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Page 1: Infant & Young Child - FSN  · PDF fileInfant and Young Child Feeding Counselling i Infant & Young Child Feeding Counselling A Community–Focused Approach TRAINER’S GUIDE
Page 2: Infant & Young Child - FSN  · PDF fileInfant and Young Child Feeding Counselling i Infant & Young Child Feeding Counselling A Community–Focused Approach TRAINER’S GUIDE
Page 3: Infant & Young Child - FSN  · PDF fileInfant and Young Child Feeding Counselling i Infant & Young Child Feeding Counselling A Community–Focused Approach TRAINER’S GUIDE

Infant and Young Child Feeding Counselling i

Infant & Young Child Feeding Counselling

A Community–Focused Approach

TRAINER’S GUIDE

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ii Infant and Young Child Feeding Counselling

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Infant and Young Child Feeding Counselling iii

T

Continued

Acknowledgments

HEtrainingpackageforInfant and Young Child Feeding Counselling: A

Community-Focused Approachreflectsacollaborationthatdrawsonthe

experiencesandpastworkofmanyindividualsandgroups.Thispackage,

includinganintegratedsetofcounsellingcards,anIYCF Counselling Trainer’s Guideand

trainingaids,hasbeendevelopedundertheCAREInfantandYoungChildFeedingin

Emergencies(IYCF-E)Initiative,inpartnershipwithURC/CHS.Thecommunity-focused

counsellingpackagewaspilotedandfirstusedtosupportprogrammingintheDadaab

CampsinnortheasternKenya,wheretheIYCF-EInitiativecurrentlysupportstheworkof

theDadaabIYCFTeam,whosemembersincludeCAREKenya,UNHCR,GTZandNCCK.

TheworkoftheCAREIYCF-EInitiativeissupportedbyagrantfromaprivatedonorto

CAREUSA.

ThetechnicalcontentofthetrainingpackageisbasedontheWHO/UNICEF

breastfeedingcounselling,complementaryfeedingcounselling,andinfantandyoung

childfeedingintegratedcounsellingcourses.Theapproachdrawsfrominfantfeeding

andotherbehaviourchangecommunicationmaterialspreviouslydevelopedbyURC/

CHSinTanzania,Niger,BeninandGuatemala,withsupportfromUSAID.

ItalsoreflectstrainingmaterialdevelopedbytheAcademyforEducational

Development’sLINKAGESProjectandtheIFE(InfantFeedinginEmergencies)Core

Group’sIFE Module 2forhealthandnutritionworkersinemergencysituations.TheIFE

CoreGroupisaninteragencycollaboration(ENN,IBFAN,CAREUSA,UNICEF,UNHCR,

WHOandWFP)focusedonthedevelopmentofpolicyandtrainingmaterialstosupport

appropriateinfantandyoungchildfeedinginemergencies.

Thisversionofthetrainingpackageisa“livingdocument”thathasbeenupdated

followinganinitialpilottestingintheDadaabCampsinMay2007.Additional

adjustmentsareanticipated,basedonfutureuseandtechnicalfeedback.

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iv Infant and Young Child Feeding Counselling

Wewouldliketoacknowledgetheactiveparticipationofthefollowingagenciesand

individualsinthedevelopmentofthismaterial:

FromtheDadaabCampsinteragency(UNHCR,CARE,GTZandNKKC)IYCFTeam:

DadaabIYCFCoordinationTeam:RoseNdolo,CAREKenya;GloriaKisia,UNHCR;AnneNjuguna,formerlyCAREKenya

HagaderaCampTeam:MillicentKavosa,KhadijoNoorUbahle,FatumaMohamedAli,DekaAbdiAhmed

DagahaleyCampTeam:VictorMwiti,HabiboYahveIman,AnnaOmarIsmail,MaryanneMohamudAden

IfoCampTeam:PhyllisObote,RoseKathuri(GTZ),HawoNegashStephano,OgudDidumoCham,BashirIbrahimMohamed

FromCAREKenya:

KristinHelz,MohammedQazilbash,FelixOkech,AgnieszkaKorus

IndependentConsultants:

MaryanneStone-Jiménez,InfantandYoungChildFeedingandtrainingspecialist

Dr.FelicitySavage,HonorarySeniorLecturer,InstituteofChildHealthLondon;Chairperson,WorldAllianceforBreastfeedingAction;formerMedicalOfficerDepartmentofChildandAdolescentHealth,WorldHealthOrganization,Geneva

FromURC:

PeggyKoniz-Booher,Sr.TechnicalAdvisor;VictorNolasco,Artist;Kurt

Mulholland,GraphicDesigner;TisnaVeldhuyzenvanZanten,VicePresident

FromtheCAREUSAIYCF-EInitiative:

MaryLung’aho,SpecialAdvisor,IYCF-Emergencies;AbigailBeeson,ProgramAssociate,IYCF-E;BethannCottrell,ChildHealthandNutritionTeamLeader

Mostimportantly,wewouldliketoacknowledgethewomenandyoungchildrenliving

intheDadaabCamps.Wethankthewomenfortheirinspiration,andtheirdesireto

improvethehealthandwholenessofthemselvesandtheirfamilies.

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Infant and Young Child Feeding Counselling v

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

5-DayIYCFCounsellingTrainingAgenda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

SESSION1 Introductions,Expectations,WhyWeAreHere . . . . . . . . . . . . . . . . . . . . . . . . . . .7

SESSION2 HowtoCounsel:TalkingwiththeMother/Caregiver. . . . . . . . . . . . . . . . . . . . . .11

SESSION3 ImportanceofBreastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

SESSION4 HowtoBreastfeed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

SESSION5 CommonBreastConditions:Symptoms,PreventionandSolutions;andInsufficientMilk…. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

SESSION6 CommonSituationsthatCanAffectBreastfeeding;andIdentifyingSignsthatRequireMother/Caregiver/FamilytoSeekCare. . . . . . . . . . . . . . . . . .36

SESSION7 HowtoCounsel:PractiseCounsellingwithMothersofBabiesLessthan6Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

SESSION8 HowtoCounsel:Communityand/orFacilityPractiseandFeedback. . . . . . . . . . .56

SESSION9 ComplementaryFeedingPracticesforChildren6–23Months . . . . . . . . . . . . . . .58

SESSION10 FeedingoftheSickInfantandYoungChild. . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

SESSION11 InfantFeeding:HIV-PositiveMother,andSevereMalnutritionofInfantandYoungChild . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

SESSION12 HowtoCounsel:PractiseCounsellingwithMothers/CaregiversofBabiesGreaterthan6Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

SESSION13 HowtoCounsel:Communityand/orFacilityPractiseandFeedback. . . . . . . . . . .82

SESSION14 FinalEvaluationofIYCFCounsellingTraining . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

APPENDIX1 KeyandSupportingMessagesofCounsellingCards . . . . . . . . . . . . . . . . . . . . . .87

APPENDIX2 ContentsofTrainingPackage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105

APPENDIX3 DirectionsforMakingBreastModels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

APPENDIX4 CutOutsforDailyEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107

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vi Infant and Young Child Feeding Counselling

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Infant and Young Child Feeding Counselling �

TIntroduction

HEInfant and Young Child Feeding Counselling Trainer’s Guideispartofatrainingpackage

totrainlowliteracy,community-levelInfantandYoungChildFeeding(IYCF)Counsellors

tohelpmothers,fathersandothercaregiversoptimallyfeedtheirinfantsandyoung

children.TheGuideisintendedtoequiptrainerswithbasiccounsellingskills,andtechnical

knowledgeofkeypracticesandmessagesrelatedtobreastfeeding,infantandyoungchild

complementaryfeeding,andfeedingofthesickchild.Basiccounsellingskillsinclude:listening

andlearning,buildingthemother’s/caregiver’sconfidence,providingsupportandpracticalhelp,

andnegotiating(“reaching-an-agreement”inDadaab)byapplyingthe“assess,analyzeandact”

steps.

Thekeypracticesareillustratedonanintegratedsetof18counsellingcards,anddescribedin

aMessageBookletthataccompaniestheTrainer’sGuide.Participantsbecomefamiliarwiththe

basiccontentofthekeypracticesandmessagesthroughtheuseofthecounsellingcards.Hands-

onpracticeisthefocusoftheIYCFCounsellorstraining,withemphasisoncounsellingskillsand

theeffectiveuseofthecounsellingcardsandothervisualmaterials.IYCFCounsellorsmaybe

TBAs,CommunityHealthWorkers(CHWs)orprojectstaffwithmoreadvancedIYCFtrainingwho

actaspointsofreferralforthelow-literate,lessexperiencedIYCFCounsellorsandtogetherforma

communitynetworkofIYCFsupport.

TheInfant and Young Child Counselling Trainer’s Guideandtrainingaidsweredevelopedforuse

inlowresourcesettings,withoutdependenceontheuseofslidesorothermediaprojection,flip

chartsorwritingmaterials.(SeeAppendix1forthecontentsofthekeyandsupportingmessages

ofthecounsellingcards;seeAppendix2forthetrainingaids.)

ThroughouttheIYCF Counselling Trainer’s GuidethetrainersarereferredtoasFacilitatorsandthe

traineesasParticipants.

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� Infant and Young Child Feeding Counselling

Training AgendaTheIYCF Counselling Trainer’s Guideisdividedinto2–3hoursegmentsandcanbeconductedatdifferenttimeintervalsdependingonvariousprogrammeandhumanresourceconsiderations.Thismodularapproachallowsforflexibilityinschedulingtrainingsessions,andalsoallowsforpracticebetweentheteachingsegments.EachindividualsessionoftheIYCF Counselling Trainer’s Guideoutlinesspecificlearningobjectives,activitydetails,timeallotted,materialsneeded,andmethodologiesforthelearningactivitiesthatFacilitatorsandParticipantswilluse.Theadditionalinstructionsinitalics(andshadedportions)areintendedforusewhentheGuideisusedforpreparingtrainersofIYCFCounsellors.

Training methodologyThecompetency-basedparticipatorytrainingapproachusedinthisGuidereflectskeyprinciplesofbehaviourchangecommunication(BCC)withafocusonthepromotionofsmalldoableactions,andrecognitionofthewidelyacknowledgedtheorythatadultslearnbestbyreflectingontheirownpersonalexperiences.TheapproachusestheexperientiallearningcyclemethodandpreparesParticipantsforhands-onperformanceofskills.Thecourseemploysavarietyoftrainingmethods,includingtheuseofcounsellingmaterials,visualaids,demonstrations,groupdiscussion,casestudies,roleplays,andpractise.Participantsalsoactasresourcepersonsforeachother,andbenefitfromclinicaland/orcommunitypractise,workingdirectlywithbreastfeedingmothers,pregnantwomen,andmothers/caregiverswhohaveyoungchildren.Ideally,

theratioofthenumberofFacilitatorstoParticipantspertrainingshouldbeonetosix.ThetrainingmethodologyusedthroughouttheIYCF Counselling Trainer’s GuidemodelsthesametypeoftrainingusedwithlowliterateParticipants:noflipchartsorwritingmaterials,andpreandpostassessmentsstructuredinawaythatsuggeststheParticipantsmaybenon-literate.

Training LocationWhereverthetrainingisplanned,aclinicalorcommunity-basedsiteshouldbereadilyavailabletosupportthepracticumforcounsellingandnegotiation(“reaching-an-agreement”)withmothers/caregiversonsmalldoableinfantandyoungchildfeedingpractices.Preparethepracticumsitebycoordinatingwithclinicand/orcommunityforarrivalofParticipantsandarrangingforspacetopractisetheskills.

Overview of “Why We Are Here”

General objectives of the IYCF Counselling-A Community-Focused Approach training

Thistrainingisintendedtoaccomplishthefollowing:

1. RaiseawarenessamongIYCFCounsellorsontheimportanceofoptimalbreastfeedingandcomplementaryfeedingforchildren0–23months

2. SensitizeIYCFCounsellorsaboutkeycontactpointsformeetingwithmothers/fathers/caregiverstodiscussandsupportoptimalinfantandyoungchildfeedingpractices

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Infant and Young Child Feeding Counselling �

3. IncreasetheknowledgeofIYCFCounsellorsinordertoenablethemtohelpmothersandcaregiverstooptimallyfeedtheirinfantsandyoungchildrenfromunder2years

4. EnhancetheskillsofIYCFCounsellorstosupportmothersandcaregivers.Skillsinclude:

– listeningandlearning

– buildingthemother’s/caregiver’sconfidence

– providingsupportandpracticalhelp—forexample,withattachmentandpositioning,and

– negotiating(“reaching-an-agreement”),ifmodificationofabehaviourisneeded

Specific objectives of the IYCF Counselling - A Community-Focused Approach training

Bytheendofthetraining,Participantswillbeableto:

1. Describepracticesandkeymessagesoninfantandyoungchildfeeding(IYCF)from0–<6months,startingat6months,6–8months,9–11monthsandfrom12–23months

2. Describepracticesandmessagesonfeedingofthesickchildlessthan6monthsandgreaterthan6months

3. Identifywaystopreventandsolvecommonbreastconditions

4. Discussinsufficientmilk,preventionandbuildingupmilksupply

5. Describecommonsituations,beliefsandmythsaffectingbreastfeeding

6. Describebasicinformationofinfantfeedinginthefollowingsituations:1)HIV-positivewoman,and2)severelymalnourishedinfantoryoungchild

7. Identifysignsthatrequirereferraltoahealthpost

8. Mastercounsellingskills:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,andnegotiating(“reaching-an-agreement”)byapplyingthe“assess,analyze,andact”stepsinordertopromotebehaviouralchangeinmothersandcaregiverssothattheyimprovetheirIYCF-relatedpractices

9. Demonstratetheuseoftheintegratedsetofcounsellingcardsonbreastfeeding,complementaryfeedingforchildren6–23months,hygiene,feedingofthesickchild,andsignsthatrequirereferraltothehealthpost,and

10.Practisetheinitialvisitofcounsellingandnegotiating(“reaching-an-agreement”)withamotherofababy0–<6months,andamotherofababy6–23months(practiseallcounsellingskills:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,andnegotiating(“reaching-an-agreement”)byapplyingthe“assess,analyze,andact”steps.

Additional Objectives of the Preparation of Trainers Course:

Bytheendofthetraining,ParticipantsattendingthePreparationofTrainersCoursewillalsobeableto:

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� Infant and Young Child Feeding Counselling

1. Prepareatrainingformatbyoutliningtheobjectives,activities,timeallotted,materialsneeded,andmethodologiesdescribedintheIYCF Counselling Trainer’s Guide

2. AssigntrainingresponsibilitiesandtasksamongFacilitators

3. UsetheTrainingPackage(integratedsetofcounsellingcards,IYCF Counselling Trainer’s Guide,andtrainingaids)intheroll-outtrainingofIYCFCounsellors

Training Exercises

Forming Small Groups

1. DependingonthenumberofParticipants(forexample,20),andthenumberofgroupstobeformed(forexample,5)askParticipantstocountoffnumbersfrom1to5.Begintocountinaclockwisedirection.Onanotheroccasionbegintocountcounter-clockwise.

2. DependingonthenumberofParticipants(forexample,16),andthenumberofgroupstobeformed(forexample,4),collect16bottlecapsof4differentcolours:4red,4green,4orange,and4black.AskParticipantstoselectabottlecap.Onceselected,askParticipantstoformgroupsaccordingtothecolourselected.

3. Sinkingship:askParticipantstowalkaroundasiftheywereonaship.Announcethattheshipissinkingandlifeboatsarebeinglowered.ThelifeboatswillonlyholdacertainnumberofParticipants.CalloutthenumberofpersonsthelifeboatswillholdandaskParticipantsto

groupthemselvesinthenumbercalled-out.RepeatseveraltimesandfinishwiththenumberofParticipantsyouwisheachgrouptocontain(forexample,todivide15Participantsintogroupsof3,thelast“lifeboat”calledwillbethenumber3).

Review Energizers

ThefollowingaredescriptionsofseveralreviewenergizersthatFacilitatorscanselectfromattheendofeachsessiontoreinforceknowledgeandskillsacquired.

1. ParticipantsandFacilitatorsformacircle.OneFacilitatorhasaballthats/hethrowstooneParticipant.TheFacilitatorasksaquestionoftheParticipantwhocatchestheball.TheParticipantresponds.WhentheParticipanthasansweredcorrectlytothesatisfactionofthegroup,thatParticipantthrowstheballtoanotherParticipantaskinghim/heraquestioninturn.TheParticipantwhothrowstheballasksthequestion.TheParticipantwhocatchestheballanswersthequestion.

2. Form2rowsfacingeachother.Eachrowrepresentsateam.AParticipantfromoneteam/rowasksaquestiontotheParticipantoppositeher/himinthefacingteam/row.ThatParticipantcanseekthehelpofher/histeaminrespondingtothequestion.Whenthequestionisansweredcorrectly,therespondingteamearnsapointandthenasksaquestionoftheotherteam.Ifthequestionisnotansweredcorrectly,theteamthataskedthequestionrespondsandearnsthepoint.Questionsandanswersareproposedbackandforthfromteamtoteam.

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Infant and Young Child Feeding Counselling �

3. Form2teams.Eachpersonreceivesacounsellingcardoravisualimage.ThesevisualaidsareanswerstoquestionsthatwillbeaskedbyaFacilitator.Whenaquestionisasked,theParticipantwhobelievess/hehasthecorrectanswerwillshowhercounsellingcardorvisualimage.Ifcorrect,s/hescoresapointforher/histeam.Theteamwiththemostcorrectanswerswinsthegame.

4. Fromabasket,aParticipantselectsacounsellingcardorvisualimageandisaskedtosharethepractices/messages;feedbackisgivenbyotherParticipants.TheprocessisrepeatedforotherParticipants.

5. Form2circles.Onamatinthemiddleofthecircleasetofcounsellingcardsisplaced“facedown”.AParticipantisaskedtochooseacounsellingcardandtelltheotherParticipantsinwhatsituationsanIYCFCounsellorcansharethepractices/messagesthecounsellingcardrepresents.OneFacilitatorispresentineachcircletoassistinresponding.

Daily Evaluations

ThefollowingaredescriptionsofseveraldailyevaluationsthatFacilitatorscanselectfromattheendofeachday(orsession)toassesstheknowledgeandskillsthathavebeenacquiredand/ortoobtainfeedbackfromParticipants.

A. Formbuzzgroupsof3andaskParticipantstoanswerone,two,orallofthefollowingquestionsinagroup*:

1.Whatdidyoulearntodaythatwillbeusefulinyourwork?

2.Whatwassomethingthatyouliked?

3.Giveasuggestionforimprovingtoday’ssessions.

* Ask a Participant from each buzz group to respond to the whole group

B. “Happyfaces”measuringParticipants’moods.Imagesofthefollowingfaces(smiling,neutral,frowning)areplacedonabenchorthefloorandParticipants(attheendofeachday[orsession])areaskedtoplaceastoneorbottlecaponthe“face”thatbestrepresentstheirlevelofsatisfaction(satisfied,mildlysatisfiedandunsatisfied).(SeeAppendix4forCutOuts)

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� Infant and Young Child Feeding Counselling5-D

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SESSION1

Introductions, Expectations, Why We Are Here

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. BegintonamefellowParticipantsandFacilitators

2. Discussexpectations

3. Explain“whywearehere”

4. Becomefamiliarwiththeintegratedsetofcounsellingcards

5. For the Preparation of Trainers Course: Become familiar with the IYCF Counselling Trainer’s Guide

ActivitiesActivity1 Introductions(�0 minutes)

Activity2 Whatdoweknownow?(�0 minutes)

Activity3 “Whywearehere”:comparethegeneralandspecificcourse objectiveswiththeParticipants’expectations,andgivean overviewofthetraining(�0 minutes)

Activity4 Presentandreviewtheintegratedsetofcounsellingcards(�0 minutes)

Activity5 Discussadministration,groundrulesandlogistics(�0 minutes)

Activity6 For the Preparation of Trainers Course: Present and review the IYCF Counselling Trainer’s Guide and training aids (�0 minutes)

Total Time 1 hour

Materials needed√ Onecopyoftheintegratedsetofcounsellingcardsforeachparticipant

√ Onecopyof“Whatdoweknownow?”pre-assessmentguidefortheFacilitator(s)

√ For the Preparation of Trainers Course: One IYCF Counselling Trainer’s Guide for each Participant and one or two complete sets of training aids per training team.

Note to the Facilitator: Present an overview of objectives for this session (listed below) and the time allotted for this session.

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ACTIVITY 1

Introductions and expectations (�0 minutes)

Methodology: Introduce participant sitting beside you

• AskParticipantstotalktothepersonsittingbesidethem;eachParticipantintroduceshis/herneighborbyname,theirexpectationofthetraining,andsomethingofinterest(favouritecolour).

ACTIVITY 2

“What do we know now?” (�0 minutes)

Methodology: Participants sit in circle facing outwards

• AskParticipantstoformacircleandsitsothattheirbacksarefacingthecenter.

• ExplainthatquestionswillbeaskedandaskParticipantstoraiseonehand(withopenpalm)iftheythinktheansweris“Yes”,toraiseonehand(withclosedfist)iftheythinktheansweris“No”,andtoraiseonehand(pointing2fingers)ifthey“Don’tknow”.

Pre-assessment: What do we know now?

1. Ababyshouldbreastfeedwithinanhourafterbirth.

2. Toproducesenoughmilk,amothershouldbreastfeedfrequently, dayandnight.

3. Colostrumhelpstoprotectbabiesfromillnesseslikediarrheaand respiratoryinfections.

4. At4months,infantsneedwaterandotherdrinksinadditiontobreastmilk.

5. At9-11months,ababyneedscomplementaryfoods4timesaday.

6. Onesignofgoodattachmentisthatthenewborn’schintouchesthe mother’sbreast.

7. Breastfeedingbenefitsthebaby,butnotthemother.

8. Amothercanstillsuccessfullybreastfeedherbabyevenifshethinksshe doesnothaveenoughmilk.

9. Amothercanpreventsoreandcrackednipplesbycorrectlyattachingher babytothebreast.

10. Ababybeginstoneedfoodsinadditiontobreastmilkatabout6months.

11. Amothercanproduceenoughmilktobreastfeedtwins.

Yes No Don’t know

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• OneFacilitatorreadsthestatementandanotherFacilitatorrecordstheanswersandnoteswhichtopics(ifany)presentconfusion.

• AdviseParticipantsthatthesetopicswillbediscussedingreaterdetailduringthetraining.

ACTIVITY 3

Summary of purpose and learning objectives (�0 minutes)

Methodology: Brainstorming; Facilitator discusses purpose and learning objectives of training (“why we are here”) with Participants

• Introducelearningobjectives(generalandspecificobjectivesfoundintheIntroductionoftheIYCF Counselling Trainer’s Guide).

• ComparetheobjectiveswiththestatedexpectationsoftheParticipants.

• Presentanoverviewoftraining:buildonParticipants’knowledge,practicecounsellingskills:listeningandlearning;buildingconfidence;providingsupportandpracticalhelp(attachmentandpositioning);andnegotiating(“reaching-an-agreement”)skillsattrainingsiteandwithmothers/caregiversinclinicorcommunitysettingsbyapplyingthe“assess,analyze,andact”steps.

• For the Preparation of Trainers Course, explain that this is a preparation for trainers, and they alone will receive the Trainer’s Guide. Participants of their “roll-out” trainings will ONLY receive the integrated set of counselling cards and key messages booklet.

ACTIVITY 4

Present and review the integrated set of counselling cards (�0 minutes)

Methodology: Buzz groups of 3 Participants

• DistributetheintegratedsetofcounsellingcardstoeachParticipantandthenaskParticipantstoformgroupsof3.

• Explainthatthecounsellingcardsaregoingtobetheirtoolstokeepandthattheyaregoingtotakeafewminutestoexaminethecontentofthecounsellingcards.

• Eachgroupistofindthecardthatshows:apieceoffruit(CCs11,12,13)

• Askagrouptoreportwhichcounsellingcard(s)showtheitem.

• Asktheothergroupsiftheyagree,disagreeorwishtoaddanothercounsellingcard.

• Repeattheprocesswiththeremainingitems/characteristics.Find:– anIYCFcounselortalkingwithamother(CC1)– asignorsymbolthatindicatesthatsomethingshouldhappenduring‘thedayandat

night’,orthatindicatesthechildshouldhave‘amealorasnack’(CCs6,10,11,12,13)

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– asignorsymbolthatindicatesthatthechildshouldhave‘amealorasnack’(CCs12,13)

– agrandmotherorguardianwithmother(CC2b,3)– asignorsymbolthatindicatesthatayoungchildshouldeat3timesadayand2snacks

(CC13)– asickbabylessthan6months(CC15)– thecardwiththemessagethat‘handsshouldbewashedwithsoapaswellaswater’

(CC14)– thecardwiththemessagethatayounginfantdoesnotneedwater(CC7)

ACTIVITY 5

Discuss administration, ground rules and logistics (�0 minutes)

ACTIVITY 6

For the Preparation of Trainer’s Course: Present and review the IYCF Counselling Trainer’s Guide and training aids (�0 minutes)

Methodology: Small groups according to training team

• Distribute the IYCF Counselling Trainer’s Guide to each Participant, and a set of training aids to each group representing a training team.

• Ask small groups to examine the contents of the IYCF Counselling Trainer’s Guide and the set of training aids.

• Explain the following:

– Facilitators will be modeling the training that Participants will in turn conduct

– Participants will need to become familiar with the IYCF Counselling Trainer’s Guide and the training aids because they will be their tools in training IYCF Counsellors

• Together with Participants, go through Session 1 of the IYCF Counselling Trainer’s Guide, pointing out objectives, activities, time allocated, materials needed, and details/methodology of each activity.

• Guide discussion of Participants’ role as trainers.

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SESSION2

How to Counsel: Talking with the Mother/Caregiver

Learning objectiveBytheendofthesession,Participantswillbeableto:

1. IdentifylisteningandlearningskillsandPRACTISEusingthem

ActivitiesActivity1 Facilitatorsdemonstratelisteningandlearningskills(�0 minutes)

Activity2 Participantspractiselisteningandlearningskills(�0 minutes)

Total Time 1 hour

Materials needed√ SixlisteningandlearningdemonstrationcasesforFacilitators

√ PractiseexercisesfromBreastfeedingCounselling:ATrainingCoursedevelopedbyWHO/UNICEF

Note to the Facilitator: Present an overview of objectives for this session (listed below) and the time allotted for this session.

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ACTIVITY 1

Facilitators demonstrate listening and learning skills (�0 minutes)

Methodology: Demonstration

• Explainthat‘listeningandlearning’skillsarethefirstsetofskillstobelearnedandpractised.Otherskillsare:buildingthemother’s/caregiver’sconfidence;providingsupportandpracticalhelp;andnegotiating(“reaching-an-agreement”)byapplyingthe“assess,analyze,andact”steps.

• Prepareanddemonstratedifferentrole-playsoflisteningandlearningskillsusingthefollowing6exercises(teamof2Facilitators).

• AskParticipantstoidentifythedifferentskills.

• Discuss,summarize,andrepeatthedifferentlisteningandlearningskills.

Demonstration �:

Non-verbal communication

Witheachdemonstrationsayexactlythesamefewwords,andtrytosaytheminthesameway,forexample:“Good morning, Habiba. How is breastfeeding going for you and the baby?”

A. Posture:

Hinders: standwithyourheadhigherthanthemother’s

Helps: sitsothatyourheadislevelwithhers

B. Eye contact:

Helps: lookatherandpayattentionasshespeaks

Hinders: lookawayatsomethingelse,ordownatyournotes

C. Barriers:

Hinders: sitbehindatable,orwritenoteswhileyoutalk

Helps: removethetableorthenotes

Note to the Facilitator: ThefollowingListeningandLearningdemonstrationsarefrom:Breastfeeding Counselling: A Training CoursedevelopedbyWHO/UNICEF

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D. Taking time:

Helps: makeherfeelthatyouhavetime.Sitdownandgreetherwithout hurrying;thenjuststayquietlysmilingather,watchingherbreastfeed, andwaitingforhertoanswer

Hinders: beinahurry.Greetherquickly,showsignsofimpatience,andlookat yourwatch

E. Touch:

Helps: touchthemotherorbabyappropriately

Hinders:touchherinaninappropriateway(Note: If you cannot demonstrate an inappropriate touch, simply demonstrate not touching).

Demonstration �:

Closed questions to which mother can answer `yes’ or `no’

CW = IYCF Counsellor

CW: “Goodmorning,(name).Iam(name),theIYCFCounsellor. Is(nameofbaby)well?”

Mother: “Yes, thank you.”

CW: “Areyoubreastfeedinghim?”

Mother: “Yes”.

CW: “Areyouhavinganydifficulties?”

Mother: “No”.

CW: “Ishebreastfeedingveryoften?”

Mother: “Yes”.

Demonstration �:

Open questions

CW: “Goodmorning,(name).Iam(name),thecommunityIYCFCounsellor. Howis(nameofbaby)?”

Mother: “He is well, and he is very hungry.”

CW: “Tellme,howareyoufeedinghim?”

Mother: “He is breastfeeding. I just have to give him one bottle feed in the evening.”

CW: “Whatmadeyoudecidetodothat?”

Mother: “He wants to feed too much at that time, so I thought that my milk is not enough”.

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Demonstration �:

Using responses and gestures that show interest

CW: “Goodmorning,(name).Howisbreastfeedinggoingforyouthesedays?”

Mother: “Good morning. It is going quite well, I think.”

CW: “Mmm.”(nods,smiles.)

Mother: “Well, I was a bit worried the other day, because he vomited.”

CW: “Ohdear!”(raiseseyebrows,looksinterested.)

Mother: “I wondered if it was something that I ate, so that my milk did not suit him.”

CW: “Aha!”(nodssympathetically).

Demonstration �:

Reflecting back

CW: “Goodmorning(name).Howareyouand(name)today?”

Mother: “He wants to feed too much—he is taking my breast all the time!”

CW: “(Name)isfeedingveryoften?”

Mother: “Yes. This week he is so hungry. I think that my milk is drying up.”

CW: “Heseemshungrierjustforaboutaweek?”

Mother: “Yes, and my sister is telling me that I should give him some bottle feeds as well.”

CW: “Yoursistersaysthatheneedssomethingmore?”

Mother: “Yes. Which formula is best?”

Demonstration �:

Avoid using judging words (� skits)

Skit 1:

CW: “Goodmorning(name).Is(name)breastfeedingnormally?”

Mother: “Well I think so.”

CW: “Doyouthinkyouhaveenoughbreastmilkforhim?”

Mother: “I don’t know……I hope so, but maybe not…..” (She looks worried.)

CW: “Hashegainedweightwellthismonth?MayIseehisgrowthchart?”

Mother: “I don’t know…….”

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Avoiding judging words

Skit 2:

CW: “Goodmorning(name).Howisbreastfeedinggoingforyouand(name)?”

Mother: “It’s going very well. We both enjoy it.”

CW: “Howishisweight?CanIseehisgrowthchart?”

Mother: “Nurse said that he gained more than half a kilo this month. I was pleased.”

CW: “Heisobviouslygettingallthebreastmilkthatheneeds.”

ACTIVITY 2

Participants practise exercises from “Breastfeeding Counselling: A Training Course” developed by WHO/UNICEF (�0 minutes)

Methodology: Small working groups

• FormsmallgroupswithaFacilitatorineachgroup.

Open questions

• Facilitatorreadstheclosedquestion:Doyoubreastfeedyourbaby?andchangesitintoan‘open’question:How are you feeding your baby?

• NexttheFacilitatorreadsthe‘closed’questionsandasksParticipantstochangetheminto‘open’questions.

1.Areyouoftenawayfromyourbaby?Possibleanswer:How many hours are you away from your baby on a daily basis?

2.Areyournipplessore?Possibleanswer:Can you tell more about how your nipples feel?

• Readtheshortstory:

JosephandMabelbring3-month-oldJohnnytotheclinic.Theywanttotalktoyoubecauseheisnotgainingweight.

• AskParticipantstomentiontwoopenquestionsthatyouwouldaskJosephandMabel.Thequestionsmustbeonesthattheycannotsayjust`yes’or`no’to.

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Reflecting back what a mother says

• Facilitatorreadsthestatement:MymothersaysthatIdon’thaveenoughmilk,andthenasksPartici-pantstodecidewhichexamplesofthefollowingstatementsshow‘reflectingback:

a.Doyouthinkyouhaveenough?

b.Whydoesshethinkthat?

c. She says that you have a low milk supply?

• Mentionthat‘c’reflectsbacktheoriginalstatement.

• ReadthestatementsandaskParticipantstomentionwhichanswercorrectly‘reflectsback’thestatement.

1.Mybabyispassingalotofstools—sometimes8inaday.

a. He is passing many stools each day?

b.Whatarethestoolslike?

c.Doesthishappeneveryday,oronlyonsomedays?

2.Hedoesn’tseemtowanttosucklefromme.

a.Hashehadanybottlefeeds?

b.Howlonghasbeenrefusing?

c. He seems to be refusing to suckle?

• AskParticipantsto‘reflectback’thefollowingstatements.

3.Sometimeshedoesn’tpassastoolfor3or4days.Possibleresponse:he doesn’t pass stools for � or � days?

4.Myhusbandsaysthatourbabyisoldenoughtostopbreastfeedingnow.Possibleresponse:your husband thinks the baby is old enough to stop breastfeeding?

• Readtheshortstory:

YoumeetCorainthemarketwithher2-month-oldbaby.Yousayhowwellthebabylooks,andaskhowsheandthebabyaredoing.Corasays“Oh,we’redoingfine.Buthealwaysseemsespeciallyhungryintheevening.”

• AskParticipantstoreflectbackwhatCorasays,andtoencouragehertotellyoumore?Possibleresponse:so you’re doing fine, but you think the baby is especially hungry in the evening? What makes you say this?

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Avoiding judging words

• Reviewthefollowinglistofjudgingwords

Well Normal Enough Problem Crying `too much’

good correct adequate fail unhappy

bad proper inadequate failure happy

badly right satisfied succeed fussy

wrong plentyof success colicky

sufficient

• Readthejudgingstatement:Doeshesucklewell?andtheexampleofputtingthestatementintoanon-judgingstatement:How do you feel he is suckling?

• AskParticipantsto put the following judging questions into non-judging questions

1.Arehisstoolsnormal?Possibleresponse:can you tell me what his stools look like?

2.Ishegainingenoughweight?Possibleresponse:can you please show me his weight card?

3.Doyouhaveanyproblemsbreastfeeding?Possibleresponse:how is breastfeeding going?

4.Doeshecrytoomuchatnight?Possibleresponse:how many times does he wake up at night?

• Reviewlisteningandlearningskillsinplenary

1.Usehelpfulnon-verbalcommunication

– Keepyourheadlevelwithmother/parent/caregiver

– Payattention(eyecontact)

– Removebarriers(tablesandnotes)

– Taketime

– Appropriatetouch

2.Askopenquestions

3.Useresponsesandgesturesthatshowinterest

4.Reflectbackwhatthemothersays

5.Avoidusingjudgingwords

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SESSION3

Importance of Breastfeeding

Note to the Facilitator:Present an overview of objectives (listed below) and the time allocated for this session.

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. Listthecommonillnessesofbabiesintheircommunities

2. Reflectonhowbreastfeedingcanpreventthesecommonillnesses

3. Definecolostrumandexclusivebreastfeeding

4. Discusscommunitybreastfeedingpractices

5. Listthekeycontactpointswhereandwhenoptimalinfantandyoungchildfeedingpracticescanbepromoted

6. Observecounsellingcards1–3(antenatal,delivery,earlypost-partum)andnametheoptimalbreastfeedingpracticesand/ormessages

7. Reviewthebenefitsofbreastfeedingforbaby,motherandfamily

ActivitiesActivity1 Discussiononcommonillnessesofbabiesinthecommunityand

reflectionontherelationshipbetweenbreastfeedingandcommon illnessesofbabies;definitionandimportanceofcolostrum;and definitionofexclusivebreastfeeding (�0 minutes)

Activity2 Sharingofcommunitybreastfeedingpractices(�0 minutes)

Activity3 Keycontactpointstopromoteoptimalinfantandyoungchildfeeding (�0 minutes)

Activity4 Observationofcounsellingcards1–3(antenatal,delivery,early post-partum)anddiscussionoftheoptimalbreastfeedingpracticesand messagesduringthesetimes(�� minutes)

Activity5 Reviewbenefitsofbreastfeedingforbaby,motherandfamily (�� minutes)

Total Time 2 hours

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Materials needed√ Imagesofcommonillnessesinthecommunity:diarrhoea,cough/pneumonia,

malnutrition,vomiting,fever,anaemia

√ Imagesofbreastfeedingmotherandbaby,andhealthymotherandbaby

√ Counsellingcards1-3:antenatal,delivery,andearlypost-partumoptimalpractices/messages

ACTIVITY 1

Discussion of common illnesses of babies in the community (�0 minutes)

Methodology: Brainstorm common illnesses of infants and young children, definition and importance of colostrum, and definition of exclusive breastfeeding

• AskParticipants:“WhatarethecommonillnessesofinfantsandyoungchildreninDadaab?

• AsParticipantsmentioneachillness,putanimageoftheillnessonthefloororwallsothatallcansee.

• Probeuntilallimagesaredisplayed(perhapsskindiseasewillbementioned,butthereisnoimage).

• Putthe‘breastfeedingmotherandbaby’inthecentreoftheotherimages.

• AsksParticipants:whatistherelationshipbetween“theseillnesses”andbreastfeeding(especiallyrespiratoryanddiarrhoealinfections)?

• Putthe‘healthymotherandbaby’inthecentreasaresultofbreastfeeding.

• AskParticipantstodefinecolostrumorthelocalnameforthe“firstmilk”.

• Explaintheimportanceofcolostrum.

• AskParticipantstodefineexclusivebreastfeeding.

• Discussionandsummary.

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Components and Properties of Colostrum Importance

Antibodies Protectagainstinfectionandallergy

Whitecells Protectagainstinfection

Growthfactors Helpintestinestomatureandpreventsallergiesandfoodintolerance

VitaminA Reducesseverityofsomeinfections(e.g.,measlesanddiarrhea)and preventsvitaminA-relatedeyedisease

Purgativeeffects Cleansmeconium(darkblackstool)topreventjaundiceinnewborns

Content for Activity 1

Colostrumisthefluidinthebreastattheendofpregnancyandintheearlypostpartumperiod.Itisthickerandmoreyellowthanmaturemilk,richinproteinsandvitamins.

Modified:UNICEF/WHO–Breastfeedingcounselling:Atrainingcourse,1993

Exclusive breastfeedingisgivinganinfantnofoodordrink,includingwater,apartfrombreastmilk(includingexpressedbreastmilk),withtheexceptionofdropsorsyrupscontainingvitamins,mineralsupplements,ormedicine.

ACTIVITY 2

Sharing of breastfeeding practices in the community (�0 minutes)

Methodology: Brainstorm community breastfeeding practices

• AskParticipantstosharecommunitybreastfeedingpracticesbyansweringthefollowingquestions:

1.Whendomothersinthecommunityinitiatebreastfeeding?

2.Untilwhatagedomothersexclusivelybreastfeed(onlybreastfeedingwithnowater,liquidsorsolids)?

3.Howfrequentlydomothersbreastfeedovera24hourperiod?

4.Untilwhatagedomothersbreastfeedtheirbabies(howmanymonths/years)?

• Summarizepractices.

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Infant and Young Child Feeding Counselling ��

ACTIVITY 3

Where are there opportunities for IYCF Counsellors to promote optimal infant and young child feeding? (�0 minutes)

Methodology: Small groups

• DivideParticipantsintosmallgroupsandaskthemtolisttheplacesandtimes(keycontactpoints)wheretheycanpromoteoptimalinfantandyoungchildfeedingpractices.

• Askonesmallgrouptosharetheiranswerswiththewholegroup.Othersmallgroupsaddadditionalpoints.

• Probeuntilthefollowingpoints(whereandwhenIYCFCounsellorscanshareinformationwithmothersandcaregivers/familymembers)arementioned.

Content for Activity 3

KeycontactpointswhereandwhenIYCFCounsellorscanshareinformationwithmothersandcaregivers/familymembers:

• Ateverycontactwithapregnantwoman(athealthpostorinthecommunity)

• Atdeliveryinhealthcentreorathome

• Atpostpartumcontactsondays2-3,and5-7,andat2weeks,athomeorinthecommunity

• Duringfamilyplanningsessionsathealthpost(orinthecommunity)

• AtEPI(immunization)andgrowthmonitoringsessionsathealthpostorinthecommunity

• Ateverycontactwithmotherorcaregiverofasickchild

Information can also be shared at:

–Supplementaryfeedingprogrammes(SFPs)

–Therapeuticfeedingcentres(TFCs)

–Communitytherapeuticcareprogrammes(CTCs)

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ACTIVITY 4

Discuss the optimal breastfeeding practices and/or messages (�� minutes)

Methodology: Small working groups—Participants observe counselling cards 1, 2a, 2b, and 3 and name the breastfeeding practice(s) and key message(s) illustrated in the counselling cards (CCs)

• Explainthatthisactivitywillconcentrateonlearningthekeymessages.InSession7on“Howtocounselamother”,Participantswillpractisehowtocombinethemessageswithcounsellingskills:howtodecidewhetheramotherneedsadditionalinformation;prioritizeandselectamongkeymessages,andpresentasmallamountofrelevantinformationasasuggestion,notadirective.

• DivideParticipantsintosmallgroups,askingParticipantsineachgrouptousetheircounsellingcardsforthefollowingexercise.

• HaveeachgroupstudyCC1andnamethebreastfeedingpractice/sand/orkeymessage/sthatcanbesharedwiththeexpectantmother.

• Askonesmallgrouptosharewiththewholegroupandothersmallgroupsaddadditionalpoints.

• Probeuntilthekeyandsupportingmessages(foundinAppendix2oftheIYCFCounsellingTrainer’sGuide)arementioned.

• HavethesmallgroupsrepeattheprocessuntilCCs2a,2b,and3havebeenobservedandstudied,andthebreastfeedingpractice/sand/orkeymessage/sarenamed.

ACTIVITY 5

Review the benefits of breastfeeding for the baby, mother and family (�� minutes)

Methodology: Circle and ball

• AskParticipantstoformacircle.

• Throwtheballtooneparticipantandaskher/himtonameabenefitofbreastfeedingforthebaby,themotherorthefamily.

• Whens/hehasnamedabenefitofbreastfeedingforthebaby,themotherorthefamily,s/heinturnthrowstheballtoanotherparticipantandasksthatparticipanttogiveanotherbenefitofbreastfeedingtothebaby,motherorfamily.

• Continueuntilthefollowingbenefitsofbreastfeedingforthebaby,motherorfamilyhavebeenmentioned.

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Content for Activity 5

Benefits of Breastmilk for the Baby

• Savesbabies’lives.

• Thebabybenefitsfromthecolostrum,whichprotectshim/herfromdiseases.Thecolostrumactsasalaxativecleaningthebaby’sstomach.

• Hasallthebabyneedsforthefirst6months.

• Containsenoughwaterforthebaby’sfirst6months.

• Providefoodsecurityinemergencies.

• Promotesadequategrowthanddevelopment

• Stimulatesoptimalbraindevelopment

• Protectsagainstdiseases,especiallyagainstdiarrhoeaandrespiratoryinfections.

• Isalwaysclean,ready,andattherighttemperature.

• Iseasytodigest.

Benefits of Breastfeeding for the Mother

• Puttingthebabytothebreastimmediatelyafterbirthhelpsexpeltheplacenta,andreducesbleedingafterdelivery.

• Thebaby’ssucklingstimulatesuterinecontractions.

• Breastfeedingthebabyimmediatelyandfrequentlystimulatesmilkproduction.

• Breastfeedingthebabyimmediatelyandfrequentlypreventsengorgement.

• Breastfeedingiseconomical.

• Breastfeedingstimulatesbondingbetweenamotherandherbaby.

• Breastfeedingisgoodformaternalhealth.

• Breastfeedingprotectsagainstearlypregnancywhichhelpsprotectawoman’sownhealthandnu-trition.

• Breastfeedingcontributestofoodsecurityfortheinfant.

Benefits of Breastfeeding for the Family

• Decreasedsickness

• Decreasedmedicalexpenses

• Protectionagainstearlypregnancy

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SESSION4

How to Breastfeed

Note to the Facilitator:Present an overview of objectives (listed below) and the time allocated for this session.

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. For the Preparation of Trainers Course: Make dolls and model breasts

2. Recognizegoodandpoorattachment

3. Demonstrategoodattachmentandpositioning

4. Explaintheresultsofpoorattachment

5. Describeeffectivesuckling

6. Describehandexpressionandstorageofbreastmilk;andhowtocupfeed

ActivitiesActivity1 For the Preparation of Trainers Course: Making dolls

and breast models (�0 minutes)

Activity2 Goodattachmentandpositioningatthebreast(� hour)

Activity3 Signsofeffectivesuckling(�0 minutes)

Activity4 Breastfeedingpattern(frequency,duration,demand,nightfeeding), andexclusivebreastfeeding(�0 minutes)

Activity5 Howtohandexpressandstorebreastmilk;andhowtocupfeed (�0 minutes)

Total Time 2½–3 hours

Materials needed√ For the Preparation of Trainers Course: Materials to make dolls and breast

models

√ Counsellingcards4and5onattachmentandpositioning

√ Dollsand/orbabies

Note: If possible, make arrangements in advance to have breastfeeding women present to demonstrate positioning and attachment.

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√ Imagesof‘goodattachment’and‘poorattachment’,and‘Howthebreastmakesmilk’

√ Counsellingcard6:BreastfeedonDemand,BothDayandNight;CC7:DuringtheFirst6Months,YourBabyNeedsONLYYourBreastmilk;andCC8:HowtoHandExpressBreastmilkandCupFeed

√ Photoofmilkexpressionandcupfeeding

√ Smallcupwithliquid

ACTIVITY 1

For the Preparation of Trainer’s Course: Making dolls and breast models (�0 minutes)

Methodology: Small groups from the same health post help each other make dolls and breast models

• Demonstrate how to make a doll using simple materials (paper rolled into a ball for the head covered in same fabric used for the body, small bottle filled with water for trunk of doll, rubber bands to help define neck, arms and legs, typical baby clothes if available, and a cloth or blanket to cover the doll).

• Participants work together to make their dolls.

• Demonstrate how to make a breast model using simple materials (2 socks: 1 sock resembling skin colour to show the outside of the breast, and another sock to show the inside of the breast – Instructions for Making Cloth Breast Models, Appendix 1, Breastfeeding Management and Promotion in a Baby-Friendly Hospital, an 18 hour course for maternity staff, UNICEF/WHO 1993. Appendix 3.

Note: Each training team should create at least one doll for use in conducting future trainings.

ACTIVITY 2

Good attachment and positioning at the breast (�0 minutes)

Methodology: Small groups and Demonstration

• Formsmallgroupsof6ParticipantswithaFacilitatorineachgroup.

• PassaroundtoParticipantstheimagesof‘goodattachment’and‘poorattachment’.Askforcommentsanddescriptionofimages.

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• UsingCounsellingCard#4ANDifpossiblearealmother,pointoutandexplainthe4signsofgoodattachment:mouthopen,moreareolashowingabovethanbelowthenipple,lowerlipturnedout,andchintouchingbreast.(Aimthebaby’slowerlipwellbelowthenipplesothatthenipplegoestothetopofthebaby’smouthandthebaby’schintouchesthebreast.)

• Explainwhathappensiftheattachmentiswrong:

– Soreandcrackednipples

– Painleadstopoormilkreleaseandslowsmilkproduction.

• UsingCounsellingCard#5ANDifpossiblearealmother,demonstrateandexplainthevariouspositionsdeliberatelyandclearly(pointoutwhenheadshouldnotbeheld,anddonotholdbabytoofarouttotheside)andrepeatthe4signsofgoodattachment:mouthopen,moreareolashowingabovethanbelowthenipple,lowerlipturnedout,andchintouchingbreast.

• Explainhowtohelpamotherattachandpositionababyatherbreast

– alwaysobserveamotherbeforeyouhelpher

– giveamotherhelponlyifshehasdifficulty

– letthemotherdoasmuchaspossibleherself

– makesuresheunderstandswhattodosothatshecandoitherself

• Demonstratewithparticipanthowtohelpattachandpositionababy(Facilitatoractsascounsellor,andparticipantasmother)—seetablebelow

• Inworkinggroupsof6,askParticipantstopractiseintriadswithdollsorrolled-uptowels/material:mother,counsellorandobserver—helping‘mother’tousegoodattachment(4signs)andgoodpositioning.Eachparticipantpractiseseachrole.(ParticipantscanpractisePOSITIONINGababyandhelpingamothertodoso,buttheycannotpractiseATTACHMENTuntiltheyarewitharealmotherandbaby.Theycangothroughallthestepswitheachotherandwithadollsothattheyknowwhattodowitharealmother.)

• Motherandbabydemonstrateattachmentandpositioning(orFacilitatordemonstrateswithadollorrolled-uptowel/material).AskParticipantstoobserveattachmentandpositioninganddecideifmotherisusinggoodattachmentandpositioning,explainanydifferencestheysaw,andhelpmothertomodifyattachmentandpositioning.

• Recapcounsellingcards4and5:howtohelpmotherattachandposition,andmessagesforthemother.

• Discussionandsummary.

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Content for Activity 2

How to help attach a baby

• Greetmother,introduceyourself

• Assessabreastfeed

• Ifthebabyispoorlyattached,askmotherifshewouldlikesomehelptoimprovebaby’sattachment

–makesuremotherissittinginacomfortable,relaxedposition

–becomfortableandrelaxedyourself

–explainthe4signsofgoodattachment

–showmotherhowtosupportherbreastwithherhandtoofferittoherbaby(sheshouldrestherfingersonherchestwallunderherbreast)

–explainhowsheshouldtouchherbaby’slipswithhernipple,sothatheopenshis/hermouth

–explainthatsheshouldwaituntilherbaby’smouthopenswide

–explainhowtoquicklymovethebabytoherbreast(aimingherbaby’slipbelowhernipple,sothathis/herchinwilltouchherbreast)

• Noticehowthemotherresponds

• Lookforallthesignsofgoodattachment

• Iftheattachmentisnotgood,tryagain

ACTIVITY 3

Signs of effective suckling (�0 minutes)

Methodology: Small groups

• Insmallgroupsof6Participants,passaroundtoParticipantstheimagesof‘Howthebreastmakesmilk’.

• AskParticipantstoexplainhowtheythinkthebreastmakesmilk.

• FollowthearrowswiththeParticipantsandexplainthatsucklingatthenipplestimulatesnervepathwaysandsendsamessagetothebraintomakemilkandto“letdown”themilk—makesthemilkflow.

• Explainthat‘themorethebabysucklesandremovesthemilk,themoremilkisproduced’—buildsupmilksupply.

• Explainthatgood suckling achieves EFFICIENT milk transfer.

• AskParticipants:“whatarethesignsofeffectivesuckling?”

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• ProbeParticipantstomentionthekeyandsupportingmessages(foundinAppendix1oftheIYCF Counselling Trainer’s Guide—CC#4:Howtoattachbabytobreast;fill-inthegaps.

–Tosucklewell,ababyneedstobewellattachedatthebreast.

–Thebabyshouldbeclosetothebreast,withawideopenmouth,sothats/hecantakeinplentyoftheareolaandnotjustthenipple.

–Youshouldseemoreareolaabovethebaby’smouththanbelow;andthechinshouldtouchthebreast(thishelpstoensurethatthebaby’stongueisundertheareolasothats/hecanpressoutthemilkfrombelow).

–Youmaybeabletoseethatthebaby’slowerlipisturnedoutwards(butitmaybedifficulttoseeifthechinisclosetothebreast).

–Goodattachmenthelpsthebabytogetthemilkmoreeasily.

–Goodattachmentalsohelpsthemother’smilkflowwellandensuresagoodsupply.

–Goodattachmenthelpstopreventsoreandcrackednipples.

–Theinfanttakesslowdeepsuckles,sometimespausing.

–Themothermaybeabletoseeorhearherbabyswallowingafteroneortwosuckles.

–Sucklingiscomfortableandpainfreeformother.

–Babyfinishesthefeed,releasesbreastandlookscontentedandrelaxed.

–Thebreastissofterafterthefeed.

• Discussionandsummary.

ACTIVITY 4

Discuss breastfeeding pattern (frequency, duration, demand, night feeding), and exclusive breastfeeding.

Methodology: Participants observe counselling cards 6 and 7 and name the breastfeeding practice(s) and key message(s) demonstrated in the counselling cards

• DivideParticipantsintosmallgroups,askingParticipantsineachgrouptousetheircounsellingcardsforthefollowingexercise.

• HaveeachgroupstudyCCs6and7andnamethebreastfeedingpractice/sandkeymessage/sthecardsrepresent.

• Askonesmallgrouptosharetheirresultswiththewholegroup.Othersmallgroupsaddadditionalpoints.

• Probeuntilthekeyandsupportingmessages(foundinAppendix2oftheIYCFCounsellingTrainer’sGuide)arementioned.

• Discussionandsummary.

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ACTIVITY 5

How to hand express and store breastmilk; and how to cup feed (�0 minutes)

Methodology: Presentation/demonstration and triads

• DistributeCounsellingCard#8

• FollowthestepsintheCounsellingCardverydeliberately,sothatParticipantscancopythisactionafterwards.

• Askawillingbreastfeedingmothertodemonstratethetechniqueofexpressingbreastmilk.

• Ifnobreastfeedingmotherisavailable,Facilitatorcandemonstratethetechniqueusingthebreastmodel.

• AskParticipantstopractiseusingbreastmodels.

• AskParticipantstolistthe“steps”ofexpression.

• Ingroupsof3askParticipantstotaketurnsexplainingtoeachotherhowtoexpressbreastmilk,andhowtostoreit.

• Explainstorageprocedures:

–Storebreastmilkinaclean,coveredcontainer.Milkcanbestored8–10hoursatroomtemperatureinacoolplaceand72hoursintherefrigerator.

–Giveinfantexpressedbreastmilkfromacup.

–Bottlesareunsafetousebecausetheyaredifficulttowashandcanbeeasilycontaminated.

• Distributephotoofmilkexpressionandcupfeeding.

• Demonstratecupfeeding:

–Bringcuptothebaby’slowerlipandallowbabytotakesmallamountsofmilk.Donotpourthemilkintobaby’smouth.

• Passaroundadollandacupwithliquidinitforeachparticipanttopractisecupfeedingtechnique.

• Discussionandsummarywiththewholegroup.

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SESSION5

Common Breast Conditions: Symptoms, Prevention and Solutions; and Insufficient Milk

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. Recognisecommonbreastconditionsthatcanoccurduringbreastfeeding

2. Describethesymptomsoftheconditions

3. Describehowtopreventtheseconditions

4. Helpmotherstoovercometheseconditions

5. Helpmotherswhohaverealorperceivedinsufficiencyofmilk

ActivitiesActivity1 Identifycommonbreastconditionsthatcanoccurduringbreastfeeding

(�� minutes)

Activity2 Identifysymptoms,preventionmeasuresandtreatmentfor3ofthe mostcommonbreastconditions(�0 minutes)

Activity3 Discussinsufficientmilk:perceivedandrealandhowtobuildupmilk supply(�0 minutes)

Total Time 1 hour 15 minutes

Materials needed√ Photosofengorgement,sore/crackednipple,blockedductandmastitis,inverted

nipples,Candida(thrush),andcheckingforthrushinbaby’smouth

Note to the Facilitator:Present an overview of objectives (listed below) and the time allocated for this session.

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ACTIVITY 1

Identify common breast conditions that can occur during breastfeeding (�� minutes)

Methodology: Brainstorm

• BrainstormcommonbreastconditionsthatParticipantshaveidentifiedintheircommunities.

• AsParticipantsmentioneachbreastcondition,putanimageoftheconditiononthefloororwallsothatallcansee.

• Probeuntilallimagesaredisplayed.

ACTIVITY 2

Identify symptoms, prevention measures and solutions for 3 of the most common breast conditions (�0 minutes)

Methodology: Small working groups

• DivideParticipantsinto3workinggroupsandassignacommonbreastcondition,withcorrespondingphoto,toeachgroup:engorgement,soreandcrackednipples,orpluggedductsthatcanleadtomastitis.

• Askeachgrouptodiscusssymptoms,preventionandtreatmentoftheassignedcommonbreastcondition.

• Eachgrouppresentstheirfindingstothewholegroup.

• Discussionandsummarywiththewholegroup.

• Fill-ingapsusingTable1:Commonbreastfeedingconditions

ACTIVITY 3

Identify symptoms and prevention measures for insufficient milk: perceived or real, and how to build up milk supply (�0 minutes)

Methodology: Small working groups

• Inthesameworkinggroups,askeachgrouptodiscussinsufficientmilk:perceivedorrealintermsofsymptomsandprevention,andhowtobuildupmilksupply.

• Askonegrouptopresenttheirfindingstothewholegroup.

• Askothergroupstocontributeanyadditionalpoints.

• Discussionandsummarywiththewholegroup.

• Fill-ingapsusingTable2:Insufficientbreastmilk

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Breast Condition

Engorgement

Table 1: Common Breastfeeding Conditions

Symptoms:

• Swelling

• Tenderness

• Warmth,

• Slightredness

• Pain

• 24hourfever

• Skinshiny,tightandnippleflattened

• Usuallybeginsonthe3rd–5thdayafterbirth

Sore or Cracked Nipples

Symptoms:

• Breast/nipplepain

• Cracksacrosstopofnippleoraroundbase

• Occasionalbleeding

• Maybecomeinfected

Prevention

• Goodattachment

• Startbreastfeedingwithinanhourofbirth

• Breastfeedfrequentlyondemand(asoftenandaslongasbabywants)dayandnight:10–12timesper24hours

• Goodattachment

• Donotusebottles

• Donotusesoaporcreamsonnipples

Solutions

q Applycoldcompressestobreaststoreduceswelling;thenapplywarmthtohelpmilktoflow

q Breastfeedmorefrequently

q Offerbothbreasts

q Improveattachment

q Gentlestrokingofbreastshelpstostimulatemilkflow

q Pressaroundareolatoreduceoedema,tohelpbabytoattach

q Expressmilktorelievepressureuntilbabycansuckle

Warmth may be warm water, shower or bath if possible, warm dry cloth, not necessarily compress

q Donotstopbreastfeeding

q Improveattachment

q Begintobreastfeedonthesidethathurtsless

q Varybreastfeedingpositions

q Letbabycomeoffbreastbyhim/herselforremovethebabyfromthebreastbybreakingsuctionfirst

q Applydropsofbreastmilktonipplesandallowtoairdry

q Donotusesoaporcreamonnipples

q Donotwaituntilthebreastisfulltobreastfeed

q Donotusebottles

Continued

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• Getsupportfromthefamilytoperformnon-infantcarechores

• Ensuregoodattachment

• Breastfeedondemand,andletinfantfinish/comeoffbreastbyhim/herself

• Avoidholdingthebreastinscissorshold

• Avoidtightclothing

Plugged Ducts and Mastitis q Donotstopbreastfeeding(ifmilkisnotremovedriskofabscessincreases;letbabyfeedasoftenass/hewill)

q Applywarmth(water,hottowel,warmsunetc.)

q Holdbabyindifferentpositions,andensuregoodattachment

q Applygentlepressuretobreastwithflatofhand,rollingfingerstowardsnipple;thenexpressmilkorletbabyfeedevery2–3hoursdayandnight

q Rest(mother)

q Drinkmoreliquids(mother)

q Ifnoimprovementin24hoursreferforantibiotics

Breast Condition Prevention Solutions

Symptoms of Plugged Ducts:

• Lump,tender,localizedredness,feelswell,nofever

Symptoms of Mastitis

• Hardswelling

• Severepain

• Rednessinonearea

• Generallynotfeelingwell

• Fever

• Sometimesababyrefusestofeedasmilktastesmoresalty

Flat and inverted nipples q IfnipplesareFLAT,feednormally

q Babysucklesfromthebreast—notfromthenipple

q Helpisonlyneededtoattachbabyafterdelivery;nothingisusefulbeforedelivery,butnipplesoftenimproveatthetimeofbirth

q Ifnipplecanbepulledout,thenbabycanpullitouttoo;ifnipplegoesin,stilltrytoattachbaby.Leaningoverbabycanhelp.

q Helpbabytoattachasearlyaspossiblebeforemilkcomesinandthereisriskofengorgement.Sucklingearlyatdeliveryprobablyhelps.Stimulatingthenippleatdeliverymayhelpnippletostandoutmore.

q Trydifferentpositions

q Enticebabywithdropsofexpressedbreastmilkonnipple

q Expressmilkuntilbabyisabletoattach—sendtomoreexperiencedcounsellor

q Ifnipplesarelargeorelongated,trytogetbabytotakemorebreastintomouth

Continued

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Breast Condition Prevention Solutions

Candida (Thrush) q Checkforthrushinbaby’smouth:whitepatchesinsidecheckorontongue

q Babymayhaverashonbottom

q Refertohealthpersonneltoconfirmdiagnosis

q Followtreatmentdirectionsofhealthpersonnelforbothmotherandbaby

Sore, red, itchy nipples

whitepatchesinsideorontongue,ormaybearashonbottom

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Insufficient Breastmilk Prevention Solutions

Table 2: Insufficient Breastmilk

Perceived by mother

• You“think”youdonothaveenoughmilk

• (Babyrestlessorunsatisfied)

Firstdecideifthebabyisgettingenoughbreastmilkornot(weight,urineoutput)

• Startbreastfeedingwithinanhourofbirth

• Staywithbaby

• Ensuregoodattachment

• Encouragefrequentdemandfeeding

• Letbabyfinishfirstbreastfirst

• Breastfeedexclusivelydayandnight

• Avoidbottles

• Encourageuseofnon-oestrogenfamilyplanningmethods

• SameasaboveBaby not getting enough Breastmilk

• Insufficientweightgain

• Fewerthan6wets/day

q Listentomother’sconcernsandwhyshethinksshedoesnothaveenoughmilk

q Decideifthereisaclearcauseofthedifficulty(poorbreastfeedingpattern,mother’smentalcondition,babyormotherill)

q Checkbaby’sweightandurineoutput(ifpoorweightgainrefer)

q Buildmother’sconfidence—reassureherthatshecanproduceenoughmilk

q Explainwhattheproblemmaybe—growthspurts

q Explainforeandhindmilk

q Checkandimproveattachment

q Suggeststoppinganysupplements—water,formulas,tea,orliquids

q Avoidseparationfrombabyandcareofbabybyothers

q Suggestimprovementstofeedingpattern.Feedbabyfrequentlyondemand,dayandnight.

q Finishthefirstbreastfirst—letthebabycomeoffthebreastbyhim/herself

q Ensuremothergetsenoughtodrink

q Thebreastsmakeasmuchmilkasthebabytakes—ifs/hetakesmore,thebreastsmakemore(thebreastislikea“factory”—themoredemandformilk,themoresupply)

q Sameasabove

q Ifnoimprovementinweightgainafter1week,refermotherandbabytonearesthealthpost

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SESSION6

Common Situations that Can Affect Breastfeeding; and Identifying Signs that Require Mother/Caregiver/Family to Seek Care

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. Discusscommonsituationsthatcanaffectbreastfeeding

2. Identifysignsthatrequirethemother/caregiver/familytoseekcare

ActivitiesActivity1 Discusscommonsituationsthatcanaffectbreastfeeding(�0 minutes)

Activity2 Referralfordifficultproblems(�0 minutes)

Activity3 Identifysignsrequiringthemother/caregiver/familytoseekcarefor theirchild(�0 minutes)

Total Time 1½ hours

Materials needed√ 2envelopes,eachwithasetofimagesofcommonsituationsthatcanaffect

breastfeeding:sickmother,feedingalowbirthweightbaby(kangaroomothercare),malnourishedmother,twins,refusaltobreastfeed,pregnancy,andmotherawayfrombaby

√ CounsellingCard17:SignsRequiringtheMother/Caregiver/FamilytoSeekCare

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

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ACTIVITY 1

Discuss Common Situations that can affect breastfeeding (�0 minutes)

Methodology: “Pick from the envelope”

• DivideParticipantsintotwogroupstoplay“pickfromtheenvelope”.

• Giveeachgroupabasketwithasetofimagesrepresentingacommonsituationorbeliefthatcanaffectbreastfeeding.

• Eachgroupisdividedinto2teams.

• Oneparticipantfromteam1isaskedto“pickfromtheenvelope,”lookattheimage,consultwithotherteammembers,andanswerthequestionofhowawomanwiththissituationorbeliefcanbesupportedtosuccessfullybreastfeedherbaby.

• Discussion.

• Then,oneparticipantfromteam2“picksfromtheenvelope”andanswers(withthehelpofteam)thenextsituationthatcanaffectbreastfeeding.

• Switchfromoneteamtotheotheruntilall‘commonsituationsthatcanaffectbreastfeeding’havebeen“pickedfromtheenvelope”.

• Discusshowstresscanaffectbreastfeeding(noimageavailable).

• Discussionandsummary.

Content for Activity 1 on following page

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Content for Activity 1

• Whenthemotherissufferingfromheadaches,backaches,colds,diarrhea,oranyothercommonillness(malaria,anemia,evencholera),sheSHOULDCONTINUETOBREASTFEEDHERBABY.

• Themotherneedstorestanddrinkplentyoffluidstohelpherrecover.

• Ifmotherdoesnotgetbetter,sheshouldconsultadoctorandsaythatsheisbreastfeeding.

• Motherneedssupportforgoodattachment,andhelpwithsupportiveholds.

• Feedingpattern:longslowfeedsareOK—keepbabyatthebreast.

• Directbreastfeedingmaynotbepossibleforseveralweeks,butmothersshouldbeencouragedtoexpressbreastmilkandfeedthebreastmilktotheinfantusingacup.

• Ifthebabysleepsforlongperiodsoftime,trytolooselycoverbabytohelpawakenhim/her.

• Cryingisthelastsignofhunger.EarliersignsofhungerincludeaCOMBINATIONofthefollowingsigns:beingalertandrestless,openingmouthandturninghead,puttingtongueinandout,suckingonhandorfist.Onesignbyitselfmaynotindicatehunger.

• Position(placedbetweenmother’snakedbreastwithlegsflexedandsecuredinacloththatpassesjustundertheinfant’searsandistiedaroundthemother’schest)

– Skin-to-skincontact(SSC)

– Provideswarmthandstabilizesbreathing

– Mother’ssmell,touch,feel/warmth,voice,andtasteofthebreastmilk helptostimulatethebabytoestablishsuccessfulbreastfeeding

• Breastfeeding(earlyandexclusivebreastfeedingbydirectexpressionorexpressedbreastmilkgivenbycup)

• Motherandbabyarerarelyseparated

• MothersneedstoeatmorefoodFORHEROWNHEALTH(“feedthemotherandletherbreastfeedherbaby”).

• MothersneedtotakevitaminAwithin6weeksafterdelivery,andadailymultivitamin,ifavailable.

• Motherscanproducemilkifthebabysuckles

Sick Mother

Low Birth Weight Baby

Kangaroo Mother Care

Malnourished mother

Continued

Common Situations that Can Affect Breastfeeding

Special Situation Solutions

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• Amothercanexclusivelybreastfeedbothbabies.

• THEMOREABABYSUCKLES,THEMOREMILKTHEMOTHERPRODUCES.

• Mothersoftwinsproduceenoughmilktofeedbothbabiesifthebabiesbreastfeedfrequentlyandarewellattached.

• Thetwinsneedtostartbreastfeedingassoonaspossibleafterbirth—iftheycannotsuckleimmediately,helpthemothertoexpressandcupfeed.Buildupthemilksupplyfromveryearlytoensurethatbreastsmakeenoughfortwobabies.

Usuallyrefusaltobreastfeedistheresultofbadexperiences,suchaspressureonthehead.Refusalmayalsoresultwhenmastitisresultsinthechangedtasteofthebreastmik(moresalty).

• Letthebabyhavelotsofskin-to-skincontact;letbabyhaveagoodexperiencejustcuddlingmotherbeforepressingtosuckle

• Donotpressuretobreastfeed

• Donotpressbackofhead

• Expressandfeedbycupuntilbabyiswillingtosuckle

• Expressdirectlyintobaby’smouth

• Letbabytrylotsofdifferentpositions

• Avoidgivingthebabyteatsandbottles

• Checkbaby’smouthforsignsofthrush

• Waitforthebabytobewideawakeandhungry(butnotcrying)beforeofferingthebreast.

• Gentlyteasethebaby’sbottomlipwiththenippleuntils/heopenshis/hermouthwide.

• Inmostcountriesamotherisencouragedtodiscontinuebreastfeedingwhenshebecomespregnant.Shemaybelieveitisharmfultooneorotherbabytobreastfeedwhilesheispregnant.Sometimesthemother’snipplesfeeltenderifsheispregnant.Itisperfectlysafetobreastfeedtwobabiesandwillnotharmeitherbaby—therewillbeenoughmilkforboth.

• Ifbabyisunder1yearofage,itmaybemorebeneficialtothebabytocontinuebreastfeedingtosustainhealth,growth,anddevelopment.

• Motherneedstobeencouragedtoeatmoretimesadayforherownhealthandtosupportbothbreastfeedingandthegrowthofthefetus.

Common Situations that Can Affect Breastfeeding Continued

Special Situation Solutions

Twins

Baby who refuses the breast

New pregnancy

Continued

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Common Situations that Can Affect Breastfeeding Continued

Special Situation Solutions

• Breastmilkdoesnotspoilbecauseofmother’sstress,andproductiondoesnotdecrease.However,milkmaynotflowwelltemporarily.

• Ifmothercontinuestobreastfeed,milkflowwillstartagain.

• Keepbabyinskin-to-skincontactwithmotherifshewillpermit.

• Findreassuringcompanionstolisten,givemotheranopportunitytotalk,andprovideemotionalsupportandpracticalhelp.

• Trytorelaxandbreastfeedbaby.

• Drinkawarmbeveragesuchasteaorwarmwater,tohelprelaxandassisttheletdownreflex.

• Ifnecessary,providetemporaryartificialfeedsbycup.

• Mothershouldexpressmilkandstorethebreastmilkforusewhileawayfromthebaby;thebabyshouldbefedthismilkattimeswhens/hewouldnormallyfeed.

• Teachcaregiverhowtosafelyfeedexpressedbreastmilk.

• Mothershouldsleepwithbabyandallowinfanttofeedfrequentlyatnightandwhensheisathome.

• Motherwhoisabletokeepherinfantwithherattheworksiteshouldfeedherinfantfrequently.

Stress

Mother away from baby

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Infant and Young Child Feeding Counselling ��

ACTIVITY 2

Referral for difficult problems (�0 minutes)

Methodology: Brainstorm

• Brainstormwhereand/ortowhomtheIYCFcounsellorscangoforreferralwhenthereareproblemss/heisunabletohandle.

• Discussionandsummary.

ACTIVITY 3

Identify signs requiring the mother/caregiver/family to seek care (�0 minutes)

Methodology: Brainstorm and small groups

• Brainstormsignsthatrequirereferraltothehealthpostbymother/caregiver/family.

• DivideParticipantsintosmallgroups.

• AskeachgrouptostudyCounsellingCard17andtoidentifythesignsthatrequirereferraltothehealthpostbymother/caregiver/family.

• Askonesmallgrouptosharewiththewholegroupthesignsrequiringreferraltoahealthpostbymother/caregiver/familyshownintheCounsellingCard17.Othersmallgroupstoaddadditionalpoints.

• Probeuntilthekeyandsupportingmessages(foundinAppendix1oftheIYCFCounsellingTrainer’sGuide)arementioned.

• Discussionandsummary:

– Recognizesignsrequiringreferraltothehealthpostbymother/caregiver/family

– Refermother

– Supportmother

• Discussionandsummary.

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SESSION7

How to Counsel: Practise Counselling with Mothers of Babies Less than 6 Months

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. Listcounsellingskills:

– listeningandlearning

– buildingthemother’s/caregiver’sconfidence

– providingsupportandpracticalhelp,and

– negotiating(“reaching-an-agreement”)

2. Describethe“assess,analyzeandact”stepstocounselling

3. UseaCounsellingCardincounselling

4. Practisetheprocessofcounsellingwithamotherofababylessthan6months

ActivitiesActivity1 Listcounsellingskills,anddescribethe“assess,analyzeandact”steps

tocounselling(�0 minutes)

Activity2 Modelthe“assess,analyzeandact”stepstoCounsellingtoencourage motherstotryoptimalbreastfeedingpractices:initialcontactwith motherofbabylessthan6months(�� minutes)

Activity3 Discussmodeldemonstration(�� minutes)

Activity4 Practisethe“assess,analyzeandact”stepstocounsellinginaninitial contactwithmotherofbabylessthan6months(�0 minutes)

Activity5 Discussthe“assess,analyzeandact”stepstocounsellingforfollow-up contact(s)(�0 minutes)

Activity6 Prepareforpracticum(�0 minutes)

Total Time 2½ hours

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Materials needed√ 4CaseStudiesofcounsellingforbabylessthan6months

√ 4follow-upCaseStudiesofcounsellingforbabylessthan6months

√ Eachparticipanthasasetofcounsellingcards

ACTIVITY 1

List counselling skills and describe the “assess, analyze and act” steps to counselling (�0 minutes)

Methodology: Brainstorming and description of “assess, analyze and act” steps of counselling

á List counselling skills

• Brainstormwithwholegroupthekindsofcounsellingskills

• Probeuntilthefollowingcounsellingskillshavebeenmentioned:listeningandlearning(practicedinSession2),buildingthemother’s/caregiver’sconfidence,providingsupportandpracticalhelp,andnegotiating(“reaching-an-agreement”)

• Fill-ingapswithadescriptionofthe“assess,analyzeandact”stepsofcounselling

á Describe the “assess, analyze and act” steps

Assess mother and baby situation

• Greetthemother/fatherandestablishconfidence

• Askthemotheraboutageofbaby,currentfeedingpractices,andhealth

• Askquestionstolearnmother’ssituationandconcerns

• Listentotheconcernsofthemotherandfather,andobservebabyandmother

• Acceptwhatmotherisdoingwithoutdisagreeingoragreeing

• Lookforthingsthatmotherisdoingrightorthataregoingwelltopraise

Analyze

• Identifyfeedingdifficulty,ifany,andcausesofthedifficulty

• Ifthereismorethanonedifficulty,prioritizedifficulties

• Answerthemother’squestions(ifany)

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Act

• Dependingontheageandsituationofthebaby,selectandgivesmallamountofRELEVANTINFORMATIONononeortwoofthefollowingtopicscoveredintheCCs;useCCstohelpmotherunderstandandremembertheinformation.

• Benefitsofcolostrum(Session3:ImportanceofBreastfeeding,andCCs2aand2b)

• Thatthereisenoughwaterforthebabyinthebreastmilk(CC7)

• Benefitsofexclusivebreastfeedinguntilthebabyis6months(CC7)

• Therisksofgivingwatertothebaby

• Howababysuckles(attachmentandpositioning)(CCs4and5)

• Ababy’snormalfeedingpattern

• Thebreastsmakeasmuchmilkasthebabytakes—ifhetakesmore,thebreastsmakemore.Thebreastislikea“factory”—themoredemand(formilk),themoresupply(CC6)

• KangarooMotherCare

– Skin-to-skincontact(SSC)

– Warmth

• Whenandhowtoexpressbreastmilkandhowtofeedthebabywithacup(CC8)

• Whentostartcomplementaryfoodsandhowtodoit(moreinformationlater)

• ShowrelevantCounsellingCard(s)andaskmothertocommentonwhatsheobservesishappeninginthecard,andtorelateittoherownsituation.

• Askthemotherwhatshethinksaboutthisinformation.

• Discusswiththemother/fatherdifferentfeasibleoptionstoovercomethedifficulty.

• Suggestwhatthemothermightdo,givingheratleasttwopossibilities,andaskherwhatshefeelsabletodo.

– Putas“suggestionnotcommand”(meaningnottellingamotherwhattodo)

– Presentoptions/smalldo-ableactions(time-bound)andhelpmotherselectonethatshecantry

– Givemotherasayinthedecision,andtheopportunitytosayno,ortochooseanotherway

• Negotiate(“reach-an-agreement”)withthemothertotryanewbehaviour,ortotakeafurtherstepsuchasdiscussingthesuggestionswithanotherfamilymember.

• Makeafollow-upappointmentwithmother.

• Praisethemotherandthankherforhertime.

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ACTIVITY 2

Model the “assess, analyze and act” steps to counselling to encourage mothers to try optimal breastfeeding practices: initial contact with mother of baby less than 6 months (�� minutes)

Methodology: Demonstration

á Model the “assess, analyze and act” steps

• Model(2Facilitators)theinitialcounsellingcontactofanIYCFCounsellortoTamimawith2-monthsonAhmed(modelthe“assess,analyzeandactsteps”).(Thefacilitatorsshouldpreparethisdemonstrationinadvance).

Assess mother and baby situation

• ListentowhatTaminasays[TaminatellstheCounsellorshebreastfeeds,butdoesnotproduceenoughmilk,andsoshefeedsAhmedothermilk.]

• AskafewquestionstounderstandwhyTamimathinksshedoesnothaveenoughmilk.

• PraiseTaminaforbreastfeedingAhmed.

Analyze

• Taminahasapparentorrealinsufficiencyofbreastmilk.

Act

• Relatethereasonsforapparentorrealinsufficiencybreastmilk(keyandsupportingmessages:Session5).

• CheckattachmentandifpossibleweightgainoratleastappearanceandhealthofAhmed.

• AskTaminahowmanytimesAhmedhasurinatedduringthelast24hours(fromthistimeyesterdaytotoday.

• ShowCCs6and7:‘BreastfeedonDemand,bothDayandNight’and‘Duringthefirst6Months,YourBabyNeedsONLYYourBreastmilk’andaskTaminatocommentonwhatsheobservesishappeninginthecardandtorelateittoherownsituationofinsufficiencyofbreastmilk.

• Ifattachmentisnotgood,showCCs4and5:‘HowtoAttachBabytotheBreast’and‘BreastfeedingPositions’andaskTaminatocommentonwhatsheobservesishappeninginthecardandtorelateittohowsheattachesandpositionsAhmed.

• GiverelevantandsmallamountofinformationregardingthemessagesofCCs4,5,6and7usingsimplelanguage.

• AskTaminawhatshethinksaboutthisinformation.

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• DiscusswithTaminadifferentfeasibleoptionstoovercomethedifficultyofapparentorrealinsufficientmilk.

• Putas“suggestionnotcommand”(meaningnottellingTaminawhattodo).

• Presentoptions/smalldo-ableactions(time-bound)andhelpTaminaselectonethatshecantry.

• GiveTaminaasayinthedecision,andtheopportunitytosayno,ortochooseanotherway.

• Modifyrecommendations,ifnecessary,tosuitTamina’spreferences.

• Makeafollow-upappointmentwithTamina.

• PraiseTaminaandthankherforhertime.

ACTIVITY 3

Discuss model demonstration (�� minutes)

Methodology: Presentation and discussion

á Discuss model demonstration

• TwoFacilitators(CounsellorandTamina)repeatinitialcounsellingcontactwithTamina,stoppingaftereachstepof“assess,analyzeandact”

• CounsellorshowsCounsellingCard4anddiscusseswithTamina:

1.Observe—WhatishappeningintheCounsellingCard?

2.Relatetoyourownsituation–Whatdoyouagreeordisagreewith?Why?Whatdopeopleinyourcommunitydo?

• GivesrelevantandsmallamountofinformationregardingmessagesofCounsellingCard4usingsimplelanguage

• AsksTaminawhatshethinksaboutthisinformation.

• RepeatsstepsusingCounsellingCard5,6and7.

• Discussesdifferentfeasibleoptionstoovercomethedifficultyofapparentorrealinsufficientmilk.

• HelpsTaminaselectasmalldo-ableactions(time-bound)thatshecantry.

• Makesafollow-upcontactappointment.

• Discussionandrepetitionof“assess,analyze,andact”stepswithParticipants.

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Infant and Young Child Feeding Counselling ��

ACTIVITY 4

Practise the “assess, analyze, and act” steps to counselling in an initial contact with mother of baby less than months (�0 minutes)

Methodology: Practise and role-play counselling skills during initial contact

á Practise

AskParticipantstorecalltheoptimalbreastfeedingpractices(CC1).

Participantsaredividedintotriads:mother,IYCFCounsellor,andobserver.

• PractiseCaseStudy1:Askthe‘mothers’ofthetriadstogathertogether.

• AcasestudyisreadONLYtothe‘mothers’ofthetriads,andthe‘mothers’returntotheirtriads.

• The‘Counsellorofeachtriad’asksthemotherabouthersituation,andpractisesthe“assess,analyze,andact”steps:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),andshowingrelevantCounsellingCard(s).

• InthetriadtheObserver’staskistorecalltheskillsthe‘Counsellor’practised(observer’schecklistfollowsforeachcasestudy).

TheParticipantsinthetriadsswitchroles.

• PractiseCaseStudy2:AsecondcasestudyisreadONLYtothe‘mothers’ofthetriads,andthe‘mothers’returntotheirtriads.

• The‘Counsellorofeachtriad’asksthemotherabouthersituation,andpractisesthe“assess,analyze,andact”steps:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),andshowingrelevantCounsellingCard(s).

• InthetriadtheObserver’staskistorecalltheskillsthe‘Counsellor’practised(observer’schecklistfollowsforeachcasestudy).

TheParticipantsoncemoreswitchrolesintheirtriads.

• PractiseCaseStudy3:AthirdcasestudyisreadONLYtothemothersofthetriads,andthe‘mothers’returntotheirtriads.

• The‘Counsellorofeachtriad’asksthemotherabouthersituation,andpractisesthe“assess,analyze,andact”steps:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),andshowingrelevantCounsellingCard(s).

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• InthetriadtheObserver’staskistorecalltheskillsthe‘Counsellor’practised(observer’schecklistfollowsforeachcasestudy).

• Onetriaddemonstratesacasestudyinfrontofthewholegroup.

• Discussionandsummary.

• Repeatprocessonemoretimewithamorecomplicatedcasestudy(CaseStudy4)thatneedsreferral.

Case Studies for Activity 4

Case Study �:

Initial Contact

Read to mother:YouareFatuma.Yourson,Shukri,istwoweeksold.Youhavebeenbreastfeedingandyouwanttocontinue,butyournipplesareverysore.

Checklist for Observer (of the ‘Counsellor’)—Did the Counsellor?

• AskFatumaquestions,listentoherandacceptFatuma’spracticesandconcerns.

• PraiseFatumaforbreastfeedingherbaby,Shukri.

• ObservehowFatumabreastfeeds.

• ObservethatShukriisnotATTACHEDwell(possibly).

• ExplainthatthenipplesorenesscouldbeduetothewaythatShukriissuckling.

• AskFatumaifshewouldliketheCounsellortoshowheradifferentwaytoattachandholdShukri.

• ShowCCs4and5:‘HowtoAttachBabytotheBreast’and‘BreastfeedingPositions’andaskFatumatocommentonwhatsheobservesishappeninginthecardandtorelateittoherownsituation.

• ShowFatumahowtoattachandpositionShukriatherbreast.

• ObtainanagreementwithFatuma:e.g.FatumaagreedtotryattachingandpositioningShukriinthiswayforthenextcoupleofdaystoseeifhernipplesimprove.

• Makeafollow-upappointmentwithFatuma.

• PraiseFatumaandthankherforhertime.

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Case Study �:

Initial Contact

Read to mother:YouareMurayo.Yourdaughter,Habiba,isthreeweeksold.YouarebreastfeedingHabibabecauseyouknowbreastmilkisthebestfoodforher.YouarealsogivingHabibasipsofwaterbecauseitissohot.

Checklist for Observer (of the ‘Counsellor’)—Did the Counsellor?

• AskMurayoquestions,listentoherandacceptMurayo’spracticesandconcerns.

• PraiseMurayoforbreastfeedingherbaby,Habiba.

• ACCEPTthatMurayoisgivingwateraswell.

• ProvideMurayowithinformationthatbreastmilkcontainsallthewaterHabibaneedsduringthefirst6-months,eveninveryhotweather.

• ShowCounsellingCard7:‘Duringthefirst6Months,YourBabyNeedsONLYYourBreastmilk’andaskMurayotocommentonwhatsheobservesishappeninginthecardandtorelateittoherownsituation.

• SUGGESTthatMurayoconsidertheoptionofexclusivelybreastfeeding(givingonlybreastmilkandnootherliquids),askingifMurayowouldbewillingtotryexclusivelybreastfeedingHabibaforafewdays.

• Murayothenwantedtodiscussandsays:“Well,butwhatifsheisthirsty”,andthen‘Counsellor’suggestedbreastfeedingmoreoftenandexplainedthatHabibawillgetmorewaterthatway.

• ObtainanagreementwithMurayo:e.g.Murayoagreedtotryexclusivelybreastfeedingforthenextfewdays.

• Makeafollow-upappointmentwithMurayo.

• PraiseMurayoandthankherforhertime.

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Case Study �:

Initial Contact

Read to mother:YouareTamima.Youarepregnantwithyoursecondchild.YoucometovisittheCounsellorwithyourmother.Yourfirstchild,Hussein,is2½yearsold.WhenHusseinwasbornyouwereverytired.YourmothertookHusseinawayforafewdaystoallowyoutorest.Yourmotherplanstodothesameafterthenewbabyisborn.

Checklist for Observer (of the ‘Counsellor’)—Did the Counsellor?

• AskTaminaquestions,listentoherandacceptTamina’spracticesandconcerns.

• TalktoTaminaandhermother,praisethemotherforsupportingTamima,andagreethatitisgoodforanewmothertorestafterdelivery.

• Explaintheimportanceofstartingbreastfeedingverysoonafterbirth,andofbreastfeedingexclusively.

• AskifitwouldbepossibleforTamima’smothertofindawaytolookafterTamimaandherbabytogether,sothatTamimacouldrestandbreastfeedthebaby?

• ShowCCs2a,2band3:‘DeliveryinFacility’,‘HomeDelivery’,and‘GrandmotherOfferingFoodtoBreastfeedingDaughter/Daughter-in-law’andaskTaminatocommentonwhatsheobservesishappeninginthecard(s)andtorelateittoherownsituation.

• ExplaintheimportanceofgoodnutritionforTaminaandaskifitwouldbepossibleforTamina’smothertoseethatTaminaeatsmorethanusual.

• ObtainanagreementwithTamina’smother:e.g.Tamima’smotheragreedtohelpTaminawithherotherworkandcarefortheolderchildwhileTaminacaresforthenewbaby;shealsoagreedtomakesureTaminaeatsanextramealaday).

• Makeafollow-upappointmentwithTamina.

• PraiseTaminaandthankherforhertime.

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Case Study �:

Initial Contact

Read to mother:YouareSaidia.Youarebreastfeedingyourthreemonthold,Mohammed.Youhave2otherchildren.Youandyourhusbandwantmorechildrenandyouwouldliketobecomepregnantthisyear.

Checklist for Observer (of the ‘Counsellor’)—Did the Counsellor?

• AskSaidiaquestions,listentoherandacceptSaidia’spracticesandconcerns.

• PraiseSaidiaforbreastfeedingMohammed.

• ExplaintheimportanceofexclusivelybreastfeedingMohammedfor6months.

• ProvideinformationabouttheimportanceofcontinuingtobreastfeedMohammedfor2years.

• ShowCounsellingCard6:‘OptimalChildSpacing’andaskSaidiatocommentonwhatsheobservesishappeninginthecardandtorelateittoherownsituation.

• Explainthatcloselyspacedpregnanciesriskherhealthandthatoftheolderbabyandthenewborn.

• ReferSaidiatothefamilyplanningcounsellor.

• ObtainanagreementwithSaidia:e.g.Saidiaagreedtoseethefamilyplanningcounsellor.

• Makeafollow-upappointmentwithSaidia.

• PraiseSaidiaandthankherforhertime.

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ACTIVITY 5

Discuss the “assess, analyze and act” steps to counselling for follow-up contact(s) (�0 minutes)

Methodology: Brainstorm and practise

• Withthewholegroup,brainstormadditionalpointstobediscussedwithmotherduringcounsellingforfollow-upcontact(s).

• DivideParticipantsintoasmanygroupsasthereareFacilitators(withaFacilitatorineachgroup).

• Read(Facilitatorineachgroup)follow-upcontactcasestudyandaskoneParticipantinthesmallgrouptocommentonwhats/hewouldsaytothemotherduringthisfollow-upcontact.

• Askifanyonehasanythingelsetoadd?

• AskParticipantstoreflectonthe“assess,analyzeandact”stepsofcounselling,askingthequestion:DidtheCounsellor...........?(SeeActivity1ofSession7andfollowthe“assess,analyzeandact”steps).

• Whenthefirstfollow-upcontactiscomplete,repeatthesameprocessfortheremindingfollow-upcontactcasestudies(4follow-upcontactcasestudiesintotal).

• Discussionandsummary.

Content for Activity 5

Points to discuss in Follow-up Contact(s) Counselling

• Askhowthebabyandmotheraredoing(isthebabybetterorworse?)

• Askwhetherthemothertried(orcontinued)theagreeduponnewbehaviour.

• Congratulatemotherfortrying(orcontinuing)thenewbehaviour.

• Ifthemotherdidnottrythenewbehaviourorgaveup,askwhy?

• Askwhathappenedwhenshetried(orcontinued)thenewbehaviour.

• Askwhethershemadeanychangestothenewbehaviourandwhy?

• Askwhatdifficultiesshehad,howshesolvedthem,orhelpherfindwaystosolvethedifficultiesshemighthavehadorthinkofalternatives.

• Listentothemother’squestions,concernsanddoubts.

• Askwhethershelikesthenewbehaviouragreeduponandifshethinksshewillcontinueorwhattodoifshedoesnotcontinue.

• Praisethemotherandmotivatehertocontinuethenewbehaviour.

• Remindthemothertotakethechildtobeweighed(attendEPI,immunizationsandgrowthmonitoringsessions).

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• Tellthemotherwhereshecangetadditionalsupportfromcommunity-basedhealthworkers,healthposts,ormothersupportgroups.

• Agreeonadateforthenextcontact.

• Dependingontheageofthechild:

– talktothemotheraboutanewbehaviour

– encouragethemothertotryanewbehaviour

Follow-up contact case studies for Activity 5

Case Study �:

Follow-up Contact

FatumatellsyouthathernipplesaremuchbetterandShukriwhoisonemontholdisbreastfeedingwell.FatumaiswonderinghowshecanknowthatShukriisgrowingenough.

Did the Counsellor?

• AskhowShukriandFatumaaredoing(isthebabybetterorworse?)

• PraiseFatumaforchanginghowShukriwasattachedtoherbreast.

• AskthenumberoftimesShukriwets,frequencyoffeedings,Shukri’sbehaviour,cryingetc.

• ShowCounsellingCard6:‘BreastfeedonDemand,BothDayandNight’andaskFatumatocommentonwhatsheobservesishappeninginthecardandtorelateittoherownsituation.

• ReviewwithFatumathatbreastmilkcontainsallthenutrientsShukrineedsinhisfirst6monthstogrowstongandhealthy

• SUGGESTthatFatumacontinueexclusivelybreastfeedingShukriondemand,bothdayandnight.

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Case Study �:

Follow-up Contact

MurayotellsyouthatsheisonlygivingbreastmilkandHabiba,whois3monthsold,isbreastfeedingwell.Murayotellsyouthatshedoesn’tthinksheshouldexclusivelybreastfeedHabibafor6monthsandthatHabibaneedsfoodbeforethen.

Did the Counsellor?

• PraiseMurayofortryingthenewpracticeofexclusivelybreastfeedingHabiba.

• ListentoherstoryandacceptedMurayo’sfeelings.

• ReviewwithMurayoinformationthatbreastmilkcontainsallthewaterHabibaneedsduringthefirst6-months,eveninveryhotweather.

• ShowCounsellingCard7:‘Duringthefirst6Months,YourBabyNeedsONLYYourBreastmilk’andaskedMurayotocommentonwhatsheobservesishappeninginthecardandtorelateittoherownsituation.

• SUGGESTthatMurayocontinueexclusivelybreastfeedingHabiba.

Case Study �:

Follow-up Contact with Tamina and her mother

Tamina’smothertellsyouthatshestillthinksherdaughterneedstorestafterthebirth,“shewillbeweakandthebreastmilkwillnotyethavecomein”.

Did the Counsellor?

• AskhowTaminaisdoing.

• Listentowhatthegrandmotherhadtosay,askheraboutherownexperienceswhenshegavebirthandwhatthepracticeswerethen,andwhattheoutcomewas.

• Praisegrandmotherforbeingconcernedaboutherdaughter.

• Talktograndmotheragainaboutearlyinitiationandmilkproduction,andtheimportanceofcolos-trum.

Continued

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Infant and Young Child Feeding Counselling ��

ACTIVITY 6

Prepare for practicum (�0 minutes)

• Participantsformpairs(Facilitatorneedstobesensitivetolanguageandgender)

• AskeachParticipanttobringhis/hersetofcounsellingcards

• Arrangetimeformeetingandtransportation(ifneeded)

Case Study �: Continued

• ShowCCs2aor2band3:‘DeliveryinFacility’,‘HomeDelivery’,and‘GrandmotherOfferingFoodtoBreastfeedingDaughter/Daughter-in-law’andaskTamina’smothertocommentonwhatsheobservesishappeninginthecard(s)andtorelateittoherdaughter’ssituation.

• SUGGESTthatgrandmotherhelpherdaughtergettherestsheneedsafterdeliveryandkeepmotherandbabytogether.

Case Study �:

Follow-up Contact

SaidiatellsyoushehasbeenfeedingAli,whois4monthsold,asoftenandaslongashewantsbothdayandnight.Saidiatellsyouthatsheistalkingtoherhusbandaboutvisitingthefamilyplanningcounsellortogether,buthestillwantsanotherbabysoon.

Did the Counsellor?

• AskhowSaidiaandAliaredoing.

• PraiseSaidiaforexclusivelybreastfeedingAli.

• CongratulateSaidiaforherintentionofgoingtogetherwithherhusbandtoseethefamilyplanningcounsellor.

• EncourageSaidiatomakeanappointmenttoseethefamilyplanningcounsellor.

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SESSION8

How to Counsel a Mother with a Baby less than 6 Months: Community and/or Facility Practise and Feedback

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

Learning objectiveBytheendofthesession,Participantswillbeableto:

1. PractiseCounselling:listeningandlearningskills,buildingthemother’s/caregiver’sconfidence,providingsupportandpracticalhelp,andnegotiating(“reaching-an-agreement”)withmothersofbabieslessthan6monthsathealthcentersorinthecommunity

ActivitiesActivity1 Practisecounselling:listeningandlearningskills,buildingthemother’s/

caregiver’sconfidence,providingsupportandpracticalhelp,and negotiating(“reaching-an-agreement”byapplyingthe“assess,analyze andact”steps(� hours)

Activity2 Feedbackonpractise(� hour)

Total Time 3 hours

Materials needed√ Counsellingcardsonbreastfeedingpractices:2–9

Advance preparation• Makeanappointmentatthehealthpostaweekaheadtodothefieldpractise

duringimmunizationorweighingsessions,or

• Makeanappointmentwiththecommunityhealthworkeraweekaheadforcommunityvisits

• Preparegroups,giveinstructionsthedaybefore

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Infant and Young Child Feeding Counselling ��

ACTIVITY 1

Practise counselling: listening and learning skills, building the mother’s confidence, providing support and practical help, and negotiating (“reaching-an-agreement” by applying the “assess, analyze and act” steps) (� hours)

Methodology: Practise

• BeforetheParticipantsleaveforthepractice-site,brieflyreviewCounsellingskills:listeningandlearning,buildingthemother’sconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),anduseofcounsellingcardsbyapplyingthe“assess,analyze,andact”steps.

• DivideParticipantsinpairsandexplaintheexercise:oneParticipantwillpractiseCounselling:listeningandlearningskills,buildingthemother’sconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”)anduseofcounsellingcardsbyapplyingthe“assess,analyzeandact”stepswiththemother,whiletheotherParticipantfollowsthedialogueinordertogivefeedbacklater.

• ParticipantschangerolesuntileachParticipantpractisesatleast2counsellingactivities.

ACTIVITY 2

Feedback on practise session (� hour)

Methodology: Feedback discussion

• Attrainingsite,withthewholegroup,eachpairofParticipantswillsummarizeforthegrouptheiruseoflisteningandlearningskills,buildingthemother’sconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”)anduseofcounsellingcardsbyapplyingthe“assess,analyzeandact”steps.Theirsummaryshouldincludethechild’snameandage,anydifficultyidentified,optionssuggested,andbehaviourmotheragreedtotry.

• Participantsreceiveandgivefeedback

• Discussionandsummary

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SESSION9

Complementary Feeding Practices for Children from 6–23 Months

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. Describekeypractices/messagespertainingtochildfeedingfrom6to23months.

2. Describethecharacteristicsofcomplementaryfeedingforeachagegroupwithregardto:Frequency,Amount,Thickness(consistency),Variety(differentfoods),Activeorresponsivefeeding,andHygiene(FATVAH).

3. Comparethedifferencebetweenrunnysoftfoods(poorthickness/consistency)andcorrectthickness/consistency(firstsoftcomplementaryfoodsshouldbethickenoughtostayonspoon).

ActivitiesActivity1 Answerquestionsoncurrentcomplementaryfeedingpracticesinyour

communityforchildrenfrom6–23months(�� minutes)

Activity2 UsingtheCCs,discusstherecommended(oroptimal)infantand youngchildcomplementaryfeedingpracticesforchildrenfrom 6–23monthsandmessages(� hour �� minutes)

Activity3 Demonstrationofappropriatethickness/consistencyoffirstsoftfoods (�0 minutes)

Total Time 3 hours

Materials needed√ Counsellingcardsonkeycomplementaryfeedingpractices/messagesfor

childrenfrom6–23months(CCs10,11,12,13,and14)

√ Image:‘Feedmoreasthebabygrows’

√ Smallamountofpreparedporridge,smallamountofmilk,2bowlsand2spoons

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

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ACTIVITY 1

Answer questions on current complementary feeding practices in your community for children from 6–23 months (�� minutes)

Methodology: Small working groups/questions and answers

• DivideParticipantsinto5workinggroups.

• Haveeachgroupanswer2questions(Facilitatorsrotateamongthegroupsand‘read’thequestions).

• RemindParticipantsthatquestionsrelatetoFrequency,Amount,Thickness(consistency),Variety(differentfoods),Activeorresponsivefeeding,andHygiene:FATVAH.

• Group 1:Inyourcommunity,

1.Whendoesababybegintoeatsomethingelseotherthanbreastmilk?

2.Howmanytimesadaydoesababyeat:at6months,from6–8months,from9–11months,andfrom12–23months?

• Group 2:Inyourcommunity,

1.Howmuchdoesababyeat:at6months,from6–8months,from9–11months,andfrom12–23months?

2.Whatisthethicknessorconsistencyofthefoodababyeats:at6months,from6–8months,from9–11months,andfrom12–23months?

• Group 3:Inyourcommunity,

1.Whatdoesababyeat:at6months,from6–8months,from9–11months,andfrom12–23months?

2.Aretherefoodsayoungchildshouldnoteat?

• Group 4:Inyourcommunity,

1.Whohelpstheyoungchildeat?—motherorcaregiver,brotherorsister,noone?

2.Doesaninfantandyoungchilduseaseparatebowl/dish?Doyouthinkayoungchildshoulduseaseparatebowl/dish?

• Group 5:Inyourcommunity,

FacilitatorneedstoremindtheParticipantsthatthequestionsrelatetoFATVAH.

1.Whatdoesamotherorcaregiverdobeforepreparingfood,andbeforeayoungchildeats?

2.Howlongshouldbreastfeedingcontinue?

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• Havethesmallgroupssharetheiranswerswiththewholegroup.

• Reviewthecharacteristicsofcomplementaryfeedingpracticesforchildrenfrom6–23months:frequency,amount,thickness(consistency),variety(differentfoods),activefeedingandhygienicpreparationoffood(FATVAH).

• ReviewwithParticipantstheconceptofactiveorresponsivefeeding(below)

• Discussionandfill-ingaps.

Content for Activity 1

Active or Responsive feeding

• Feedinfantsdirectlyandassistolderchildrenwhentheyfeedthemselves.Feedslowlyandpatiently,andencouragechildrentoeat,butdonotforcethem.

• Ifchildrenrefusemanyfoods,experimentwithdifferentfoodcombinations,tastes,texturesandmethodsofencouragement.

• Minimisedistractionsduringmealsifthechildlosesinteresteasily.

• Rememberthatfeedingtimesareperiodsoflearningandlove—talktochildrenduringfeeding,witheyetoeyecontact.

ACTIVITY 2

Discuss the key complementary feeding practices and messages for children from 6–23 months (�½ hours)

Methodology: Participants observe counselling cards 10, 11, 12, 13, and 14 and name optimal complementary feeding practices and messages for children from 6–23 months

• DivideParticipantsintosmallgroups,askingParticipantsineachgrouptousetheircounsellingcardsforthefollowingexercise.

• HaveeachgroupstudyCounsellingCard10andnamethecomplementaryfeedingpractice/sandmessage/sthatthecardrepresentsforyoungchildrenat6months.

• AskonesmallgrouptosharewiththewholegroupthecomplementaryfeedingpracticesandmessagesshownintheCounsellingCard.Othersmallgroupsshouldaddadditionalpoints.

• Probeuntilthekeyandsupportingmessages(foundinAppendix1oftheIYCF Counselling Trainer’s Guide)arementioned.

• Haveeachsmallgrouprepeattheprocessuntilthesetofcounsellingcardsoncomplementaryfeedingpracticeshasbeenobservedandstudied(CCs11–14)andthekeyandsupportingmessages(foundinAppendix1oftheIYCF Counselling Trainer’s Guideandthefollowingtable)arementioned.

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Content for Activity 2

ACTIVITY 3

Review the key complementary feeding practices and messages for children from 6–23 months (�0 minutes)

Methodology: Passing ball game

• AskParticipantstoformacircle.

• PassaroundtheImagetitled‘Feedmoreasthebabygrows’andtogetherlookatFrequency,Amount,Thickness(consistency),andVariety.

• Toconsolidatenewknowledge—throwtheballtooneParticipantandaskher/himtonameacomplementaryfeedingpracticeormessage(s)forchildrenfrom6–23months.

• WhentheParticipanthasnamedacomplementaryfeedingpracticeormessageforchildrenfrom6–23months,s/hethrowstheballtoanotherParticipantandasksthatParticipanttomentionadifferentpracticeormessage.

• Continueuntilallcomplementaryfeedingpracticesormessagesforchildrenfrom6–23monthshavebeenrepeated.

• ReviewGuidingPrinciplesforComplementaryFeeding(below)

Amounts of Foods to Offer

Age

6–8months

Texture

Startwiththickporridge,wellmashedfoods

Continuewithmashedfamilyfoods

Finelychoppedormashedfoods,andfoodsthatbabycanpickup

Frequency

2–3mealsperdayplusfrequentbreastfeeds

Dependingonthechild’sappetite1–2snacksmaybeoffered

3–4mealsplusbreastfeeds

Dependingonthechild’sappetite1–2snacksmaybeoffered

3–4mealsplusbreastfeeds

Dependingonthechild’sappetite1–2snacksmaybeoffered

Amount of food an average child will usually eat at each meal*

Startwith2–3tablespoonfulsperfeed

Increasegraduallyto½ofa250mlcup

Ifbabyisnotbreastfed,giveinaddition:1–2cupsofmilkperday,and1–2extramealsperday.

WHO/CAH(ChildandAdolescentHealth)2006

*Adaptthecharttouseasuitablelocalcup/bowltoshowtheamount.Theamountsassumeanenergydensityof0.8to1Kcal/g.

½ofa250mlcup/bowl

¾to1250mlcup/bowlFamilyfoods,choppedormashedifnecessary

9–11months

12–23months

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Content for Activity 3

Guiding Principles for Complementary Feeding

1. Practiceexclusivebreastfeedingfrombirthto6monthsofageandintroducecomplementaryfoodsat6monthsofage(180days)whilecontinuingtobreastfeed.

2. Continuefrequent,on-demandbreastfeedinguntil2yearsofageorbeyond.

3. Practiceactiveorresponsivefeeding,applyingtheprinciplesofpsychosocialcare.

4. Practicegoodhygieneandproperfoodhandling.

5. Startat6monthsofagewithsmallamountsoffoodandincreasethequantityasthechildgetsolder,whilemaintainingfrequentbreastfeeding.

6. Graduallyincreasefoodconsistencyandvarietyastheinfantgrowsolder,adaptingtotheinfant’srequire-mentsandabilities.

7. Increasethenumberoftimesthatthechildisfedcomplementaryfoodsasthechildgetsolder.

8. Feedavarietyofnutrient-richfoodstoensurethatallnutrientneedsaremet.

9. Usefortifiedcomplementaryfoodsorvitamin-mineralsupplementsfortheinfant,asneeded.

10.Increasefluidintakeduringillness,includingmorefrequentbreastfeeding,andencouragethechildtoeatfavouritesoftfoods.Afterillness,givefoodmoreoftenthanusualandencouragethechildtoeatmore.

ACTIVITY 4

Demonstrate appropriate thickness/consistency of first soft foods (�0 minutes)

Methodology: Demonstration of preparation of runny porridge and correct thickness/consistency porridge

• Bringasmallamountofpreparedporridge,asmallamountofmilk,2bowlsand2spoons.

• Inonebowl,mixsomepreparedporridgewithtoomuchmilk.Asaresulttheporridgerunsoffthespoon.

• PassaroundthebowlwithrunnyporridgetotheParticipants.

• Inanotherbowl,mixsomepreparedporridgewithalittlemilk.Asaresulttheporridgeisthickeranddoesnotrunoffthespoon.

• PassaroundthebowlwiththickerporridgetotheParticipants.

• Discussandcomparecorrectandincorrectthickness/consistencyoffirstsoftfoods.

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Infant and Young Child Feeding Counselling ��

SESSION10

Feeding the Sick Infant and Young Child

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. Counseloninfantandyoungchildfeedingduringandafterillness.

2. Explainthereasonsfortherecommendedpractices.

ActivitiesActivity1 Currentpracticesonfeedingthesickinfantandyoungchild

(�0 minutes)

Activity2 Idealfeedingofthesickinfantandyoungchild(�0 minutes)

Total Time 1 hour

Materials needed√ Counsellingcards15and16:FeedingtheSickInfantandYoungChild(lessthan

6months,andgreaterthan6months)

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

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ACTIVITY 1

Current practices in Feeding the Sick Infant and Young Child (�0 minutes)

Methodology: Small working groups

• DivideParticipantsinto4workinggroups.

• Ask2groupstodiscussthecurrentpracticesinyourcommunityforfeedingasickinfantfrom0<6monthsduringandafterillness.

• Ask2groupstodiscussthecurrentpracticesinyourcommunityoffeedingasickinfantandyoungchildfrom6–23monthsduringandafterillness.

• Haveoneofeachofthepairedgroupsreporttothewholegroup.Othergroupshouldnotrepeatthesameinformation,butonlyaddnewinformation.

• Discussionandsummary.

ACTIVITY 2

Feeding of the Sick Infant and Young Child (�0 minutes)

Methodology: Observe/reflect on practices/messages on Feeding the Sick Infant and Young Child using counselling cards 15 and 16

• DivideParticipantsintosmallgroups.

• Haveeachgroup:

– studyCCs15and16:FeedingtheSickInfantandYoungChild(lessthan6monthsandgreaterthan6months)andnamethepracticesandmessage(s).

– discussthepreventionandmanagementofdiarrhoeaforinfantslessthan6monthsandforinfantsandyoungchildrengreaterthan6months.

• AskonesmallgrouptosharewiththewholegroupthefeedingofthesickinfantandyoungchildpracticesandmessagesshownintheCCs15and16.Othersmallgroupsaddadditionalpoints.

• Probeuntilthekeyandsupportingmessages(foundinAppendix1oftheIYCFCounsellingTrainer’sGuide)arementioned.

• Askanothergrouptosharewiththewholegroupthepreventionandmanagementofdiarrhoeaforinfantslessthan6monthsandforinfantsandyoungchildrengreaterthan6months.Othersmallgroupsaddadditionalpoints.(below)

• Discussionandsummary.

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Content for Activity 2

Prevention of diarrhoea

• Exclusivelybreastfeedingfrom0–<6months

• Washhandswashingbeforepreparingfood,feedinginfantsandyoungchildren,andafterusingthelatrineandcleaningbaby’sbottom

• Disposeofwastes

• Keepdrinkingwaterincleancoveredcontainer

• Makesureyourbabyandyoungchildareup-to-dateontheirimmunizations

• BeginvitaminAsupplementationtwiceyearlyat6months

• Donotusefeedingbottles

Management of infant and young child with diarrhoea

• Continueexclusivebreastfeeding

• Increasefrequencyofbreastfeedingtoreplaceliquidlost,andafter6months,increasebreastfeedingandincreasefrequencyofcomplementaryfoods

• Donotusefeedingbottles

• Identifyandtreatunderlyingcause

• Seekhelpathealthpost

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SESSION11

Infant Feeding: HIV-positive Mother; and Severe Malnutrition of Infant and Young Child

Learning objectiveBytheendofthesession,Participantswillbeableto:

1. Describebasicinformationofinfantfeedinginthefollowingcircumstances:1)HIV-positivemother,and2)severemalnutritionofinfantandyoungchild.(30minutes)

ActivityActivity1. Presentinformationofinfantfeedinginthefollowingcircumstances:

HIV-positivemother,andseveremalnutritionofinfantandyoungchild (�0 minutes)

Total Time 30 minutes

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

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Infant and Young Child Feeding Counselling ��

ACTIVITY 1

Present information of infant feeding in the following circumstances: HIV-positive mother, and severe malnutrition of infant and young child (�0 minutes)

Methodology: Presentation

A. PresentinformationoninfantfeedingwhenwomanisHIV-positive.

HIV-positive woman

• VariousinfantfeedingoptionsshouldbediscussedwiththeHIV-positivewoman:

1.Replacementfeedingwhenacceptable,feasible,affordable,sustainableandsafe

– Acceptable:themotherperceivesnobarriertoreplacementfeeding(culturalorsocial,fearofstigmaordiscrimination)

– Feasible:themother(orfamily)hasadequatetime,knowledge,skillsandotherresourcestopreparethereplacementfoodandfeedtheinfantupto12timesin24hours

– Affordable:themotherandfamily,withcommunityorhealth-systemsupportifnecessary,canpayforthecostofpurchasing/producing,preparingandusingreplacementfeeding,includingallingredients:fuel,cleanwater,soapandequipment,withoutcompromisingthehealthandnutritionofthefamily.

– Sustainable:availabilityofcontinuousanduninterruptedsupply,anddependablesystemofdistributionforallingredientsandproductsneededforsafereplacementfeeding,foraslongastheinfantneedsit,uptooneyearofageorlonger

– Safe:replacementfoodsarecorrectlyandhygienicallypreparedandstoredandfed,preferablebycup.

2.Exclusivebreastfeedingforthefirst6monthsfollowedbycessationoncereplacementfeedingisAFASS.

3.Otherbreastmilkoptions:

– expressionandheattreatmentofherownbreastmilk

– wet-nursing(breastfeedingfromanHIV-negativewoman)

• IfanHIV-positivemotherchoosestobreastfeed,sheshouldpracticeexclusivebreastfeedingforthefirst6months,OR,sheshouldformulafeedexclusively.

• Mixedfeedingisthemostdangerousthingtodo,andmayincreaseHIVtransmission.

• Preventbreastproblemsbybreastfeedingfrequentlyandondemand;makecertaininfantiswell-attachedandsucklingwell.

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• Motherswhoexperiencebreastdifficultiessuchasmastitis,crackednipples,orbreastabscessshouldbreastfeedwiththeunaffectedbreastandexpressanddiscardmilkfromtheaffectedbreast.

• Mothershouldseekimmediatecareforababywiththrushororallesions.

• At6monthsmothershouldintroduceappropriatecomplementaryfoods.

• Whenbabyis6months,referHIV-positivemotherstoanHIVcounsellorwhocanreviewinfantfeedingoptionswiththemother.

Note:Thelactatingwomanshouldusecondomstoprotectherselffromre-exposure.

B. Presentinformationonbreastfeedingwheninfantoryoungchildisseverelymalnourished

Severely malnourished infants or young children

• Breastfeedingisprotectivewhenchildissuspectedofbeingmalnourishedorisvisiblythin.

• Refermalnourishedchildrenforcarewhichshouldinclude:

– Assessmentofchild’sfeedinghistoryandcurrentfeedingpracticesuponadmission.

– Monitoringbreastfeeds(halfanhourbeforeeachtherapeuticfeed)andweightgainduringtreatment.

– Supportformaintenanceofmilksupplybeforeandaftertreatmentinthe2scenarios:separationofmother/babyormother/babytogether.

– Supplementalsucklingasrecommended.

– Correctionoffeedingproblemsandcurrentfeedingpracticespriortodischarge;developmentoffollow-upplantosupportthemothertofeedappropriatelyfollowingdischarge.

• Supportlinksbetweenrehabilitationprograms(supplementary,therapeuticandcommunitytherapeuticcareprograms)andcommunitysystems.

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Infant and Young Child Feeding Counselling ��

SESSION12

How to Counsel: Practise Counselling with Mothers/Caregivers of Babies Greater than 6 Months

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

Learning objectivesBytheendofthesession,Participantswillbeableto:

1. Listcounsellingskills:

– listeningandlearning

– buildingthemother’s/caregiver’sconfidence

– providingsupportandpracticalhelp,and

– negotiating(“reaching-an-agreement”)

2. Describethe“assess,analyzeandact”stepstocounselling

3. UseaCounsellingCardincounselling

4. Practisetheprocessofcounsellingwithamotherofayoungchildfrom6–23months

ActivitiesActivity1 Listcounsellingskills,anddescribethe“assess,analyzeandact”steps

tocounselling(�0 minutes)

Activity2 Modelthe“assess,analyzeandact”stepstoCounsellingtoencourage motherstotryoptimalcomplementaryfeedingpractices:initialcontact withmotherofyoungchildfrom6–23months(�� minutes)

Activity3 Discussmodeldemonstration(�� minutes)

Activity4 Practisethe“assess,analyzeandact”stepstocounsellinginaninitial contactwithmotherofbabylessthan6months(�0 minutes)

Activity5 Discussthe“assess,analyzeandact”stepstocounsellingforfollow-up contact(s)(�0 minutes)

Activity6 Prepareforpracticum(�0 minutes)

Total Time 2 ½ hoursContinued

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Materials needed√ 4CaseStudiesofcounsellingforyoungchild6–23months

√ 4follow-upCaseStudiesofcounsellingforyoungchild6–23months

√ Eachparticipanthasasetofcounsellingcards

ACTIVITY 1

List counselling skills and describe the “assess, analyze and act” steps to counselling (�0 minutes)

Methodology: Brainstorming and presentation

á List counselling skills

• Brainstormwithwholegroupthekindsofcounsellingskills

• ProbeuntilthefollowingCounsellingskillshavebeenmentioned:listeningandlearning(practisedinSession2),buildingthemother’s/caregiver’sconfidence,providingsupportandpracticalhelp,andnegotiating(“reaching-an-agreement”)

• Fill-ingapswithadescriptionofthe“assess,analyzeandact”stepsofcounselling

á Describe the “assess, analyze and act” steps

Assess mother and baby situation

• Greetthemother/fatherandestablishconfidence

• Askthemotheraboutageofbaby,currentfeedingpractices,andhealth

• Askquestionstolearnmother’ssituationandconcerns

• Listentotheconcernsofthemotherandfather,andobservebabyandmother

• Acceptwhatmotherisdoingwithoutdisagreeingoragreeing

• Lookforthingsthatmotherisdoingrightorthataregoingwelltopraise

Analyze

• Identifyfeedingdifficulty,ifany,andcausesofthedifficulty

• Ifthereismorethanonedifficulty,prioritizedifficulties

• Answerthemother’squestions(ifany)

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Act

• Dependingontheageandsituationofthebaby,selectandgivesmallamountofRELEVANTINFORMATIONusingsimplelanguageononeortwoofthefollowingtopics:

– Bytheageof6monthsthestomachofthebabyisreadytoreceivefoodotherthanbreastmilk

– Discussthecharacteristicsofcomplementaryfeeding:frequency,amount,thickness(consistency),andvariety(differentkindsoffoods),activefeeding,andhygiene(FATVAH)

– Duringthefirstyear,breastmilkcontinuestobethemostimportantpartofyourbaby’sdiet

– At6monthsbegintogivesoftfoods2timesdaily(2–3tablespoonsofsoftfoodseachtime)

– From6–8months,givefood3timesdaily(graduallyincreaseto½cup[250ml]offoodeachtime)

– From9–11months,givefood3timesdailyplus1snack(give½cup[250ml]offoodeachtime)

– From12–23months,givefood3timesdailyplus2snacks(graduallyincreaseto¾to1cup[250ml]offoodeachtime)

– Increasetheamountoffoodasbabygetsolder

– Around9monthsbegintogivesolidfoods

– Enrichthedietbyaddingothercerealsandlegumes,fruitsandvegetables,animalproducts

– Talktobabywhilefeeding

– Washhandsandutensilsbeforepreparationoffoodandfeedingthebaby

– Storefoodincleanarea;don’tgivefoodthatwaspreparedthedaybefore.

– Continuebreastfeedingupto2yearsandbeyond

• Ifafeedingdifficultyhasbeenidentified,showrelevantCounsellingCard(s)andaskmothertocommentonwhatsheobservesishappeninginthecard,andtorelateittoherownsituation.Ifnofeedingdifficultyhasbeenidentified,congratulatemotherandaskhertocontinueattendingwellbabygrowthpromotionandmonitoringsessions.

• Askthemotherwhatshethinksaboutthisinformation.

• Discusswiththemother/fatherdifferentfeasibleoptionstoovercomethedifficulty.

• Suggestwhatthemothermightdo,givingheratleasttwopossibilities,andaskherwhatshefeelsabletodo.

– Putas“suggestionnotcommand”(meaningnottellingamotherwhattodo)

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– Presentoptions/smalldo-ableactions(time-bound)andhelpmotherselectonethatshecantry

– Givemotherasayinthedecision,andtheopportunitytosayno,ortochooseanotherway

• Negotiate(“reach-an-agreement”)withthemothertotryanewbehaviour,ortotakeafurtherstepsuchasdiscussingthesuggestionswithanotherfamilymember.

• Makeafollow-upappointmentwithmother.

• Praisethemotherandthankherforhertime.

ACTIVITY 2

Model the “assess, analyze and act” steps to counselling to encourage mothers to try optimal complementary feeding practices: initial contact with mother of young child from 6–23 months (�� minutes)

Methodology: Demonstration

á Model the “assess, analyze and act” steps

• Model(2Facilitators)theinitialCounsellingcontactofanIYCFCounsellortoFatumawith6½monthdaughterSafio(modelthe“assess,analyzeandact”steps).(Thefacilitatorsshouldpreparethisdemonstrationinadvance).

Assess mother and baby situation

• ListentowhatFatumasays[FatumatellstheCounsellorshefeedsherdaughterwateryporridgeoranjeraandgiveswatertoSafiobesidesbreastfeeding.]

• AskafewquestionstounderstandwhatfoodsFatumagivestoSafio,howoftenandhowmuch,andwhyFatumagiveswatertoSafio.

• PraiseFatumaforbreastfeedingSafio.

Analyze

• FatumaneedsguidanceonoptimalcomplementaryfeedingpracticesforSafio.

Act

• CheckappearanceandhealthofSafio

• TalktoFatumaaboutthecharacteristicsofcomplementaryfeeding:frequency,amount,thickness(consistency),variety(differentkindsoffood),activeorresponsivefeedingandhygiene

• ShowCCs10and11:‘ComplementaryFeedingat6Months’and‘ComplementaryFeedingfrom6–8Months’andaskFatumatocommentonwhatsheobservesishappeninginthecardsandtorelateittoherownsituation.

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• Giverelevantinformationandsmallamountofinformationregardingthemessagesofcounsellingcards10and11,usingsimplelanguage.

• AskFatumawhatshethinksaboutthisinformation.

• DiscusswithFatumadifferentfeasibleoptionstohelpheroptimallyfeedSafio.

• Putas“suggestionnotcommand”(meaningnottellingFatumawhattodo).

• Presentoptions/smalldo-ableactions(time-bound)andhelpFatumaselectonethatshecantry

• GiveFatumaasayinthedecision,andtheopportunitytosayno,ortochooseanotherway

• Modifyrecommendations,ifnecessary,tosuitFatuma’spreferences.

• Makeafollow-upappointmentwithFatuma.

ACTIVITY 3

Discuss model demonstration (�� minutes)

Methodology: Presentation and discussion

á Discuss model demonstration

• TwoFacilitators(CounsellorandFatuma)repeatinitialcounsellingcontactwithFatuma,stoppingaftereachstepof“assess,analyzeandact”.

• CounsellorshowsCounsellingCard10anddiscusseswithFatuma:

1.Observe—WhatishappeningintheCounsellingCard?

2.Relatetoyourownsituation—Whatdoyouagreeordisagreewith?Why?Whatdopeopleinyourcommunitydo?

• GiverelevantandsmallamountofinformationregardingthemessagesofCounsellingCard10,usingsimplelanguage.

• AskFatumawhatshethinksaboutthisinformation.

• RepeatstepsusingCounsellingCard11.

• DiscussdifferentfeasibleoptionstoguideFatumainofferingcomplementaryfoodstoSafio.

• HelpFatumaselectsmalldo-ableactions(time-bound)thatshecantry.

• Makeafollow-upcontactappointment.

• Discussionandrepetitionof“assess,analyze,andact”stepswithParticipants.

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�� Infant and Young Child Feeding Counselling

ACTIVITY 4

Practise the “assess, analyze, and act” steps to counselling in an initial contact with mother of a young child from 6–23 months (�0 minutes)

Methodology: Practise and role-play counselling skills during initial contact

á Practise

AskParticipantstorecalltheoptimalcomplementaryfeedingpractices(Session9).

Participantsaredividedintotriads:mother,IYCFCounsellor,andobserver.

• PracticeCaseStudy1:Askthe‘mothers’ofthetriadstogathertogether.

• AcasestudyisreadONLYtothe‘mothers’ofthetriads,andthe‘mothers’returntotheirtriads.

• The‘Counsellorofeachtriad’asksthemotherabouthersituation,andpractisesthe“assess,analyze,andact”steps:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),andshowingrelevantCounsellingCard(s).

• InthetriadtheObserver’staskistorecalltheskillsthe‘Counsellor’practised(observer’schecklistfollowsforeachcasestudy).

TheParticipantsinthetriadsswitchroles.

• PracticeCaseStudy2:AsecondcasestudyisreadONLYtothe‘mothers’ofthetriads,andthe‘mothers’returntotheirtriads.

• The‘Counsellorofeachtriad’asksthemotherabouthersituation,andpractisesthe“assess,analyze,andact”steps:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),andshowingrelevantCounsellingCard(s).

• InthetriadtheObserver’staskistorecalltheskillsthe‘Counsellor’practised(observer’schecklistfollowsforeachcasestudy).

TheParticipantsoncemoreswitchrolesintheirtriads.

• PracticeCaseStudy3:AthirdcasestudyisreadONLYtothemothersofthetriads,andthe‘mothers’returntotheirtriads.

• The‘Counsellorofeachtriad’asksthemotherabouthersituation,andpractisesthe“assess,analyze,andact”steps:listeningandlearning,buildingconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),andshowingrelevantCounsellingCard(s).

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• InthetriadtheObserver’staskistorecalltheskillsthe‘Counsellor’practised(observer’schecklistfollowsforeachcasestudy).

• Onetriaddemonstratesacasestudyinfrontofthewholegroup.

• Discussionandsummary.

• Repeatprocessonemoretimewithamorecomplicatedcasestudy(CaseStudy4)thatneedsreferral.

Case Studies for Activity 4

Case Study �:

Initial Contact

Read to mother:YouareMurayo.YourdaughterHabibais12monthsoldandyougiveherporridgeoranjera2timesadayandbitesofwhateveryouarefeedingthefamilythatday.YouarealsobreastfeedingHabiba.

Checklist for Observer (of the ‘Counsellor’) – Did the Counsellor?

• AskMurayoquestions,listentoherandacceptMurayo’spracticesandconcerns.

• PraiseMurayoforbreastfeedingherbaby,Habiba.

• DiscusswithMurayoselectedpointsofCCs13and14:‘Complementaryfeedingforyoungchildren12–23months’,and‘Hygiene’.

• SuggestwhatMurayomightdo,giveheratleasttwopossibilities,andaskherwhatshefeelsabletodo.

• ObtainagreementwithMurayototryanewbehaviour:e.g.MurayoagreestotryfeedingHabibamoretimeseachday.

• Makeafollow-upappointmentwithFatuma.

• PraiseFatumaandthankherforhertime.

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Case Study �:

Initial Contact

Read to mother:YouareFatuma.Youhavea9month-olddaughter,Mariam,whoiseatingsomewateryporridgeonceaday.Mariamhaddiarrheathelast2days.

Checklist for Observer (of the ‘Counsellor’) – Did the Counsellor?

• AskFatumaquestions,listentoherandacceptFatuma’spracticesandconcerns.

• ReviewwithFatumaselectedpointsofCCs12,14,and16:‘Complementaryfeedingforyoungchildren9–11months’,‘Hygiene’,and‘Feedingsickyoungchildgreaterthan6months’.

• SuggestwhatFatumamightdo,gaveheratleasttwopossibilities,andaskedherwhatshefeelsabletodo.

• ObtainanagreementwithFatumatotryanewbehaviour,ortotakeafurtherstep.

• Madeafollow-upappointmentwithFatuma.

• PraisedFatumaandthankherforhertime.

Case Study �:

Initial Contact

Read to mother:YouareHalima.Youarebreastfeedingyourbaby,Sheikhwhois7monthsold,andyouarenotgivinganyfoodstohim.

Checklist for Observer (of the ‘Counsellor’) – Did the Counsellor?

• AskHalimaquestions,listentoherandacceptHalima’spracticesandconcerns.

• ReviewwithHalimaselectedpointsofCCs11and14:‘Complementaryfeedingforyoungchildren6–8months’,and‘Hygiene’.

• SuggestwhatHalimamightdo,giveheratleasttwopossibilities,andaskherwhatshefeelsabletodo.

• ObtainanagreementwithHalimatotryanewbehaviour,ortotakeafurtherstep.

• Makeafollow-upappointmentwithHalima.

• PraiseHalimaandthankherforhertime.

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Case Study �:

Initial Contact

Read to mother:YouareHalimo.YourbabyTaminais6½monthsold.Youtellthe‘Counsellor’thatTaminaistooyoungforfoodbecauseherstomachistoosmall.Youmentionthatyouwillcontinuetoonlybreastfeedheruntilsheisolder.Yourhusbandandmother-in-lawagreewithyou.Taminahasnotgainedweightinthelast2weeks.

Checklist for Observer (of the ‘Counsellor’) – Did the Counsellor?

• AskHalimoquestions,listentoherandacceptHalimo’spracticesandconcerns.

• PraiseHalimoforbreastfeedingherbaby.

• DiscusswithHalimoselectedpointsofCCs10and11:‘Complementaryfeedingat6months’,and‘Complementaryfeedingfrom6–8months’.

• SuggestwhatHalimomightdo,givingheratleasttwopossibilities,andaskherwhatshefeelsabletodo.

• Referhertothehealthposttobeweighed,andtotalktotheHealthWorkerthere.

• ObtainanagreementwithHalimo:e.g.togotothehealthpost.

• Makeafollow-upappointmentwithHalimo.

• PraiseHalimoandthankherforhertime.

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ACTIVITY 5

Discuss the “assess, analyze and act” steps to counselling for follow-up contact(s) (�0 minutes)

Methodology: Brainstorm and practise

• Withthewholegroup,brainstormadditionalpointstobediscussedwithmotherduringcounsellingforfollow-upcontact(s).

• DivideParticipantsintoasmanygroupsasthereareFacilitators(withaFacilitatorineachgroup).

• Read(Facilitatorineachgroup)follow-upcontactcasestudyandaskoneParticipantinthesmallgrouptocommentonwhats/hewouldsaytothemotherduringthisfollow-upcontact.

• Askifanyonehasanythingelsetoadd?

• AskParticipantstoreflectonthe“assess,analyzeandact”stepsofcounselling,askingthequestion:DidtheCounsellor………………?(SeeActivity1ofSession12andfollowthe“assess,analyzeandact”steps).

• Whenthefirstfollow-upcontactiscomplete,repeatthesameprocessfortheremainingfollow-upcontactcasestudies(4follow-upcontactcasestudiesintotal).

• Discussionandsummary.

Content for Activity 5

Points to discuss in Follow-up Contact(s) Counselling

• Askhowthebabyandmotheraredoing(isthebabybetterorworse?)

• Askwhetherthemothertried(orcontinued)theagreeduponnewbehaviour.

• Congratulatemotherfortrying(orcontinuing)thenewbehaviour.

• Ifthemotherdidnottrythenewbehaviourorgaveup,askwhy?

• Askwhathappenedwhenshetried(orcontinued)thenewbehaviour.

• Askwhethershemadeanychangestothenewbehaviourandwhy?

• Askwhatdifficultiesshehad,howshesolvedthem,orhelpherfindwaystosolvethedifficultiesshemighthavehadorthinkofalternatives.

• Listentothemother’squestions,concernsanddoubts.

• Askwhethershelikesthenewbehaviouragreeduponandifshethinksshewillcontinueorwhattodoifshedoesnotcontinue.

• Praisethemotherandmotivatehertocontinuethenewbehaviour.

• Remindthemothertotakethechildtobeweighed(attendEPIimmunizationsandgrowthmonitoringsessions).

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• Tellthemotherwhereshecangetadditionalsupportfromcommunity-basedhealthworkers,healthposts,ormothersupportgroups.

• Agreeonadateforthenextcontact.

• Dependingontheageofthechild:

– talktothemotheraboutanewbehaviour

– encouragethemothertotryanewbehaviour

Follow-up Contact Case Studies for Activity 5

Case Study �:

Follow-up Contact

Murayoannouncesthather1yearold,Habiba,noweatswhateverthefamilyeatsthatday,onceinthemorningandonceatnight.Murayotellsyouthatsheisplanningtostopbreastfeedingsoon.

Did the Counsellor?

• AskhowsheandHabibaaredoing(isHabibabetterorworse?)

• ListentoMurayo’sstoryandacceptherfeelings.

• ListentodetailsofHabiba’sbehaviour.

• AskMurayowhysheisplanningtostopbreastfeeding.

• TalkwithMurayoaboutcontinuedfrequent,on-demandbreastfeedinguntil2yearsofageorbeyond.

• SUGGESTthatMurayocontinuebreastfeedingHabibalonger.

• ReviewwithMurayothepointsdiscussedinCC13:‘Complementaryfeedingforyoungchildren12–23months’:

– InHabiba’s2ndyear,breastmilkcontinuestomakeup1/3ofherdiet.

– From12monthsonwards,feedHabiba5timesaday(3mealsand2snacks).

• ObtainanewagreementwithMurayo.

• Makeafollow-upappointmentwithMurayo.

• PraiseMurayoandthankherforhertime.

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Case Study �:

Follow-up Contact

Fatumatellsyouthatshehasbeengivingthickporridgetoher9-montholdbaby,Shukri,onceaday.Sheisalsobreastfeedingmorefrequentlyandhasnoticedlessdiarrhoea.

Did the Counsellor?

• AskhowsheandShukriaredoing(isShukribetterorworse?)

• ListentoFatuma’sstory.

• PraiseFatumaforbreastfeedingmorefrequently.

• ListentodetailsofShukri’sbehaviour.

• ReviewwithFatumathepointsdiscussedinCC12:‘Complementaryfeedingforyoungchildren9–11months’:

– From9monthsonwards,feedShukri4timesaday(3mealsand1snack).

• ObtainanewagreementwithFatuma.

• Makeafollow-upappointmentwithFatuma.

• PraiseFatumaandthankherforhertime.

Case Study �:

Follow-up Contact

Halimasaysthather7-montholdbaby,Sheikh,noweatsporridgeoranjerawithlentilsandsomeoil2timesaday.Halimathinksherbabyisdoingverywell.

Did the Counsellor?

• AskhowsheandSheikharedoing(isSheikhbetterorworse?)

• ListentoHalima’sstory.

• ListentodetailsofSheikh’sbehaviour.

• PraiseHalimaforhowwellSheikhisdoing.

• ReviewwithHalimathepointsdiscussedinCC11:‘Complementaryfeedingforyoungchildren6–8months’:

– From6monthsonwards,feedSheikh2-3timesaday.

• ObtainanagreementwithHalima.

• Makeafollow-upappointmentwithHalima.

• PraiseHalimaandthankherforhertime.

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Case Study �:

Follow-up Contact

Safiotellsyouthatshehasstillbeenfeedingherneartwo-yearold,Tamina,3timesadayaswellascontinuingtobreastfeedher.

Did the Counsellor?

• AskhowsheandTaminaaredoing(isTaminabetterorworse?)

• ListentoSafio’sstory.

• PraiseSafioforcontinuingtobreastfeedTamina.

• ListentodetailsofTamina’sbehaviour.

• PraiseSafioforhowwellTaminaisdoing.

• ReviewwithSafiothepointsdiscussedinCC13:‘Complementaryfeedingforyoungchildren12–23months’:

– InTamina’s2ndyear,breastmilkcontinuestomakeup1/3ofherdiet.

– From12monthsonwards,feedTamina5timesaday(3mealsand2snacks).(F)

• ObtainanewagreementwithSafio.

• Makeafollow-upappointmentwithSafio.

• PraiseSafioandthankherforhertime.

ACTIVITY 6

Prepare for practicum (�0 minutes)

• Participantsformpairs(Facilitatorneedstobesensitivetolanguageandgender).

• Askeachparticipanttobringhis/hersetofcounsellingcards.

• Arrangetimeformeetingandtransportation(ifneeded).

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SESSION13

How to Counsel a Mother/Caregiver with a Young Child from 6–23 Months: Community and/or Facility Practise and Feedback

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

Learning objectiveBytheendofthesession,Participantswillbeableto:

1. PractiseCounselling:listeningandlearningskills,buildingthemother’s/caregiver’sconfidence,providingsupportandpracticalhelp,andnegotiating(“reaching-an-agreement”)withmothersofyoungchildrenfrom6–23monthsathealthcentersorinthecommunity

ActivitiesActivity1 Practisecounselling:listeningandlearningskills,buildingthemother’s/

caregiver’sconfidence,providingsupportandpracticalhelp,and negotiating(“reaching-an-agreement”byapplyingthe“assess,analyze andact”steps(� hours)

Activity2 Feedbackonpractise(� hour)

Total Time 3 hours

Materials needed√ Entiresetofcounsellingcardsonoptimalbreastfeedingpracticesandoptimal

complementaryfeedingpracticesforchildrenfrom0–23months

√ CounsellingCardonHygiene:14

Advance preparation• Makeanappointmentatthehealthpostaweekaheadtodothefieldpractise

duringimmunizationorweighingsessions,or

• Makeanappointmentwiththecommunityhealthworkeraweekaheadforcommunityvisits

• Preparegroups,giveinstructionsthedaybefore

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ACTIVITY 1

Practise counselling: listening and learning skills, building the mother’s confidence, providing support and practical help, and negotiating (“reaching-an-agreement” by applying the “assess, analyze and act” steps (� hours)

Methodology: Practise

• BeforetheParticipantsleaveforthepractice-site,brieflyreviewCounsellingskills:listeningandlearning,buildingthemother’sconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”),anduseofcounsellingcardsbyapplyingthe“assess,analyze,andact”steps.

• DivideParticipantsinpairsandexplaintheexercise:oneParticipantwillpractiseCounselling:listeningandlearningskills,buildingthemother’sconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”)anduseofcounsellingcardsbyapplyingthe“assess,analyzeandact”stepswiththemother,whiletheotherParticipantfollowsthedialogueinordertogivefeedbacklater.

• ParticipantschangerolesuntileachParticipantpractisesatleast2counsellingactivities.

ACTIVITY 2

Feedback on practise session (� hour)

Methodology: Feedback discussion

• Attrainingsite,withthewholegroup,eachpairofParticipantswillsummarizeforthegrouptheiruseoflisteningandlearningskills,buildingthemother’sconfidence,providingsupportandpracticalhelp,negotiating(“reaching-an-agreement”)anduseofcounsellingcardsbyapplyingthe“assess,analyzeandact”steps.Theirsummaryshouldincludethechild’snameandage,anydifficultyidentified,optionssuggested,andbehaviourmotheragreedtotry

• Participantsreceiveandgivefeedback

• Discussionandsummary

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SESSION14

Final Evaluation of IYCF Counselling Training

Learning objectivesBytheendofthesession,Participantswill:

1. Examine“whathavewelearnedthisweek?”

2. EvaluatetheIYCFCounsellingtraining

ActivitiesActivity1 “Whathavewelearnedthisweek?”(�0 minutes)

Activity2 EvaluationofIYCFCounsellingtrainingandlistentoresults (�� minutes)

Total Time 45 minutes

Materials needed√ Onecopyof“Whathavewelearnedthisweek?”post-assessmentforFacilitator

Note to the Facilitator: Present an overview of objectives (listed below) and the time allocated for this session.

ACTIVITY 1

“What have we learned this week?” (�0 minutes)

Methodology: Participants sit in circle facing outwards

• AskParticipantstoformacircleandsitsothattheirbacksarefacingthecenter.

• ExplainthatquestionswillbeaskedandaskParticipantstoraisetheirhand(withopenpalm)iftheythinktheansweris“Yes”,toraisetheirhand(withclosedfist)iftheythinktheansweris“No”,andtoraisetheirhand(pointing2fingers)ifthey“Don’tknow”.

• OneFacilitatorreadsthequestionsandanotherFacilitatorrecordstheanswers.

• Compareresultsofpreandpost-assessmentsandsharewithParticipants.

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What have we learned this week?

1. Ababyshouldbreastfeedwithinanhourafterbirth.

2. Toproducesenoughmilk,amothershouldbreastfeedfrequently,dayandnight.

3. Colostrumhelpstoprotectbabiesfromillnesseslikediarrheaand respiratoryinfections.

4. At4months,infantsneedwaterandotherdrinksinadditiontobreastmilk.

5. At9-11months,ababyneedscomplementaryfoods4timesaday.

6. Onesignofgoodattachmentisthatthenewborn’schintouchesthe mother’sbreast.

7. Breastfeedingbenefitsthebaby,butnotthemother.

8. Amothercanstillsuccessfullybreastfeedherbabyevenifshethinksshe doesnothaveenoughmilk.

9. Amothercanpreventsoreandcrackednipplesbycorrectlyattaching herbabytothebreast.

10. Ababybeginstoneedfoodsinadditiontobreastmilkatabout6months.

11. Amothercanproduceenoughmilktobreastfeedtwins.

ACTIVITY 2

Evaluation of IYCF Counselling training and listen to results (�� minutes)

Methodology: Participants form buzz groups of 3

• AskParticipantstoformbuzzgroupsof3.

• Explainthattheirsuggestionswillbeusedtoimprovefuturetrainings.

• Explainthatquestionswillbeaskedandthateachgroupshoulddiscussamongthemselveswhattheythink.

• OneFacilitatorreadsthefollowingquestions,onebyone.Aftereachquestion,askbuzzgroupstosharetheircomments(anotherFacilitatorrecordstheanswers).

1.Whatdidyoulikeabouttheteachingmethod?

2.Howwillyouusethecounsellingcards?

3.Whatdidyoulearninthepracticeatthehealthpostorinthecommunity?

4.Doyoufeelreadytocounselmothers/caregiversaboutinfantandyoungchildfeeding?

5.Whatsuggestionsdoyouhavetoimprovethetraining?

6.Doyouhaveanyothercomments?Pleaseshare.

Don’t Yes No know

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Notes

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APPENDIX1

Counselling Cards: Key and Supporting Messages 18 counselling cards

1. Antenatal

2. DeliveryinFacility(Card2a)/HomeDelivery(Card2b)

3. GrandmotherOfferingFoodtoBreastfeedingDaughter/Daughter-in-law

4. HowtoAttachBabytotheBreast

5. BreastfeedingPositions

6. BreastfeedonDemand,BothDayandNight

7. DuringtheFirst6Months,YourBabyNeedsONLYYourBreastmilk

8. HowtoHandExpressBreastmilkandCupFeed

9. OptimalChildSpacing

10.ComplementaryFeedingStartingat6Months

11.ComplementaryFeedingfrom6–8Months

12.ComplementaryFeedingfrom9–11Months

13.ComplementaryFeedingfrom12–23Months

14.Hygiene:WashYourHandswithSoapandWater

15.BreastfeedingaSickBabyLessthan6Months

16.BreastfeedingaSickChildGreaterthan6Months

17.SignsthatRequireMother/Caregiver/FamilytoSeekCare

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CounsellingCard1

Antenatal

Key Messages

1. Breastfeedyourbabywithin1hourofbirth.(counsellingcards2aand2b)

2. Breastfeedyourbabyfrequently,dayandnight,toestablishyourbreastmilksupply.(counsellingcard6)

3. Exclusivelybreastfeedyourbabybygivingonlyyourownmilkforthefirst6months.(counsellingcard7)

4. Makesureyourbabyiswellattachedtothebreast.(counsellingcard4)

5. Makesurebabyisinacomfortablepositionatthebreastandisabletoeffectivelysuckleinthefirstweeksandmonths.(counsellingcard5)

6. Youshouldeattohungeranddrinktothirsttokeepyouandyourbabyhealthyandtoprepareyourbodyforbreastfeeding.

• Increasefoodintake:“anadditionalmeal,morefoodthanusual,andavarieddiet”.

• TakevitaminAatdeliveryorwithin6weeksafterdelivery.

• EatfoodsrichinvitaminA(papaya,mangoes,carrots,pumpkins,liver).

• Continueiron/folicacidsupplementationtocomplete6monthsintotal(duringpregnancyand/orlactation).

• Useiodizedsaltforthewholefamily.

• Usetreatedbednetstoreducemalariainfection.

• Ifavailable,takede-wormingtreatmentduring3rdtrimesterofpregnancytoreducehookworminfection.

• Reduceworkloadtoensureopportunityforresttohelpconserveenergy

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CounsellingCards2aand2b

Delivery in Facility (Card 2a) / Home Delivery (Card 2b)

Key Messages

• Assoonasyourbabyisborn,letthemidwifeputthenakedbabybetweenyourbreasts,coverhimorherlightlyandkeepthebabythereforatleastonhour—oraslongasyouwant.Thebabymayjustrestforatime,keepingwarmandlearninghowyoufeelandsmell

• Yourbabywillstartshowingsignsofinterestinbreastfeedingandmaytrytomovetothebreastwithinthehour.Letthebabystartsucklingthen—thisisthebesttimeforyouandyourbabytolearnaboutbreastfeedingandtobond.

• Thebaby’ssucklinghelpsyourwombcontract,whichpushesouttheplacentaandreducesbleeding.Youmayfeelquiteastrongcontractionatthistime;itisagoodsignthatthingsareworkingwell.

• Thefirstmilkthatcomesiscalledcolostrum.Itisyellowandstickyandfullofgoodthingswhichhelpprotectyourbaby.Makesurethatyourbabytakesthecolostrum.

• Breastfeedingfrombirthhelpsthemilk“comein”andensuresplentyofbreastmilk.

Supporting Messages

• Itiseasierforyourbabytolearntosuckleifs/hestartsearlywhilethebreastisstillsoft.

• Theamountofcolostrummaybesmall,butevenafewdropshelpprotectyourbaby.

• Colostrumwillhelpyourbabypasshis/herfirstdarkstool.

• Yourbabydoesnotneedwaterorotherfeedsgivenbeforebreastfeeding(foods,sugarwaterorliquids/fluids).Theycancauseadelayinyourmilk“comingin”(orstartingtoflow)andcanmakeyourbabyill.Calvesandbabygoatsdonotneedextrawaterafterbirth.

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CounsellingCard3

Grandmother Offering Food to Breastfeeding Daughter/Daughter-in-law

For the caregiver of mother:

Key Messages

• Keepthemotherandbabytogetherfrombirth.Stayingtogetherhelpsthemotherandbabyrestandrecover,breastfeedondemand(asoftenasthebabywants),andbond.

• Ensurethatthebreastfeedingmothereatsanadditionalmealeachdaybecausesheiseatingfortwo,herselfandthebaby.

Supporting Messages

• EnsurethatthebreastfeedingmothereatstheporridgefromthePLP(PregnantandLactatingProgramme)andpartoftheextrarationthatisgivenwhenthebabyisregistered.Eatingmorehelpshermaintainherhealthandthehealthofthebaby.

• Bringfoodandwatertothemotherandletherbreastfeedthebaby.

• Mothersneedtobeprioritizedforfamilyfoodandneedhelpwithhouseholdwork.

• Mothersneedtotakeadvantageofallopportunitiestoeatmorefood.

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CounsellingCard4

How to Attach Baby to the Breast

Skills

• Startwiththebaby’snoseoppositeyournipple,sothatthebabyhastoreachuptothenipple.

• Touchthebaby’slowerlipwiththenipple.Waituntilthebaby’smouthopenswide,andthenquicklymovethebabyontothebreast.

• Aimthebaby’slowerlipwellbelowthenipplesothatthenipplegoestothetopofthebaby’smouthandthebaby’schin

touchesthebreast(thishelpstoensurethatthebaby’stongueisundertheareolasothatthebabycanpressoutthemilk).

• Fromtheoutsidethereshouldbemoreareolashowingabovethanbelowthenipple(thisiseasierforthecounsellortoseethanyouwhocannotseewhatisbelowthebaby’smouth).

• Thebaby’slowerlipshouldbeturnedoutwards(thisiseasierforthecounsellortoseethanyouwhocannotseewhatisbelowthebaby’smouth).

Effective suckling

• Tosucklewell,ababyneedstobewellattachedatyourbreast.

• Thebaby’smouthshouldbeopenwide,sothats/hecantakeinplentyoftheareolaandnotjustthenipple.

• Thebabyshouldbeheldclosetothebreast.

• Thebabytakesslowdeepsuckles,sometimespausing.

• Youmaybeabletoseeorhearyourbabyswallowingafteroneortwosuckles.

• Sucklingiscomfortableandpainfreeforyou.

• Babyfinishesthefeed,releasesbreastandlookscontentedandrelaxed.

• Thebreastissofterafterthefeed.

• Sucklingwellhelpsyouproducemilkandsatisfyyourbaby.

Risks of poor attachment

• Soreandcrackednipples. • Poormilkrelease. • Slowmilkproduction.

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Breastfeeding Positions

Skills

• Toensuregoodattachment,yourbabyneedstobewellpositionedatthebreast.Thereareseveraldifferentpositionsthatyoucanuse.

• Youcanbreastfeedsittingorlyingdownorstandingifyouwish.

– Cradle position(mostcommonposition)

– Opposite arm—usefulfornewbornsandsmallorweakbabies,oranybabywithadifficultyattaching

– Lying down(usefulsoonafterdeliveryandatanytimetorestwhilebreastfeeding)

– Under-arm position(usefulfortwinsandlow-birth-weightbabies)

Supporting Messages

• Whateverpositionyouchooseyouneedtobecomfortablewithyourbacksupported.

• Bringthebabytoyou;donotleanforwardtothebaby.

• Thebaby’sbodyshouldbestraight,notbentortwisted,butwiththeheadslightlyback.

• Thebaby’sbodyshouldbefacingyouandclosetoyousothatyouaresupportingthebaby’swholebody,notjusttheneckandshoulders,withyourhandandforearm.

• Thebabyshouldbeabletolookupintoyourface,notheldflattoyourchestorabdomen.

• Holdyourbreastwithyourfingersina“Cshape”,withthethumbabovethedarkpartofthebreast(areola)andtheotherfingersbelow.

• Fingersshouldnotbein“scissorhold”becausethismethodtendstoputpressureonthemilkductsandcanpullthenippleoutofthebaby’smouth.

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Breastfeed on Demand, Both Day and Night

Key Messages

• Breastmilkprovidesallthenourishmentyourbabyneedsforthefirst6months.

• Breastfeedthebabyoften,atleast8–10times,dayandnight,toproducelotsofbreastmilkandensurethatyourbabygrowshealthy.(Dependingonageofbaby,s/hemaynotneed10feedsadayifsucklingeffectively.)

• Letbabysuckleaslongass/hewants—letbabycomeoffthebreasthim/herself.Donottakethebabyoff.

Supporting Messages

• Moresucklingmakesmorebreastmilk(providedbabyiswellattached),andifababysucklesless,thebreastsmakelessbreastmilk.

• Thebreastsmakeasmuchmilkasthebabytakes—ifbabytakesmore,thebreastsmakemore(thebreastislikea“factory”—themoredemandformilk,themoresupply).

• Signsthatababywantstobreastfeed:

A combination of: (not just one alone)

– Restlessness

– Openingmouthandturningheadfromsidetoside

– Puttingtongueinandout

– Suckingonfingersorfists

Note: Begin breastfeeding before the baby starts crying. Crying is a late sign of hunger.

• Feedsthatareregularlymorethanhalfanhour(exceptinthefirstweekorsoorwhenbabyislow-birth-weight)orfeedsthatareveryfrequent(moreoftenthanevery1–1.5hoursallthetime)maybeasignthatyourbabyisnotwellattached.Askthecounsellortowatchthebabyfeed,andtrytoimprovetheattachment.

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During the First 6 Months, Your Baby Needs ONLY Your Breastmilk

Key Messages

• Breastfeedingmakesyourbabygrowstrongandhealthyandhelpstopreventdiarrhoeaandrespiratoryinfections.

• Breastmilkisthebestfoodanditisallthatyourbabyneedsforthefirst6months.

• Givingotherfeedscanmakeyourbabyill.

• Donotgiveanythingelsetoyourbabybefore6months,NOTevenwater(tea,sugarwater,gripewater,otheranimalmilks,infantformulaorporridge).

• Evenduringveryhotweather,breastmilkcansatisfyyourbaby’sthirstduringthefirst6months.You may need additional water to satisfy your own thirst.

Supporting Messages

• Thereisenoughwaterforbabyinyourbreastmilk.

• Therisksofgivingwatertoyourbabyare:Riskofdiarrhea,baby’sstomachgettingfullwithwaterandfeedingless,loosingweight,malnutrition,infrequentfeedingleadingtodecreasedbreastmilkproduction.

• Ifyourbabytakeswaterorotherliquids,s/hesucklesthebreastlessandyouproducelessmilk.Thisleadstopoorgrowthofyourbaby.

• Ifyoufeedanyotherfoodsorliquidstoyourbreastfedbaby,youriskbecomingpregnantinthefirstmonthsafteryougivebirth.

• Babycamelsandgoatsdonotneedextrawaterwhentheyareborn.

• Breastfeedingisanaturalresourceforfoodsecurity.

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How to Hand Express Breastmilk and Cup Feed

• Sometimesyouneedtoexpressmilkforyourbaby:

– ifyourbabyistooweakorsmalltosuckleeffectively

– ifyourbabyistakinglongerthanusualtolearntosuckle,forexamplebecauseofinvertednipples

– ifyouhavetobeawayfromyourbabyforsomehours

– tofeedalow-birth-weightbabywhocannotbreastfeed

– tofeedasickbaby,whocannotsuckleenough

– tokeepupthesupplyofbreastmilkwhenyouorbabyisill

– torelieveengorgementorblockedduct

• Toexpressmilkfollowthesesteps:– Washhands– Prepareacleancontainer– Gentlymassagebreastsinacircularmotion—lightmassageisskinstimulationforthe

reflex– Positionthumbontheupperedgeoftheareolaandtheotherfingersontheundersideof

thebreastbehindtheareola– Presstheareolabehindthenipplebetweenthefingersandthumb– Milkmaystarttoflowindrops,orsometimesinfinestreams—collectitinthecontainer– Ifitisverysmalldropsofcolostrum,itmayhelptocollectitinasyringedirectfromthe

nipple– Avoidrubbingtheskin,whichcancausebruising;orsqueezingthenipple,whichstopsthe

flowofmilk– Forlargebreasts,firstliftthebreast– Rotatethethumbandfingerpositionsandcompressandreleaseallaroundtheareola– Expressonebreastforatleast3–5minutesuntiltheflowslows,thenexpressotherside,

thenrepeatbothsidesagain(20–30minutestotal)

• Storebreastmilkinaclean,coveredcontainer.Milkcanbestored8–10hoursatroomtemperatureinacoolplaceand72hoursintherefrigerator.

• Givebabyexpressedbreastmilkfromacup.Bringcuptothebaby’slowerlipandallowbabytotakesmallamountsofmilk.Donotpourthemilkintobaby’smouth.

• Bottlesareunsafetousebecausetheyaredifficulttowashandcanbeeasilycontaminated.

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Optimal Child Spacing

Key Messages

• Feedingyourbabyonlybreastmilkforthefirst6monthscanhelpspacebirthsinawaythatishealthyforbothyouandyourbaby.

• Optimalchildspacinghelpsensurehealthychildrenandalsoprotectsyou.

• Youarenotlikelytobecomepregnantwhenyoumeetthefollowing3criteria:

– youhavenoreturnofmenses,and

– youexclusivelybreastfedyourbabyfor6months,and

– yourbabyisyoungerthan6months

• Whenyounolongermeetoneofthesecriteria,youneedtostartafamilyplanningmethodtoavoidpregnancy

Supporting Messages

• Whenyoudonotexclusivelybreastfeedfrombirthyoucanbecomepregnantasearlyas6weeksafterdelivery.Closelyspacedpregnanciesriskyourhealth,andthatoftheolderbabyandthenewborn.

• Ifyouwantfurtherinformationaboutchildspacing,pleasegotothefamilyplanningclinic.

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Complementary Feeding Starting at 6 Months

Key Messages

• Continuebreastfeedingyourbabyondemand,dayandnight,tomaintainhis/herhealthandstrength.

• Breastmilkcontinuestobethemostimportantpartofyourbaby’sdiet.

• Atabout6months,yourbabyisdevelopmentallyreadyandbeginstoneedotherfoodsinadditiontobreastmilk.

• Thinkofthefollowingcharacteristicswhengivingcomplementaryfoodstoyourbaby:F=Frequency,A=Amount,T=Thickness(consistency),V=Variety(differentkindsoffoods),A=Active/responsivefeeding,andH=Hygiene(FATVAH)

• Introducesoftfood(mashedpotato,mashedbananaorporridge)at6monthsofage,2-to-3timesaday.(F)

• Startwith2-3tablespoonfulsperfeed.(A)

• Whenpossibleusebreastmilk,goat,camel,coworsheepmilktopreparethesoftfood.

• Theconsistencyofthesoftfoodshouldbethickenoughsothatitdoesnotrunoffthespoon.(T)

• Bepatientandactivelyencourageyourbabytoeat.(A)

• Avoidusingbottlestofeedyourbaby.Theyareverydifficulttokeepcleanandcanmakeyourbabysickwithdiarrhoea.(H)

• Foodsgiventothebabymustbestoredinhygienicconditionstoavoidcontaminationandillness.(H)

Safe preparation and storage of complementary foods

Guideline: practice good hygiene and proper food handling by

• Washyourownandbaby’shandsbeforefoodpreparationandeating,andafterusingtoiletandcleaningbaby’sbottom

• Usecleanutensilstoprepareandservefood;cleansurface,keepcleanutensilscovered;usecleancupsandbowlstofeedchildren

• Treatwaterfordrinking;keepdrinkingwaterincleancoveredcontainer

• Servefoodsimmediatelyafterpreparation

• Storefoodssafely:keepintightlycoveredcontainers,storefoodsdryifpossible

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Complementary Feeding from 6–8 Months

Key Messages

• Continuebreastfeedingyourbabyondemand,dayandnighttomaintainhis/herhealthandstrength.

• Breastmilkcontinuestobethemostimportantpartofyourbaby’sdiet.

• Thinkofthefollowingcharacteristicswhengivingcomplementaryfoodstoyourbaby:F=Frequency,A=Amount,T=Thickness(consistency),V=Variety(differentkindsoffoods),A=Active/responsivefeeding,andH=Hygiene(FATVAH)

• From7monthsonwards,feedyourbaby3timesaday.(F)

• Graduallyincreasetheamountoffoodto½ofa250mlcup.Babieshavesmallstomachsandcanonlyeatsmallamountsateachmeal.(A)

• Mashandsoftenthefoodssothebabycaneasilychewandswallow;breastmilkorotheranimalmilkcanbeusedtopreparethesoftfood.

• Thickenthebaby’sfoodasthebabygrowsolder,makingsurethatitisstillabletoeasilyswallowwithoutchoking.(T)

• Trytoincludeatleastasmallbitofafoodfromeachgroupinatleastonemealperday,orasoftenaspossible:a)wheatflour,bulgurflour,maizemeal,CSB,orpotatoes;b)lentils,greengrams,beansoryellowsplitpeas,c)meat,poultry,orfish,d)eggs,e)darkgreenvegetable,fruitssuchasmango,papaya,orangesorbananas,andf)oilorghee.(V)

• Animalmilks(goat,camel,etc.)arealsousefulsourcesofnutrients.

• Ifpossible,alsoincludegroundnutsthathavebeenroastedandthengroundorsmashedintoafinepowder.

• Bepatientandactivelyencourageyourbabytoeat.Useaseparateplatetofeedthebabytomakesures/heeatsallthefoodgiven.(A)

• Foodsgiventothebabymustbestoredinhygienicconditionstoavoiddiarrhoeaandillness.(H)

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Complementary Feeding from 9–11 Months

Key Messages

• Continuebreastfeedingyouryoungchildondemand,dayandnighttomaintainhis/herhealthandstrength.

• Breastmilkcontinuestobethemostimportantpartofyouryoungchild’sdiet.

• Thinkofthefollowingcharacteristicswhengivingcomplementaryfoodstoyouryoungchild:F=Frequency,A=Amount,T=Thickness(consistency),V=Variety(differentkindsoffoods),A=Active/responsivefeeding,andH=Hygiene(FATVAH)

• From9monthsonwards,feedyouryoungchild4timesaday(3mealsand1snack).(F)Snacks:

– extrafoodsbetweenmealsthatareeasytoprepare

– theseextrafoodsareinadditiontothemeals—theydonotreplacemeals

– goodsnacksprovideenergyandnutrients(nottobeconfusedwithsweets)

– (giveexamplesoflocalsnacks)

• Giveyouryoungchild½ofa250mlcup/bowlateachfeed.Youngchildrenhavesmallstomachsandcanonlyeatsmallamountsateachmeal.(A)

• Thickentheyoungchild’sfoodasthechildgrowsolder,makingsurethatitisstillabletoeasilyswallowwithoutchoking;breastmilkorotheranimalmilkcanbeusedtopreparethefood.(T)

• By9monthstheyoungchildshouldbeabletobegineatingfingerfoodssuchaspiecesofripemangoandpapaya,bananaandvegetables

• Trytoincludeatleastasmallbitofafoodfromeachgroupinatleastonemealperday,orasoftenaspossible:a)wheatflour,bulgurflour,maizemeal,CSB,orpotatoes;b)lentils,greengrams,beansoryellowsplitpeas,c)meat,poultry,orfish,d)eggs,e)darkgreenvegetable,fruitssuchasmango,papaya,orangesorbananas,andf)oilorghee.(V)

• Animalmilks(goat,camel,etc.)arealsousefulsourcesofnutrients.

• Ifpossible,alsoincludegroundnutsthathavebeenroastedandthengroundorsmashedintoafinepowder.

• Bepatientandactivelyencourageyouryoungchildtoeat.Useaseparateplatetofeedtheyoungchildtomakesures/heeatsallthefoodgiven.(A)

• Foodsgiventotheyoungchildmustbestoredinhygienicconditionstoavoiddiarrhoeaandillness.(H)

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Complementary Feeding from 12 – 23 Months

Key Messages

• Continuebreastfeedingyouryoungchildondemand,dayandnighttomaintainhis/herhealthandstrength.

• Inyouryoungchild’s2ndyear,breastmilkcontinuestomakeup1/3ofhis/herdiet.

• Thinkofthefollowingcharacteristicswhengivingfoodstoyouryoungchild:F=Frequency,A=Amount,T=Thickness(consistency),V=Variety(differentkindsoffoods),A=Active/responsivefeeding,andH=Hygiene(FATVAH)

• From12monthsonwards,feedyouryoungchild5timesaday(3mealsand2snacks).(F)

Snacks: – extrafoodsbetweenmealsthatareeasytoprepare– theseextrafoodsareinadditiontothemeals—theydonotreplacemeals– goodsnacksprovideenergyandnutrients(nottobeconfusedwithsweets)– (giveexamplesoflocalsnacks)

• Giveyouryoungchild¾to1250mlcup/bowlateachfeed.(A)

• Cutthefoodintosmallpiecessotheyoungchildcaneasilychewandswallow.

• Thickentheyoungchild’sfoodasthechildgrowsolder,makingsurethatitisstillabletoeasilyswallowwithoutchoking.(T)

• By12monthsothersolidfoodscanbegiveasmanytimesaspossibleeachday.

• Trytoincludeatleastasmallbitofafoodfromeachgroupinatleastonemealperday,orasoftenaspossible:a)wheatflour,bulgurflour,maizemeal,CSB,orpotatoes;b)lentils,greengrams,beansoryellowsplitpeas,c)meat,poultry,orfish,d)eggs,e)darkgreenvegetable,fruitssuchasmango,papaya,orangesorbananas,andf)oilorghee.(V)

• Animalmilks(goat,camel,etc.)arealsousefulsourcesofnutrients.

• Ifpossible,alsoincludegroundnutsthathavebeenroastedandthengroundorsmashedintoafinepowder.

• Bepatientandactivelyencourageyouryoungchildtoeat.Useaseparateplatetofeedtheyoungchildtomakesures/heeatsallthefoodgiven.Childreneatmoreslowlythanadults,soputthechild’sportionofthefamilymealinhisownbowl.(A)

• Youngchildrenshouldbesupervisedduringmealtimetomakesuretheyeatallthefoodputontheirplate.(A)

• Foodsgiventotheyoungchildmustbestoredinhygienicconditionstoavoiddiarrhoeaandillness.(H)

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Hygiene: Wash Your Hands with Soap and Water

Key Messages

• Washyourhandswithsoap(orash)andwaterbeforepreparingfood,beforeeating,andbeforefeedingyoungchildren.

• Washyourchild’shandswithsoap(orash)andwaterbefores/heeats.

• Washyourhandswithsoap(orash)andwaterafterusingthelatrineorcleaningthebaby’sbottom.

• Feedyouryoungchildusingcleanhands,cleanutensilsandcleancups.Avoidusingfeedingbottles,asthismaycauseyouryoungchildtogetdiarrhoea.

• Keepfoodsincoveredcontainersandstorefooddry,ifpossible.

– Foodshouldbetightlycoveredtopreventinsectsanddirtgettingintoit.

– Foodcanbekeptlongerwhenitisinadryformthanwhenitisinliquidorsemi-liquidform.

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Breastfeeding a Sick Baby Less than 6 Months

Key Messages

• Breastfeedingmoreduringillnesswillhelpbabyfightthesicknessandnotloseweight.

• Breastfeedingalsoprovidescomforttoasickbaby.

• Ifthebabyittooweaktosuckle,itisimportanttoexpressbreastmilktogivethebaby,eitherbycuporbyexpressingdirectlyintothebaby’smouth.Thiswillhelpthemotherkeepuphermilksupplyandpreventengorgement.

• Practiceexclusivebreastfeedingfrom0–6months.

NOTE:Themothermayneedsupporttore-establishexclusivebreastfeeding.

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Feeding a Sick Child Greater than 6 Months

Key Messages

• Duringillness,increasethefrequencyofbreastfeedingandofferadditionalfoodtoyourchildtomaintainhis/herstrength,reduceweightlossandrecoverfaster.(Oftenillyoungchildrenbreastfeedmorefrequently).

• Fluidandfoodrequirementsarehigherduringillness.

• Taketimetopatientlyencourageyoursickchildtoeatashis/herappetitemaybedecreasedbecauseoftheillness.

• Itiseasierforasickchildtoeatsmallfrequentmeals.

• Feedthechildfoodss/helikesinsmallquantitiesthroughouttheday.

• Offertheyoungchildsimplefoodslikeporridge,evenifs/hedoesnotexpressinterestineating.Avoidspicyorfattyfoods.

• Keepencouragingtheyoungchildtoeat.

Feeding during recovery

• Whenyouryoungchildhasrecovered,givehim/heroneadditionalmealofsolidfoodeachdayduringthenexttwoweeks.Thiswillhelpthechildregainweightlostduringillness.

• Alsobreastfedmorefrequentlyduringtwoweeksafterrecovery.

• Takeenoughtimetoactivelyencourageyouryoungchildtoeatthisextrafoodandbreastfeedmorefrequentlywhenhis/herappetitereturns.

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Signs that Require Mother/Caregiver/Family to Seek Care

Take your baby or young child to health post if s/he shows the following signs:

• Anaemia(lookforpalmarpallor)

• Diarrhoea(bloodinstoolorpersistentdiarrhoea,sunkeneyes)

• Fever(possibleriskofmalaria)

• Vomiting(cannotkeepanythingdown)

• Respiratoryinfections(cough,pneumonia/chestin-drawing)

• Malnourishedchild:visiblewastingoroedema

• Refusaltoeat

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APPENDIX2

Training AidsSession 3

√ Imagesofcommonillnessesinthecommunity:diarrhoea,cough/pneumonia,malnutrition,vomiting,fever,anaemia

√ Imagesof‘breastfeedingmotherandbaby’,and‘healthymotherandbaby’

Session 4

√ Materialsformakingdollsandmodelbreasts

√ Doll(s)

√ Imagesof‘goodattachment’and‘poorattachment’,and‘Howthebreastmakesmilk’

Note: If possible, make arrangements in advance to have breastfeeding women present to demonstrate positioning and attachment.

√ Photoofmilkexpressionandcupfeeding

√ Smallcupwithliquid

Session 5

√ Photosofengorgement,sore/crackednipple,andpluggedduct/mastitis

√ PhotosofCandida(thrush),checkingforthrushinbaby’smouth,andinvertednipples

Session 6

√ 2setsofimagesof“commonsituationsaffectingbreastfeeding”:

– sickmother,

– feedingalowbirthweightbaby,

– kangaroomothercare,

– malnourishedmother,

– twins,

– refusaltobreastfeed,

– pregnancy,and

– motherawayfrombaby

Session 9

√ Image:‘Feedmoreasthebabygrows’

√ Smallamountofpreparedporridge,smallamountofmilk,2bowlsand2spoons

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APPENDIX3

Instructions for making cloth breast models

Skin Colour Sock

Aroundtheheelofthesock,sewacircularrunningstitch(pursestringsuture)withadiameterof4cm.Drawittogetherto1.5cmdiameterandstuffitwithpaperorothersubstancetomakea“nipple.”Sewafewstitchesathebaseofthenippletokeepthepaperinplace.Useafelt-tippentodrawanareolaaroundthenipple.

White Sock

Ontheheelofthesock,useafelt-tippentodrawasimplestructureofthebreast:alveoli,ducts,andnipplepores.Besurethelactiferoussinuseswillbeintheareolaarea.

Putting the Two Socks Together

Stufftheheelofthewhitesockwithanythingsoft.Holdthetwoendsofthesocktogetheratthebackandformtheheeltothesizeandshapeofabreast.Variousshapesofbreastscanbeshown.Pullthebrownsockovertheformedbreastsothatthenippleisoverthepores.

Making Two Breasts

Iftwobreastsaremade,theycanbewornoverclothingtodemonstratepositioningandattachment.Holdtheminplacewithanoldnylonstockingtiedaroundthechest.Thecorrectpositionofthefingersforhandexpressionandmassagecanalsobedemonstrated.

Usetwosocks,onesockinalightbrownorothercolourresemblingskintoshowtheoutsideofthebreast,andtheothersockinwhitetoshowtheinsideofthebreast.

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APPENDIX4

Cut Outs for Daily Evaluation

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