of milk for under-12 month infants

or food for under-6 month infants.

Chapter IV

USE OF NUTRITIOUS PRODUCTS FOR INFANTS

Article 11.- Responsibilities of heads of medical examination and treatment establishments

1. Heads of medical examination and treatment establishments shall have the responsibilities to:

a) Organize communication on and encourage breastfeeding;

b) Create conditions for mothers to breastfeed their newborns within one hour after birth.

2. Heads of medical examination and treatment establishments must not:

a) Sell, or permit the sale of, milk for under-12 month infants or food for under-6 month infants at

medical examination and treatment establishments, except hospital drugstores;

b) Permit establishments producing or trading in nutritious products for infants to display, or post

up names of nutritious products for infants, feeding-bottles or dummies at medical examination

and treatment establishments, except hospital drugstores.

Article 12.- Responsibilities of physicians and medical workers in medical examination and

treatment establishments

1. Physicians and medical workers in examination and treatment establishments shall have the re-

sponsibilities to:

a) Organize communication on and encourage breastfeeding;

b) Provide guidance on proper ways of using nutritious products for infants for mothers or mem-

bers of their families in special cases where it is necessary to use such products.

2. Physicians and medical workers in examination and treatment establishments must not:

a) Receive directly or indirectly milk for under-12 month infants or food for under-6 month infants,

other material benefits or products in other forms of expression displaying names or logos of

milk for under-12 month infants, which are given by establishments producing or trading in nu-

tritious products for infants or their representatives;

b) Help production and business establishments give sample products or gifts related to nutritious

products for infants;



c) Provide guidance or advice or make prescriptions for pregnant women to use nutritious prod-

ucts for infants in cases where it is unnecessary to use these products.

Chapter V

IMPLEMENTATION PROVISIONS

Article 13.- Management responsibilities

1. The MoH shall assume the prime responsibility for, and coordinate with the Ministry of Trade, the

Ministry of Culture and Information, the Committee for Population, Family and Children, and

concerned ministries and branches in, managing the use of nutritious products for infants; manage

quality, hygiene and safety of nutritious products for infants; inspect and examine the implementa-

tion of the provisions of law on trading in and use of nutritious products for infants.

2. The Ministry of Culture and Information shall assume the prime responsibility for, and coordinate

with the Ministry of Trade and the MoH in, managing communication on and advertisement for

nutritious products for infants according to their assigned competence.

Article 14.- Implementation effect

This Decree takes effect 15 days after its publication in "CONG BAO".

To annul the Government's Decree No. 74/2000/ND-CP of December 6, 2000, on the trading in and

use of breastmilk substitutes to protect and encourage breastfeeding.

Article 15.- Implementation responsibilities

1. The Minister of Health shall assume the prime responsibility for, and coordinate with the Minister

of Trade, the Minister of Culture and Information and the Minister-Director of the Committee for

Population, Family and Children in, guiding the implementation of this Decree.

2. Ministers, heads of ministerial-level agencies, heads of Government-attached agencies, and

presidents of provincial/municipal People's Committees shall have to implement this Decree.

ON BEHALF OF THE GOVERNMENT

PRIME MINISTER

PHAN VAN KHAI




APPENDICES

AP

PE

ND

IX 1

: RO

LE

S O

F C

OM

MU

NIT

Y -B

AS

ED

WO

RK

ER

, HE

ALT

H-F

AC

ILIT

Y W

OR

KE

R A

ND

HE

ALT

H-F

AC

ILIT

Y M

AN

AG

ER

SAppendix 1


AT

HE

ALT

H F

AC

ILIT

IES

- F

RA

NC

HIS

E “

MT

TR

I BÉ

TH

”

Fra

nch

ise

Pac

kag

e1.

BF

Pro

mot

ion

2. B

F S

up

po

rt3.

BF

Man

agem

ent

4. C

F E

du

cati

on

5. C

F M

anag

emen

t

Targ

et A

udie

nce

Ph

n thai t

háng 6

-9

Khi s

inh

Bà m

có c

on 0

-6 t

háng

Bà

m c

ó c

on

5-6

th

án

gB

à m

có

co

n 6

-24

th

án

g

# C

onta

cts

31

41

6

Crit

ical

Poi

nts

6-7

month

of pre

gna

ncy

At

lea

st 2

we

eks

be

fore

deliv

ery

1-7

da

ys p

ost

de

live

ry (

athe

alth

faci

lity

or h

ome)

2nd w

eek

post

deliv

ery

1-2

month

s

2-3

month

s

4-5

month

s

5-6

mo

nth

s6

-7 m

on

ths

8-9

mo

nth

s

10

-11

mo

nth

s

12

-14

mo

nth

s

15

-18

mo

nth

s

18

-24

mo

nth

s

Hea

lth

Fac

ility

Man

ager

s -

En

sure

th

e o

per

atio

ns

of

Fra

nch

ise

“Mt

tri b

é th

”

Ensu

re th

e op

erat

ions

of

Fran

chis

e “M

t tr

i bé

th”

•

En

sure

th

at t

he

hea

lth

fac

ility

mee

ts a

ll fo

ur

fran

chis

e st

and

ard

s:

oB

rand

: M

ain

tain

& e

quip

fra

nch

ise “M

t tr

i bé

th”t

o p

rovi

de g

ood-q

ualit

y IY

CF

serv

ice

s (re

fer t

o fa

cilit

y gu

idel

ines

);M

ake

sure

that t

he fr

anch

ise h

as

“infa

nt-fe

edin

g”-f

riendly

and c

ounse

ling-f

riend

ly e

nvi

ron

me

nt,

e.g

., m

oth

er

an

d c

hild

are

no

t se

pa

rate

dafter

birth

;

oSt

anda

rdiz

ed S

ervi

ces:

Mak

e su

re th

at:

2-3

sta

ff are

tra

ined t

o b

eco

me c

ounse

lors

at

the f

ranch

ise

Sta

ff are

alw

ays

ava

ilable

at

franch

ise f

or

IYC

F c

ounse

ling

Faci

lity

identif

ies

a f

ixed-d

ay

schedule

for

gro

up-c

ounse

ling s

ess

ions

Moth

ers

/fath

ers

/gra

ndm

oth

ers

are

appro

priate

ly c

ounse

led a

s per

franch

ise p

ack

ag

e;

Moth

ers

are

follo

wed-u

p a

fter

counse

ling f

or

optim

al I

YC

F p

ract

ices

and t

o d

ea

l with

an

y p

rob

lem

s ra

ise

d.

There

is n

o v

iola

tion o

f D

ecr

ee 2

1 a

t fr

anch

ise “M

t tr

i bé

th”

oR

ecor

ding

and

repo

rtin

g:

Ensu

re that cl

ients

’ info

rmatio

n is

appro

priate

ly r

eco

rded (o

n fo

rms)

Subm

it re

port

s to

superv

isor

on t

ime

oFe

e:M

ake

sure

that

fees

for

serv

ices

are

charg

ed a

s per

guid

elin

es

and m

ana

ge

d a

pp

rop

ria

tely

.

S

upport

fra

nch

isor/

sub-f

ranch

isor

during m

onito

ring a

nd s

uperv

isin

g v

isits

Appendix 1


Hea

lth

fac

ility

wo

rker

s -

Ind

ivid

ual

an

d g

rou

p c

ou

nse

ling

Org

aniz

e in

divi

dual

-and

grou

p-co

unse

ling

ses-

sion

s fo

r m

othe

rs/h

us-

band

s/gr

andm

othe

rsfr

om th

e th

ird tr

imes

ter

of

preg

nanc

y til

l th

ech

ild is

24

mon

ths

of g

e

•F

or

pre

gn

ant

wo

men

oId

entif

y pre

gn

ant

wom

en d

uring r

egula

r A

NC

check

ups

and g

ive in

vita

tion c

ard

s to

co

me

fo

r “M

t tr

i bé

th”s

erv

ice

s

oR

egis

ter

pre

gnant

wom

en a

s cl

ients

of

the “M

t tr

i bé

th”f

ranch

ise s

ince

the

3rd

trim

est

er

of

pre

gn

an

cy

oG

ive e

ach

pre

gnant

wom

an a

moth

er-

child

book

oC

ounse

l the m

oth

er

on th

e in

itiatio

n o

f BF

; motiv

ate

the m

oth

er

to b

ring h

er

husb

an

d/m

oth

er-

in-la

w to

the

“Mt t

ri b

é th

”fra

nch

ise

for

counse

ling

oF

ollo

w-u

p the

moth

er

via t

ele

phone t

o r

em

ind h

er

of

the n

ext

vis

it

•D

uri

ng

del

iver

y:

oE

nsu

re that th

e m

oth

er

initi

ate

s B

F w

ithin

one h

our

aft

er

birth

; ensu

re s

kin-t

o-s

kin

co

nta

ct

oP

ract

ice “r

oom

ing-

in”,

no s

epara

tion o

f m

oth

er

and b

aby

oE

nco

ura

ge a

nd s

upport

the m

oth

er

to b

reast

feed p

roperly

(pos

ition

ing

and

atta

chm

ent)

oE

nsu

re n

o w

ate

r, li

quid

s, o

r pre

lact

eals

to b

e g

iven t

o t

he c

hild

befo

re t

he f

irst

bre

ast

fee

d

oE

nsu

re n

o fo

rmula

to

be g

iven t

o t

he c

hild

befo

re t

he f

irst

bre

ast

feed o

r w

hile

mo

the

r is

at

he

alth

fa

cilit

y

•E

BF

:

oE

nsu

re that m

oth

ers

com

e t

o “M

t tr

i bé

th”f

ranch

ise f

or

EB

F c

ounse

ling b

y co

nta

ctin

g m

oth

ers

via

te

lep

ho

ne

;

osc

hedule

indiv

idual-co

unse

ling s

ess

ions

on E

BF

on d

em

and;

oO

rganiz

e fix

ed-d

ay

gro

up-c

ounse

ling s

ess

ions;

oLin

k w

ith c

om

munity

-base

d w

ork

ers

for

follo

w-u

ps

of

moth

ers

.

•C

F:

oC

onduct

Indiv

idual c

ounse

ling o

n C

F o

n d

em

and.

oE

nsu

re fix

ed-d

ay

CF

gro

up-c

ounse

ling s

ess

ions

and c

onduct

food d

em

onst

ratio

ns.

oF

ollo

w u

p w

ith m

oth

ers

thro

ugh c

om

munity

-base

d w

ork

ers

and v

ia t

ele

phone;

rem

ind

mo

the

rs o

f re

gu

lar

visi

ts.

•C

on

du

ct q

uar

terl

y h

ealt

hy-

bab

y co

mp

etit

ion

s at

hea

lth

fac

iliti

es

•P

rovi

de

smal

l gif

ts/p

rize

s fo

r m

oth

ers

wh

o e

xclu

sive

ly b

reas

tfee

d a

nd

fo

llow

CF

rec

om

men

dat

ion

s.

•E

nsu

re c

om

mu

nic

atio

n m

ater

ials

are

dis

pla

yed

an

d u

sed

, an

d t

hat

co

rrec

t IY

CF

scr

ipts

/tap

es a

re p

laye

d o

n v

illag

e lo

ud

spea

k-er

s.

•S

up

ervi

se c

om

mu

nit

y-b

ased

wo

rker

s, a

sk t

hem

to

pro

vid

e m

on

thly

up

dat

es, a

nd

co

nso

lidat

e th

ese

into

a r

epo

rt.

Appendix 1


Co

mm

un

ity-

bas

ed w

ork

ers

(hea

lth w

orke

rs, n

utrit

ion

colla

bora

tors

, and

vill

age

mem

bers

of w

omen

’s u

nion

)

CB

Ws’

spe

cific

task

s:

Gen

erat

e de

man

d fo

rth

e fr

anch

ise

serv

ices

Inte

grat

e in

to

the

com

mu

nit

y-b

ased

wor

ker’

s re

gula

rho

me

visi

ts to

pro

vide

info

rmat

ion

on g

ood

IYC

F pr

actic

es

for

mot

hers

an

d fa

mily

mem

bers

•P

rep

are

a m

ap o

f th

e vi

llag

e an

d m

ark

ou

t lo

cati

on

s o

f p

reg

nan

t w

om

en a

nd

mo

ther

s o

f ch

ildre

n 0

-24

mo

nth

s:

oPr

egna

nt w

oman

:Giv

e in

vita

tion c

ard

s to

go t

o C

HC

– “M

t tr

i bé

th”f

ran

chis

e;

rem

ind

mo

the

rs o

f m

on

thly

pre

gn

an

cy c

he

cku

ps

and c

ounse

ling;

during h

om

e v

isits

dis

sem

inate

info

rmatio

n o

n in

itiatin

g B

F im

me

dia

tely

aft

er

birth

.

oM

othe

rs w

ith 0

-6 m

onth

old

chi

ld:M

ake

hom

e v

isits

at

diff

ere

nt

times

with

th

e f

ollo

win

g p

urp

ose

s:

Su

pp

ort

d

uri

ng

d

eliv

ery

if

the

m

oth

er

de

live

rs

at

ho

me

; ch

eck

o

n

mo

the

r a

nd

b

ab

y a

t h

om

e.

Du

rin

g

the

fir

st

we

ek

aft

er

deliv

ery

, h

elp

the m

oth

er

to b

reast

feed p

roperly

(pos

ition

ing

& at

tach

men

t);

Follo

w-u

p a

nd r

em

ind m

oth

er

to g

o t

o “M

t tr

i bé

th”f

ranch

ise f

or

indiv

idual a

nd

gro

up

co

un

selin

g.

When the c

hild

is 5

-6 m

onth

s of

age,

enco

ura

ge t

he m

oth

er

to g

o f

or

CF

pro

mo

tion

.

oM

othe

r hav

ing

6-23

mon

th o

ld c

hild

: Make

hom

e v

isits

to:

Motiv

ate

moth

er

to g

o t

o “M

t tr

i bé

th”f

ranch

ise f

or

CF

counse

ling a

nd f

ood

de

mo

nst

ratio

ns.

Identif

y C

F p

roble

ms;

check

if m

oth

er

pre

pare

s “b

ot”,

“cha

o”pro

perly

and h

ygie

nic

ally

; p

rovi

de

en

cou

rag

em

en

t an

d s

up

po

rt m

oth

er

toove

rcom

e b

arr

iers

to p

ract

ice a

ppro

priate

CF.

Check

if m

oth

er

still

bre

ast

feeds

and p

rovi

de m

otiv

atio

n t

o c

ontin

ue t

o B

F u

p to

24

mo

nth

s o

f a

ge

.

•C

ou

nse

l hu

sban

ds

/fat

her

s/g

ran

dm

oth

ers

to e

nsu

re s

up

po

rt f

or

the

mo

ther

.

•M

oti

vate

hu

sban

ds/

fath

ers

/gra

nd

mo

ther

s to

go

to

“Mt t

ri b

é th

”fr

anch

ise.

•Id

enti

fy

po

siti

ve

dev

ian

ts

and

se

nd

fo

r B

aby

Co

mp

etit

ion

s (a

t C

omm

une)

; en

cou

rag

e b

oth

m

oth

er

and

fa

mil

y to

p

arti

cip

ate

in c

om

mu

nic

atio

n a

ctiv

ity

and

in c

om

pet

itio

ns

in t

hei

r co

mm

un

e.

•D

istr

ibu

te c

om

mu

nic

atio

n m

ater

ials

on

IYC

F a

nd

pro

mo

tio

nal

mat

eria

ls.

AP

PE

ND

IX 2

: C

LIE

NT

RE

CO

RD

ING

AN

D R

EP

OR

TIN

G F

OR

MS

Fig

ure

1:

Too

ls D

iag

ram

Appendix 2


(Com

m. F

ranc

hise

Onl

y)

P3

Daily

Serv

ice

Reco

rd

P2

Mo

the

r Ca

rd

P1

Ma

na

ge

me

nt

Bo

ok

PY

B o

r C

om

pa

rab

le2

# E

ligib

le P

op

. in

the

C

om

mu

ne

Co

un

ting

# P

2

# R

egis

tere

d C

lients

Y1 &

YB

# E

ligib

le

Po

p. a

t ea

ch V

illa

ge

PB

1M

on

thly

FC

R

ep

ort

Pro

vin

cial L

eve

lM

an

ag

em

en

t B

oa

rd

Dis

tric

t le

vel

Exe

cutiv

e B

oard

A&

T H

an

oi &

NIN

Com

mu

ne

Fra

nch

ises

Dis

tric

t F

ranch

ises

Pro

vin

cia

l F

ranch

ises

M2

Sa

tisfa

ctio

n

Feed

ba

ck

HB

Dis

tr.

Quart

erly

Rep

ort

3

TB

Pro

v.

Quart

erly

Repo

rt3

Info

rmat

ion

Flo

w w

ith

in a

Fra

nch

ise

(FC

)

Flo

w o

f M

on

ito

rin

g a

nd

Su

per

visi

on

1F

orm

BP

-M

ont

hly

Fra

nch

ise R

epo

rt -

coul

d b

e u

sed b

y F

C a

t all

leve

ls

2T

he n

um

ber

could

als

o b

e o

btain

ed f

rom

a co

mpara

ble

sourc

e s

uch

as

a

Pre

gnant

wo

men, I

mm

uniz

atio

n,

Nutr

itio

n,

or

Po

pula

tion

reco

rd3

Repo

rts

from

a R

egio

n (V

B),

Pro

vinc

e (

TB

) and D

istr

ict (H

B)

are

sim

ilar

to th

e

PB

repo

rt b

ut w

ill b

e g

enera

ted u

sing e

-fo

rm c

reate

d in

Exc

el

A&

T R

egio

nal

Offi

ces

VB

Reg

iona

lQ

uart

erly

Repo

rt3

P4

Gro

up

Co

un

selin

g

Re

po

rt

Re

por

ting

Flo

w

Superv

isio

n F

low

(F

orm

GS

)

PB

1

Mo

nth

ly

FC

Rep

ort

PB

1

Mo

nth

ly

FC

Rep

ort

PB

1

Mo

nth

ly

FC

Rep

ort

A&

T M

on

ito

rin

g a

nd

Su

per

visi

on

Sys

tem

Fig

ure

2:

Fo

rm Y

1 -

Lis

t o

f w

om

en 7

-9 m

on

ths

pre

gn

ant

and

mo

ther

s w

ith

ch

ildre

n u

nd

er 2

yea

rsFigure 2


Y1.

LIS

T O

F P

RE

GN

AN

T W

OM

EN

7 -

9 M

ON

TH

AN

D

MO

TH

ER

S W

ITH

CH

INL

DR

EN

UN

DE

R 2

YE

AR

S

CB

W n

am

e:........................................................................................................................

.................

Vill

age:........................................................................................................................

.........................

Com

mune:........................................................................................................................

...................

Dis

tric

t:........................................................................................................

...............

.........................

Pro

vince

:........................................................................................................................

.....................

nour

ish. n

urtu

re. g

row

.

Figure 2


Y1.

Lis

t o

f p

reg

nan

t w

om

en 7

-9 m

on

ths

and

mo

ther

s w

ith

ch

ildre

n u

nd

er 2

yea

rs

89

1011

121

23

45

67

89

1011

121

23

45

67

89

1011

12

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

No

Mo

ther

's n

ame

Mo

th

er's

age

Ch

ild d

ate

of

bir

th

1st

Invi

tati

on

ca

rd r

ecei

ved

d

ate

Writ

e do

wn

child

's a

ge b

y m

onth

. Use

this

form

to c

ompl

ete

YB fo

rm.

Yea

r 20

11Y

ear

2012

Yea

r 20

13

Figure 2


Name List of pregnant women 7-9 months and mothers with children under 2 years

Symbol Y1

Purpose

To keep track of mothers from the 7th month of pregnancy until the child is 24months

Provide information to the YB form

Level/Location Hamlets/villages

Implimentor Demand generators (CBW)

Data source List of pregnant women from CHCs or CBWs which they manage themselves

Time/frequency Update monthly or whenever a new mother/pregnant woman comes to the center

Management/ Archives Form Y1 is filled and kept by CBW.

Steps to fill out theform

Fill all information one the cover page: CBW name, village, commune, districtand province name

Collumn (2) The mother’s fullname. Can add the names of their husbands or par-ents in parenthese to distinguish. For example: Nguyen Thi Thanh (Hoa). Note:Write in order of the mother who has the oldest child to pregnant women

Collumn (3) Mother’s date of birth (if known)

Collumn (4) The child's date of birth:

• Write the expected date of birth for the pregnant women update it with actual

date of birth of the child upon delivered.

• In case of premature death or neonatal motality, write down the status at birth

and cross out the rest of the form.

Collumn (5) Date received the first invitation card: The date CBW gives the firstinvitation card to the mother and introduce the Franchise - MTBT.

Collumns (6,7,8): 1 column stands for 1 month: CBW write down the child's ageby month.

Note:

• If the child is more than 24 months old then cross out the rest of the calendar

• If the mother moves to another region or the child has died then note this and

cross out the rest of the calendar.

INSTRUCTION FOR Y1 FORM

Figure 2


Validation/ supervision,support

A) Supervisor (frequency)

1. Franchise management (quarterly)

2. Supervisors from upper level (randomly)

B) Testing method:

Number of mothers matchs the information in A3 and PEMC books

C) Checklist

1. Fill out name of CBW, village, general information

2. Write down the child's age by month

Fig

ure

3:

Fo

rm Y

B –

Mo

nth

ly C

BW

rep

ort

Figure 3


Commun

e:..................................................................

Villag

e:........................................................................

CBW

's n

ame:

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

...

Province

:...

....

....

....

....

....

....

....

....

....

...

District:

....

....

....

....

....

....

....

....

....

....

....

...

June

Dec

embe

rJu

neD

ecem

ber

June

Dec

embe

r

1P

regn

ant w

om

en

7-9

mo

nth

s

2M

oth

ers

giv

ing

bir

th

3M

oth

ers

with

ch

ildre

n 0

- 4

mo

29

d

4M

oth

ers

with

ch

ildre

n 5

- 5

mo

29

d

5M

oth

ers

with

ch

ildre

n 6

- 1

1 m

o 2

9 d

6M

oth

ers

with

ch

ildre

n 1

2 -

23 m

o 9

d

7M

oth

ers

with

ch

ildre

n

24

mo

nth

s

8N

o. o

f in

vita

tion

car

ds

give

n

* Not

e: T

his

form

will

fille

d by

CBW

and

giv

en to

Com

mun

e P

roje

ct s

taff

in t

he m

onth

ly m

eetin

g tw

ice

a ye

ar in

Jun

e an

d D

ecem

ber

Nu

mb

er o

f p

reg

nan

t w

om

en a

nd

mo

ther

s w

ith

ch

ildre

n u

nd

er 2

yea

rs in

vill

age

No

Mo

the

r/p

reg

nan

t w

om

en

sta

tist

ics

2011

(1)

(2)

(3)

2012

2013

Figure 3


Name Number of pregnant women and mothers with children under 2 years in village

Symbol YB

PurposeSummary of the mothers being followed

Provide information for PYB form, only use when no A3 or PEMC books

Level/Location Village/hamlet

Implimentor Demand generator/Commune based worker (CBW)

Data source A3 and PEMC books, or Y1

Time/frequency In June and December

Management/ Archives Form YB will be completed by CBW and reported to Franchise staff


Fill each column using data from A3 and PEMC books, or using Y1 if other twounavailable in June or December

• Pregnant women 7-9 months

• Mothers giving birth

• Mothers with children 0 - 4 mo 29 d




• Mothers with children 24 months

• No. of invitation cards given



1. Franchise manager (monthly)


B) Testing method:

1. Number of subject matchs with A3 and PEMC books, or Y1

INSTRUCTION FOR YB FORM

Fig

ure

4:

Fo

rm P

YB

– S

um

mar

y C

BW

rep

ort

Figure 4


Com

mun

e:...

......

......

......

......

......

......

......

......

.....

Pro

vinc

e:..

....

....

....

....

....

....

...

Dis

trict

:...

....

....

.....

......

......

.....

.

Nu

mb

er o

f p

reg

nan

t w

om

en a

nd

mo

ther

s w

ith

ch

ildre

n u

nd

er 2

yea

rs in

th

e co

mm

un

ity

Mon

th:..

......

....

Yea

r: 20

1 _

Fran

chis

e ID

:.....

......

......

......

......

......

......

......

......

Sum

mar

ied

by n

ame:

……

……

……

……

……

……

……

……

….

Pre

gnan

t wo

me

n 7

-9 m

on

ths

Mo

the

rs g

ivin

g b

irth

Mo

the

rs w

ith c

hild

ren

0 -

4 m

o 2

9 d

Mo

the

rs w

ith c

hild

ren

5 -

5 m

o 2

9 d

Mo

the

rs w

ith c

hild

ren

6 -

11

mo

29

d

Mo

the

rs w

ith c

hild

ren

12

- 23

mo

9 d

Mo

the

rs w

ith c

hild

ren

2

4 m

on

ths

No

. of

invi

tatio

n c

ard

s giv

en

* Not

e: T

his

form

will

com

pile

d by

Com

mun

e he

alth

sta

ff in

Jun

e an

d D

ecem

ber a

t Com

mun

e H

ealth

Cen

ter b

ased

on

YB

repo

rtD

ate…

……

..mon

th…

…...

201…

.F

ran

chis

e m

anag

er

Nam

e a

nd

sig

nat

ure

Nam

e o

f v

illa

ge

s (

1 c

olu

mn

fo

r 1 v

illa

ge

)

SV

cod

e

(1)

1 2 3 4 5 6 7 8

(2)

To

tal

(3)

Lis

t

Figure 4


NameNumber of pregnant women and mothers with children under 2 years in community

Symbol PYB

Purpose Number of pregnant woman and mother with children in community

Level/Location Commune

Implimentor Franchise staff

Data source A3 and PEMC books, or Y1

Time/frequency In June and December

Management/ Archives Store at Franchise document cabinet


Fill in each column is used for village, using A3 and PEMC books, or using YB ifother two unavailable

• Pregnant women 7-9 months

• Mothers giving birth





• Mothers with children 24 months

• No. of invitation cards given

After filling out data of all hamlet/village, Franchise staff calculate and write downin “Total” column.



1. Franchise manager (monthly)


B) Testing method:

Number of subject matchs with A3 and PEMC books, or YB

INSTRUCTION FOR PYB FORM

Fig

ure

5:

Fra

nch

ise

Man

agem

ent

Bo

ok

P1

- F

orm

P1.

1 –

Fra

nch

ise

staf

f’s

trai

nin

g f

ollo

w-u

p

(Fra

nchi

se s

taff

and

coun

selo

r)

Figure 5


NO

NA

ME

TIT

LE

TR

AIN

ED

OR

GA

NIZ

ER

NO

TT

RA

INE

DR

EM

AR

KD

ate

Topi

cVD

DA

&T

Oth

er

Prov

ince

:.....

......

......

......

......

......

..H

ealth

faci

lity:

......

......

......

......

...

Dis

trict

:.....

......

......

......

......

......

.....

Fran

chis

e’s

ID:..

......

......

......

.....

1. S

TAF

F T

RA

ININ

G F

OL

LO

W-U

P O

N IY

CF

Figure 5


Fig

ure

6:

Fra

nch

ise

Man

agem

ent

Bo

ok

P1

- F

orm

P1.

2 –

Fra

nch

ise’

s B

CC

mat

eria

l man

agem

ent

follo

w-u

p c

ard

(F

ranc

hise

man

ager

)

Prov

ince

:.....

......

......

......

......

......

..

Ye

ar: 2

01__

Hea

lth fa

cilit

y:...

......

......

......

......

Dis

trict

:.....

......

......

......

......

......

.....

Fran

chis

e’s

ID:..

......

......

......

.....

NO

DA

TE

RE

CE

IVE

DD

IST

RIB

UT

ED

BA

LA

NC

ES

IGN

RE

MA

RK

Qua

ntity

From

Qua

ntity

To

2. B

CC

AN

D O

TH

ER

PR

OM

OT

ION

AL

MA

TE

RIA

LS

Item

:....

......

......

......

......

......

......

......

......

......

......

......

......

.

Figure 7


Fig

ure

7:

Fra

nch

ise

Man

agem

ent

Bo

ok

P1

– F

orm

P1.

3 –

Fra

nch

ise

item

hal

f ye

ar c

ou

nt,

pag

e 1

(Fra

nchi

se m

anag

er)

ITE

MQ

UA

NT

ITY

RE

CE

IVE

D

JUN

E'S

CO

UN

TD

EC

EM

BE

R'S

CO

UN

T

Goo

dN

ot g

ood

Rem

ark

Goo

dN

ot g

ood

Rem

ark

BC

C m

ater

ials

Counse

ling C

ard

s

Post

er

1: N

urs

e m

ore

Post

er

2: N

o w

ate

r

Post

er

3: N

o form

ula

Loudsp

eake

r sc

ripts

Vid

eo c

lip 1

: N

urs

e m

ore

Vid

eo c

lip 2

: N

o w

ate

r

Vid

eo c

lip 3

: N

o form

ula

3D

Vid

eo: B

reast

-milk

and F

eedin

g

Fu

rnit

ure

Wooden C

hair

5

Pla

stic

Sto

ols

5

Table

1

Docu

ment ca

bin

et

1

Cooki

ng d

em

onst

ratio

n m

odule

1

TV

& D

VD

Shelf

1

Dis

pla

y sh

elf

1

IEC

mate

rials

hold

er

dis

pla

y unit

1

Ch

ildre

n P

lay

Are

a

Boxe

s2

Mats

12

Toy

set 1

1

Toy

set 2

1

3. F

RA

NC

HIS

E IT

EM

(USI

NG

TH

IS C

OPY

FO

R R

EPO

RT)

F

ran

chis

e co

de:

__

__ _

_ __

__

Figure 8


Fig

ure

8:

Fra

nch

ise

Man

agem

ent

Bo

ok

P1

– F

orm

P1.

3 –

Fra

nch

ise

item

hal

f ye

ar c

ou

nt,

pag

e 2

(Fra

nchi

se m

anag

er)

ITE

MQ

UA

NT

ITY

RE

CE

IVE

D

JUN

E'S

CO

UN

TT

HN

G K

Ê T

HÁ

NG

12

Goo

dN

ot g

ood

Rem

ark

Goo

dN

ot g

ood

Rem

ark

Roo

m A

cces

scor

ies

Length

board

1

Sca

le for A

ldults

1

Sca

le for

Child

ren

1

Tease

t1

Clo

ck1

Stic

kers

Rule

r1

Sm

all

Logos

for

random

use

10

Big

Logo

1

Deco

. st

icke

rs (r

ainb

ow, f

low

ers)

1

Sign

age

Sig

nage

(out

door

)1

Sig

nage

(indo

or)

1

Coo

king

Acc

esso

ries

Big

bow

ls2

Sm

all

bow

ls12

Apro

n2

Pla

tes

3

Measu

ring c

up 5

0 m

l1

Measu

ring c

up 1

00 m

l (ho

c 150m

l)1

Measu

ring c

up 2

50 m

l1

Wate

r C

onta

ine

r1

Dip

per

1

Pla

stic

basi

n1

Oth

er re

late

d m

ater

ials

TV

DV

D p

laye

r

Food p

yram

id

PE

MC

heig

ht board

Figure 8


INSTRUCTION FOR P1 BOOK

Name Management book

Symbol

YBP1.1 Franchise staff follow-up IYCF training

P1.2 BCC and promotional materials

P1.3 Franchise item half year count

Purpose

Franchise manager use this book when:• Reporting and planning

• Auditing of property periodically

Level/Location Franchises in provinces, districts and communes


Data source Counting

Time/frequency

• Staff training follow-up on IYCF: update when ever staff change (staff move to otherCHC, new staff…)

• BCC and other promotional material management follow-up card: update wheneversomething changes (receive, distribute or report)

• Franchise item half year count: twice a year (in June and December) - Copy this pageattach to Monthly report to management board

Management/ Archives Franchise manager stores P1 book in document cabinet/folder

Steps to fill out the form

P1.1 Staff training follow-up on IYCF• Name column: Staff’s fullname. Addition will be filled at the end of the list

• Title at Franchises and health facilities

• Training: Write training time & topic.

• Cross “X” in column “Not trained” if they have not been trained

• Organizer: Multiple choice. For example: A&T and NIN

P1.2 BCC and other promotional material management follow-up cards• Use one form P1.2. for each BCC material. for example: Invitation cards, mother & child

book, posters, leaflets...

• Each time a BCC material is received or distributed, Franchise staff fill out information in1 row

• When there is no more space, start a new form, staff write down “Stored” number in to“Store” in the first row of the new form.

P1.3 Franchise item half year count (Copy for report)• This is the franchise item list for each facility

• In June and December annually, Franchise staff check the facility item and write downnumber of each item into columns: "Good" - available for using "Not good" for broken ifmissing write into "Remark". And then Franchise manager sign and attach a copy withmonthly report to managerment board.


A) Supervisor (frequency)1. Franchise manager (monthly, quaterly)2. Supervisors from the management board (monthly, quarterly)

B) Supervise method:1. Check is data is filled out on all forms

2. Randomly choose 1 BCC material: compare the stored number in form and realstored number.

Figure 9


Fig

ure

9:

Fo

rm P

2 –

Mo

ther

car

d a

t th

e fr

anch

ise,

pag

e 1

G1

a

G1

b

G1

c

G2

G3

a

G3

b

G3

c

G3

d

G4

NoM

othe

r's n

ame:

____

____

____

____

____

_

Add

ress

:___

____

____

____

____

_Pho

ne:_

____

____

__C

hild

's ID

: __

__._

__._

___

Reg

istra

tion

date

: __

__/_

_ __

/__

__

End

dat

e: _

_ __

/__

__/_

_ __

Rea

son:

____

____

____

__F

ranc

hise

's ID

:__

__ _

_ __

Yes

No

EB

F

Pro

mo

tio

n 1

EB

F

Pro

mo

tio

n 2

EB

F

Pro

mo

tio

n 3

7th

mo

nth

o

f p

regn

an

cy

8th

mo

nth

o

f p

regn

an

cy

9th

mo

nth

o

f p

regn

an

cy

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

1 2

Preg

nanc

y ou

tcom

e: 1

chi

ld;

Twin

;> 2

chi

ldre

n;

Prem

atur

e de

ath;

Neo

nata

l mor

tali

tyF

ull G

1:

Yes

N

o

EB

F s

up

po

rtD

eli

very

Init

iate

BF

<1

h:

Yes

No

EB

F

ma

na

gem

en

t 1

2 -

4 w

eeks

a

fter

deli

very

BF

[

] W

ate

r [

] O

ther

mil

k [

]

CF

[ ]

**

EB

F

ma

na

gem

en

t 2

1-2

m

on

ths

BF

[

] W

ate

r [

] O

ther

mil

k [

]

CF

[ ]

EB

F

ma

na

gem

en

t 3

2-3

m

on

ths

BF

[

] W

ate

r [

] O

ther

mil

k [

]

CF

[ ]

EB

F

ma

na

gem

en

t 4

4-5

m

on

ths

BF

[

] W

ate

r [

] O

ther

mil

k [

]

CF

[ ]

CF

ed

uca

tio

n5

-6

mo

nth

sB

F [

]

Wa

ter

[ ]

Oth

er

mil

k [

]

CF

[ ]

CH

K:

/

/Fu

ll G

3:

Yes

No

Fu

ll G

1 r

ecei

ve:

a

t lea

st 1

co

nta

ct a

t 9th

m

on

th

/

/

/

/

Exp

ecte

d da

te o

f birt

h:D

ate

of b

irth:

Del

iver

y pl

ace:

CH

C; D

ist.

hosp

ital

; Pr

ov/N

aon

al h

ospi

tal;

Hom

e; O

ther

6 m

onth

s of

age

:(E

nd-m

onth

che

ck)

Full

G3:

rece

ived

G3a

and

G3c

EB

F un

der

6 m

onth

s:

Yes

No

Serv

ice

Tim

e t

o

co

un

sel

Receiv

er

Mo

m;

Da

d;

Gra

nd

pa

ren

ts;

Oth

er

Co

un

seli

ng

d

ate

MO

TH

ER

CA

RD

AT

FR

AN

CH

ISE

Pra

cti

ce (

tick

bo

xes

)/C

ou

ns

eli

ng

to

pic

(w

rite

do

wn

)

Ex

po

su

re

to M

M*

Nex

t co

un

sel

ing

d

ate

Hea

lth

s

taff

s

ign

atu

reR

em

ark

Figure 10


Fig

ure

10:

Fo

rm P

2 –

Mo

ther

car

d a

t th

e fr

anch

ise,

pag

e 2

G5a

G5b

G5c

G5d

G5e

G5f

G5

a

G5

b

G5

c

G5

d

CF

ma

na

gem

en

t 1

CF

ma

na

gem

en

t 2

CF

ma

na

gem

en

t 3

CF

ma

na

gem

en

t 4

CF

ma

na

gem

en

t 5

CF

ma

na

gem

en

t 6

6-7

m

on

ths

BF

[

] I

nfa

nt fo

rmu

la [

]

CF

8-9

m

on

ths

BF

[

] C

F: Q

ua

nt (2

mea

ls,1

/2 b

ow

l) [

]

Va

riety

[

]

10

-11

m

on

ths

BF

[

] C

F: Q

ua

nt (2

mea

ls,1

/2 b

ow

l) [

]

Va

riety

[

]

12

-14

m

on

ths

BF

[

] C

F: Q

ua

nt (3

mea

ls,3

/4 b

ow

l)[

]V

ari

ety

[

]

15

-18

m

on

ths

BF

[ ]

CF

: Q

ua

nt (3

-4 m

ea

ls,3

/4 b

ow

l) [

]

Va

riety

[ ]

18

-24

m

on

ths

BF

[

] C

F: Q

ua

nt (

3-4

mea

ls,1

bo

wl)

[

]V

ari

ety

[

]

CH

K:

/ /

Fu

ll G

5:

Yes

N

o

___ _

__

Fu

ll 5

p

ackag

es:

Yes

N

o

Ab

bre

via

tio

ns:

BF

=B

rea

stf

eed

ing

CF

=C

om

ple

men

tary

feed

ing

CH

C=C

om

mu

ne h

ea

lth c

en

ter

Dis

t.=D

istr

ict; P

rov.=

Pro

vin

ce

EB

F=E

xcl

isiv

e b

rea

stf

eed

ing

G=C

on

su

ltin

g p

ack

ag

e

3

24 m

on

ths o

f a

ge:

(End

-mon

th c

heck

)F

ull G

5: re

ceiv

ed G

5a, G

5b, G

5c &

G5d

BF

un

til 2

4 m

on

ths

Yes

N

o

To

tal n

um

ber

of

sevic

es

pro

vid

ed

Ful

l 5 p

acka

ge if

mot

her g

ot fu

ll G

1, G

2, G

3, G

4 an

d G

5

*E

xp

osu

re to

mass m

ed

ia o

f th

e m

oth

er:

** T

ick b

ox [

]:

X -

yes, 0 -

no

In th

e la

st 30 d

ays, h

ave y

ou

exp

osu

red

to

IY

CF

info

r. f

rom

TV

, ra

dio

, lo

ud

sp

ea

ker,

new

sp

ap

ers

,

inte

rnet?

(N

ot in

clu

de f

om

ula

pro

mo

tion

)

No

Yes

No

Serv

ice

Tim

e t

o

co

un

sel

Receiv

er

Mo

m;

Da

d;

Gra

nd

pa

ren

ts;

Oth

er

Co

un

seli

ng

d

ate

Pra

cti

ce (

tick

bo

xes

)/C

ou

ns

eli

ng

to

pic

(w

rite

do

wn

)

Ex

po

su

re

to M

M*

Nex

t co

un

sel

ing

d

ate

Hea

lth

sta

ff

sig

na

ture

Rem

ark

Figure 10


INSTRUCTION FOR P2 FORM

Name Mother card at Franchise

Symbol P2

Purpose Record services provided to each mother



Data source Counselor writes this down themselves

Time/frequencyUpdate after each service is delivered. In addition, at delivery, when the child com-pletes 6 months and 24 months check the card at the end of each month to identifyoutcome indicators.

Management/ Archives

• Franchise staff keep P2 card in Franchise Data folder/Document cabinet

• Arrange P2 cards in ascending order of the child's ID number and by groups:Pregnant women 7-9 months, child 0-5 months, child 6-23 months and child 24 months

• Pick up the card and use it in the counseling process

• After completing the counseling card, put the card in the daily box card holder

• After the working day, Franchise staff summarize service delivery and other information to update the P3 form – “Daily service record”

• After finish P3 form, put P2 card back to Data folder/Document cabinet

• When a child 24 months or a mother moves to another province, the P2 cardwill be placed in the storage folder.

• All P2 cards must be stored at least 1 year after the project is finished and handled by the management board.


A) Identify the child’s ID and get the P2 card

1. At registration (1st time): Establish a P2 card for each mother

• Identify the child's ID: based on year/month/date of child's birth (Example:110715 - child was born in 15th July 2011). For pregnant woman, give tempo-rary ID with year/month/expected date of birth by pencil and write official IDafter delivery. If the Franchise has more than 1 child born within a day, addletter "a, b, c..." to distinguish.

• Write down general information into Baby book (M1). Guide the mother on howto use this book.

2. If the mother has a P2 card, based on the child's ID, date of birth or expected birth, mother's name to find the appropriate P2

B) Filling out P2 card while counseling

Note, accept recall information for G2 and þ 1-3. While recalling G2, receivedG2 when (1) was guided on breastfeeding and (2) did not use formula

1. Rows start by "G": Based on one counseling session (pregnant, child ageby month) to identify:

Figure 10



1.1. Counseling receiver: write down all receivers by group: mother, father,grandsparents or other.

1.2. Counseling date: Date of counseling

1.3. Practice (tick boxes)/Counseling topic (write down): the day before counseling

• Tick practice boxes [ ] (X for yes and 0 for no)• Example: in G3c row: Child receiving breast milk, water and formula and not

yet receiving complementary foods, please fill in: BF [X] Water [X] Formula milk[X] CF[0]

• Write down counseling topic, note for follow-up

1.4. Mass media exposure: Ask mother about mass media exposure on infant andyoung child feeding in last 30 days if yes cross X into Yes column, if not, crossX into No column.

1.5. Next counseling date: write the next counseling date.

1.6. Health staff signature: counselor signs

1.7. Remark: Counselor writes down other criteria information

2. Rows start at tick box þ:þ 1. End of pregnancy:

Ask and write tentative birth date

When mother delivered, circle appropriate words in Pregnant outcome and

Delivery place

þ 2. Child is 6 month of age:

Exclusive breastfeeding in the first 6 months: Based on actual practice in rows G3a-d: Circle Yes if all are only BF and no water, no infant formula and no CF otherwise circle No

Call to get this information if the mother doesn't come in for counseling

Full G3: received G3a and G3c

þ 3. Child is 24 month of age:

Continue BF at 24 months: At the last contact G5f, child is still BF

Call to get this information if the mother doesn't come in for counseling

Full G5: received G5a, G5b, G5c & G5d

Count and write down total number of services provided

Full received: the mother receive G1, G2, G3, G4 and G5 when child is 24 months of age

Write the end date and reason. Common reasons for the completion of follow up are: 24 months, out migration, and death


A) Supervisor (frequency)1. Franchise manager (weekly, monthly)2. Supervisor from a district or province (monthly, quarterly)

B) Supervise method:1. Supervisor get 3 P2 forms randomly, check general information and

counseling information

2. Compare P2 form and service row of P3

Figure 11


Fig

ure

11:

Fo

rm P

3 –

Dai

ly s

ervi

ce r

eco

rds

at t

he

fran

chis

e

No

12

34

56

78

910

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

Tota

l

G1

G3

G2

G4

G5

GF

1

GF

2

Pro

vin

ce:.

......

......

......

......

......

......

.M

on

th:_

_ __

H

ealt

h f

acili

ty:

......

......

......

......

......

......

...

Dis

tric

t:...

......

......

......

......

......

......

.Y

ear:

201

__

Fra

nch

ise'

s ID

: __

__

__ _

_ __

Se

rvic

es

EB

F P

rom

otio

n

Full

G1

EB

F S

up

po

rt

EB

F m

an

agem

en

t

Full

G3

CF

ed

uca

tio

n

CF

Man

agem

en

t

Full

G5

Fu

ll 5

pa

cka

ge

(9

-14

co

nta

cts

)

Fu

ll 5

pa

cka

ge

(1

5

co

nta

cts

)

MM

oth

ers

BF

ath

ers

ÔG

ran

dp

are

nts

KH

Oth

ers

BS

Initia

te <

1h

BH

TE

BF

in f

irst

6 m

o

AB

SA

cce

pta

ble

die

t

BM

BF

at

24

mo

nth

s

No.

of

new

clie

nts

(new

P2

ca

rd)

O

utc

om

e

DA

ILY

SE

RV

ICE

RE

CO

RD

S

Clien

ts

No

. o

f co

un

se

ling

co

nta

cts

(t

ota

l P

2 c

ard

)

Exp

osu

re t

o m

ass m

ed

ia

Figure 11



Name Daily service records

Symbol P3

Purpose• Summarize delivery of daily services at the Franchise

• Provide information for form PB


Implimentor Franchise's staff

Data source P2

Time/frequency• Update after counseling

• Summarize at the end of month for the Franchise monthly report-PB


• Form P3 will be stored in the document cabinet.

• Form P3 will be arranged by month and year in 1 folder. It has label “P3 – Dailyservice record”, name of Franchise, Franchise’s ID and Franchise manager’sname outside folder.

• All P3 forms must be stored until the end of project.


A) Daily update:

1. After the working day is finished, collect all P2 forms and fill in the appropriate

column.

2. Check all P2 forms for the record number of each service, write 0 for the rest

of the rows.

Counseling service: number of services for each package

Client by groups: mother, father, grandparents and other

Number of counseling contacts: count and write number of P2 cards

New client: count and write number of new P2 cardsMass media exposure

within the last 30 days about breastfeeding and apporpiate complementary

feeding

Outcome:

Initiate BF: check P2 card every working day

Figure 11



EBF in first 6 months: Count P2 card record "Yes" in þ 2. Accept calling for information

Continue BF at 24 months: Count P2 card record "Yes" in þ 3. Accept callingfor information if the mother doesn't come

Acceptable diet: Count P2 card is acceptable (meal frequency, size and variety) the day before counseling

B) Summary at the end of monthSummarize by rows in the table to complete Franchise Monthly report -PB.



1. Franchise manager (weekly, monthly)

2. Supervisor from a district or province (monthly, quarterly)

B) Supervise method:

Check rows and columns summary with Franchise Monthly report -PB.

Figure 12


Fig

ure

12:

Fo

rm P

4 –

Gro

up

co

un

selin

g a

nd

bab

y co

mp

etit

ion

(Fra

nchi

se m

anag

er)

Pro

vinc

e:...

......

......

......

......

......

.....

Mon

th:_

_ __

H

ealth

faci

lity:

......

......

......

......

......

......

......

Dis

tric

t:....

......

......

......

......

......

......

Yea

r: 2

01 _

_F

ranc

hise

's ID

: __ _

_ __

__

__

1.

Pre

gn

an

t w

om

an

an

d m

oth

ers

Pre

gnant

wom

an

Moth

er

with

child

0

-5 m

Moth

er

with

ch

ild 6

-11

m

Mot

her

with

ch

ild 1

2-23

mF

ath

er

Gra

nd

pare

nts

2.

Healt

hy b

ab

y c

om

peti

tio

n:

1. Y

es

2. N

o

Child

0-5

mC

hild

6-1

1m

Child

12

-23

m

Dat

e……

…..m

onth

……

...20

1….

Fra

nc

his

e m

an

ag

er

Nam

e an

d si

gnat

ure

GR

OU

P C

OU

NS

EL

ING

AN

D B

AB

Y C

OM

PE

TIT

ION

Date

No.

of part

icip

ant

Topic

Date

Mate

rial used/

Dis

trib

ute

dN

o

No.

of part

icip

ant by c

ate

gory

Tota

l

Tota

l

Prorr

vivvniice

:.....

......

......

......

......

......

...M

onthtt

:___

___H

ealthtt

faffci

liiilltyt

:yyy:yyy.::....

......

......

......

......

......

......

Disii

trttirrc

t:....

......

......

......

......

......

......

Ye

YYar

:rr20

1___

Fr

FFarrnc

hisiie'

s'ID

:______

______

___

1 2No

1 2 3 4 To

tal

Figure 12



Name Group counseling and baby competition

Symbol P4

Purpose• List all group counseling delivered in a month

• Provide information for form PB



Data source Group counseling at Franchises and baby competitions organized at the facility

Time/frequency• Update each group counseling when delivered

• Send a copy for the Franchise monthly report

Management/ Archives• Keep form P4 in the document cabinet

• Send a copy for the Franchise monthly report


1. Group counseling: 1 line is used for 1 group counseling session

• Counselor observes and fills out information in columns:

• Counseling date

• Topic

• Material use/Material distributed

• Count and write down the number of participants by groups:

Pregnant women

Mothers with children 0-5 months



If fathers or grandparents participate, the counselor writes in appropreate columns

• Then write down total participation

• At the end of month, the counselor or franchise manager summarizes numberof participants in the “Total” row.

2. Baby competition: If organized circle 1. Yes and write number of participants(baby/mother). If not organized circle 2. No



1. Franchise manager (weekly, monthly)

2. Supervisor from management board (monthly, quarterly)


1. Supervisors check this form to see if all information for each counseling session is filled out

2. Participate observation: observe the counselor filling out information in counseling.

Figure 13: Form P5 – Client Referral Form

Figure 13


Mother's name:....................................... Child's ID: ___.___.___

Address:..................................................

Child's name:.......................................... Franchise's ID:__ __ __

Child's (tentative) birthday: ....../....../......

1. Name of facility making the referral: _______________________________________

2.

3.

Referal date: __ __/__ __/_________

Services received at this facility: (Circle, multiple response)

3.1. EBF promotion 3.3. EBF management

3.2. EBF support (at delivery) 3.4. CF education

3.5. CF management

4. Facility referred to: _____________________________________________________

5. Service(s) for which client is being refered: (Circle, multiple response)

5.1. EBF promotion 5.3. EBF management

5.2. EBF support (at delivery) 5.4. CF education

5.5. CF management

6. Reason for referal: (Eg: No delivery facility at health centre, high risk case, illness, etc…)

……………………………………………………………………………………………………

……………………………………………………………………………………………………

7. Outcome of referance : ……………………………………………………………………..

8. Other comments: …………………………………………………………………………….

_____, date___ month ___ year 201__ _____, date___ month ___ year 201__

Referry facility Referry facility

Franchise staff

Name and signature

Franchise staff

Name and signature

CLIENT REFERAL FORM

Figure 13



Name Client referral form

Symbol P5

Purpose To refer client to other Franchise to receive counseling service

Level/Location Franchises at province, district and commune


Data source Counselors write it themselves base on information in P2 card

Time/frequency Refer a mother to another Franchise each form is used for 1 client

Management/ Archives• Give this form for client bring to other Franchise

• Record into P2 card


• Complete general information: Mother’s name address child’s name and birth-day (if delivered) child’s ID and Franchise ID

• Name of facility, referral date

• Counselor circles the number of service(s) that mothers received at this Fran-chise and service(s) that mothers need to receive at the new Franchise

• Give this form to mother and she will send to new Franchise



1. Franchise manager (monthly, quarterly)

2. Supervisor from district or province (monthly, quarterly)


1. Supervisors check this form for filling out all information on P5 and P2 forms

2. Participate observation: observe counselor filling out information in counseling.

Figure 14: Form PB – Franchise monthly report (Franchise manager)

Figure 14


Province: .............................. Month:.... Health facility: .............................

District: ................................ Year 201.... Franchise's ID: _ _ _ _

2.1. Service delivery (from P3)

N

N

N %

7-9 months of pregnancy

7-9 months of pregnancy

Mother with a child 6-23 months old

Clients

Mothers

Fathers

Others

Mother with a child <24 months old

No. of counseling contact

No. of new clients

3. Client satisfaction result (No. of M2)

Exposure to mass media

No. of questionnaire

Outcome

Early initiation within 1h

Comment from client:

EBF under 6 months

CF: acceptable diet

Continue BF at 24 month

2.2. Group couseling (from P4)

4. Franchise material managerment (from P1 book, biannual in June and December)

No BCC materialStored

from last quarter

Receivedthis

quarter

Total Distribute this quarter

Stored next

quarter

Need morecopy

A B 1 2 3=1+2 4 5= 3-4 6

1 Poster

2 Leaflet 1

3 Leaflet 2

4 Leaflet 3

5 Invitation card

6 Baby book

7

5. Any other omment/suggestion

5.1. No. of new clients (increase or decrease): ……………………………………………………………..................................…………5.2. Negative events (natural disaster: flood, storm…) ……………………………………………………............................................…Positive event (BF, CF campaing...)……………………………………………………………………………………………………….....…5.3. Urgent need: ……………………………………………………………………………………………………………………………........

Date………..month……...201….Prepared by

Name and signatureFranchise managerName and signature

book

C

each

piece

piece

piece

each

Unit

No. of group counselled

1.2. General information (from PYB, A3, PEMC, Immunization or population record) G5 - Complementary feeding management

Complete (mother with a child 24 months old)

Full G5

GF1 - Full 5 packages (9-14 contacts)

GF2 - Totally full 5 packages (15 contacts)

G4 - Complementary feeding education

Mother with a child 0-5 months oldG3 - EBF management

G2 - EBF support

Full G3

FRANCHISE MONTHLY REPORT

Subjects

Subjects

Type of service received

G1 - EBF promotion

Mother delivered in this month Full G1

1.1. Number of clients (No. of registered P2)

Grandparents

Figure 14


INSTRUCTION FOR PB FORM

Name Franchise monthly report

Symbol PB

PurposeSummary Franchise activities of the report month Include PYB and P1.3 with thereports for June and December



Data sourceForms: P1, P3, P4, M2, PYBAlternative to form PYB, franchises at the commune level can use available infor-mation from the pregnancy book (A3) and PEMC for report to complete form PYB

Time/frequency On the 5th of every month


Save 1 copy at the FranchiseFranchise at commune and district levels send the report to the District manage-ment board, Franchise at province level send the report to the Province manage-ment board.


1.1. Number of clients (count number of P2 card are follow-up at Franchise) bygroups.

1.2. General information: from "Total" column in PYB form, which might gather fromthe Pregnant book (A3) for PEMC report. Photocopy and include PYB form.

2.1. Service delivery (from P3 form): Get data from "Total" column of P3 form tofill this session % = Service delivery / Client are followed

2.2. No. of group counseling sessions: from P4 form3. Client satisfaction results: write no of forms M2 received4. Franchise material managerment based on P1.2 report in June and Decem-

ber Copy P1.3 form and attach to this report5. Any other comments/suggestions:

• No. of new clients (increase or decrease)• Negative events (natural disaster: flood, storm…)• Positive events (BF, CF campaing...)• Urgent need



1. Supervisor from management board (quarterly)


1. Compare report with P3 card and management book.

Denominator Numerator

- Pregnant women 7th-9th months pregnant G1

- Delivery Full G1 or G2

- Mother with a child 0-5 months G3, full G3 or G4

- Mother with a child 6-23 months G5

- Complete (Mother with a child 24 months old) Full G5, GF1, and GF2

Figure 15: Form M2 – Client satisfaction questionnaire

Figure 15


Province: .............................. Health facility: ..........................................District: ................................Year: 201__ Franchise's ID: __ __ __ __ __

Date of Service ___/ ____/______

Service Received ……………………………………………………………………………

1. How did you hear about the IYCF franchise? (Multiple response)Circle

a. Health staff d. Leaflet, TV chanelsb. Community based workers e. Franchise sign at gatec. Other mother/s f. Others (specify)..............................................

2. How many minutes did you wait for counseling? Note your waiting time (in minutes)

...........................................................................................................................................................................

3. Do you feel that the counselor

a. Was friendly to you?

b. Gave enough information for you to make a decision about infant feeding: 1. YES 2. NO

c. Listened to you:

d. Responded to your concerns or problems:

e. Was supportive with no judgment:

4. Overall, how would you rate the quality of IYCF services at this facility?

Circle one: 1. POOR 2. FAIR 3. GOOD 4. EXCELLENT

Comments:…………………………………………………………..……………………………………………………………………

…………………………………………………………..……………………………………………………………………

5. Your comments and suggestions to improve the quality of the IYCF services at this facility

…………………………………………………………..……………………………………………………………………

…………………………………………………………..……………………………………………………………………

6. Will you recommend the IYCF service at this facility to a friend or family member?

Circle one: 1. YES 2. NO

If NO, please explain:…………………………………………………………..……………………………………………………………………

…………………………………………………………..……………………………………………………………………

THANK YOU VERY MUCH!

CLIENT SATISFACTION QUESTIONNAIRE

Yourhelp in completingthis questionnaireis valuablefor us to provideour clientswith the bestquality of care.Please leave the completed questionnaire in the designated box. Your responses are confidential. Thank you!

1. YES 2. NO

1. YES 2. NO

1. YES 2. NO

1. YES 2. NO

TRAINEE HANDBOOK TWO

Counseling on Infant and Young Child Feeding

at Health Facility

Ha Noi, July 2011

Alive & Thrive Vietnam203 - 204, E4BTrung Tu Diplomatic CompoundNo 6 Dang Van Ngu, Ha Noi

Tel: +84-4-3573 9066Fax: +84-4-3573 9063www.aliveandthrive.org

trainee handbook 2 - Alive & Thrive

Documents

Transcript of trainee handbook 2 - Alive & Thrive