ENA EHA Reference Manual Health Workers Nutrition

Essential Nutrition Actions
and Essential Hygiene Actions
Reference Manual:
Health Workers and
Nutrition Managers
April 2015
Acknowledgments
This Reference Manual: Health Workers and Nutrition Managers would not have been possible without the
contributions of many individuals, agencies, and institutions. The evolution of the Essential Nutrition Actions (ENA)
Framework had been influenced over the years by USAID’s generous funding to the BASICS project, and to the
LINKAGES project, the Africa’s Health in 2010 project, and the Food and Nutrition Technical Assistance Project (FANTA)
project, all managed by the Academy for Educational Development and FHI 360. The African Regional Center for the
Quality of Health Care, the West African Health Organization, the East, Central and Southern African Health
Community, and UNICEF each played key roles as well, especially in Liberia and Niger, as did the Carter Center in
Ethiopia and the Essential Services for Health in Ethiopia (ESHE) project funded by USAID and managed by John
Snow Incorporated (JSI). National training partners in a number of countries have also been central to the
development of the ENA framework, as well as to related training and behavior change communication materials.
The 2014 revision of the generic ENA materials was initiated by JSI Research & Training Institute Incorporated and
Helen Keller International, with the support of the CORE Group and the Food-for-Peace Technical and Operational
Performance Support (TOPS) Project. Revisions include work from Helen Keller International, the USAID-funded
Strengthening Partnership, Results, and Innovations in Nutrition Globally (SPRING) project in Bangladesh and
Nigeria, the USAID/Peace Corps West Africa Food Security Partnership (WAFSP), and Peace Corps Benin. Illustrations
are from SPRING/Nigeria and SPRING/India adapted from UNICEF and URC/CHS: The Community Infant and Young
Child Feeding (IYCF) Counselling Package 2013, and from the USAID/Suaahara project in Nepal.
The revised materials were tested during the joint CORE Group, JSI and HKI Training of Trainers, funded by the
USAID/Food for Peace-funded TOPS Program in December 2014.
Citation
1 2 3 4
Guyon A. MD.MPH , Quinn V.PhD , Nielsen J.PhD , Stone-Jimenez M.MSc, IBCLC , Essential Nutrition Actions and
Essential Hygiene Actions Reference Manual: Health Workers and Nutrition Managers. 2015. CORE Group:
Washington, DC.
Photo Credits:
Top Photo: Agnes Guyon, JSI Ethiopia; Middle Photo: Victoria Quinn, HKI Nepal; Bottom Photo: Ministry of Health,
Guatemala
This version of the guide was made possible in part by a grant from the USAID Technical and Operational
Performance Support (TOPS) program. The TOPS Micro Grant Program is made possible by the generous support
and contribution of the American people through the United States Agency for International Development
(USAID). The contents of the materials produced through the TOPS Micro Grants Program do not necessarily
reflect the views of TOPS, USAID or the United States Government.
1
John Snow Incorporated, Senior Child Health and Nutrition Advisor
2
Helen Keller International, Senior Vice president
3
Helen Keller International, Senior Nutrition Advisor
4
CORE Group, Consultant
Contents
Acronyms and Abbreviations ........................................................................................................................ v
Global Nutrition Efforts ................................................................................................................................. 1
About the Essential Nutrition Actions Operational Framework ................................................................... 2
The Essential Nutrition Actions ..................................................................................................................... 3
The Framework to Integrate, Communicate and Harmonize ....................................................................... 6
2015 Updates, Compared to ENA 2011 ........................................................................................................ 7
Reference Documents ................................................................................................................................... 8
About The Reference Manual ....................................................................................................................... 9
About Adapting the Reference Manual....................................................................................................... 10
Document #1: Learning Objectives for the ENA&EHA Training .................................................................. 11
Document #2: Pre-assessment ................................................................................................................... 12
Document #3: Role of Health Workers in Improving Nutrition .................................................................. 14
Document #4: Helping Health and Community Workers Use All Available Platforms and
Contact Points ......................................................................................................................................... 16
Document #5: Stages of Change Model Steps to Change Practices and behaviors, and
Role of the Support Person .................................................................................................................... 17
Document #6: Stages of Change and Interventions ................................................................................... 18
Document #7: Conceptual Framework for Nutrition .................................................................................. 19
Document #8: Implementing the ENA & EHA to Prevent Undernutrition ................................................. 20
Document #10: Interventions to Break the Intergenerational Cycle of Malnutrition ................................ 22
Document #11: Practices provided by Health Workers to Adolescent Girls,
Non-Pregnant Women, and Pregnant and Lactating Women ................................................................ 25
Document #12: Essential Nutrition Actions in the Context of HIV Pregnant and Lactating
Women and Their Children Who Are HIV Negative or of Unknown Status ............................................ 28
Document #13: The Benefits of Breastfeeding for Infants and Young Children and the
Risks of Formula Feeding ........................................................................................................................ 30
Document #14: Breastfeeding Practices from Birth up to Six Months ....................................................... 32
Document #15: How Health Workers Can Support Maternal and Child Health ........................................ 34
Document #16: Proper Breastfeeding Positioning and Attachment .......................................................... 37
Document #17: Feeding Recommendations for HIV positive mother ....................................................... 40
Reference Manual: Health Workers and Nutrition Managers | I

Document #18: How to Transition to Replacement Feeding after 12 months........................................... 42
Document #19: Replacement Feeding with Commercial Infant Formula .................................................. 43
Document #20: Family Planning, Nutrition, and Breastfeeding ................................................................. 45
Document #21: Messages on the Lactation Amenorrhea Method ............................................................ 46
Document #22: The Diarrhea Transmission Cycle: The Fecal–Oral Route ................................................. 48
Document #23: Building a Hand Washing Device ....................................................................................... 49
Document #24: Discussion Using an Illustration ........................................................................................ 51
Document #25: Listening and Learning Skills, and Building Confidence and Giving Support Skills............ 52
Document #26A: GALIDRAA Negotiation Checklist .................................................................................... 53
Document #26B: Observation Checklist of GALIDRAA Counselling Steps .................................................. 54
Document #26C: Initial Visit Negotiation Record ....................................................................................... 56
Document #27: Negotiation Checklist for Follow-Up Visits........................................................................ 57
Document #28: Practice Case Studies: Adolescents and Women’s Nutrition ............................................ 59
Document #29: Practice Case Studies: Infants from Birth up to Six Months ............................................. 61
Document #30: Preventing and Controlling Vitamin A Deficiency ............................................................. 64
Document #31: Preventing and Controlling Anemia .................................................................................. 67
Document #32: Preventing and controlling Zinc and Calcium deficiencies, and
Iodine Deficiency Disorders .................................................................................................................... 70
Document #33: Complementary Feeding Practices for Children Aged 6 up to24 Months ........................ 73
Document #34: Active Feeding ................................................................................................................... 79
Document #35: What Health Providers Can Teach Parents or Caregivers about
Complementary Feeding ........................................................................................................................ 81
Document #36: Seasonal Food Calendar .................................................................................................... 85
Document #37: Illness, Feeding, and Recovery .......................................................................................... 86
Document #38: Nutritional Care during and After Illness .......................................................................... 87
Document #39: What Health Providers Can Teach Parents or Caregivers about Feeding
During and After Illness .......................................................................................................................... 89
Document #40A: Practice Case Studies: Complementary Feeding for Children 6 up to
24 Months ............................................................................................................................................... 91
Document #40B: Practice Case Studies: Feeding the Sick Child ................................................................ 96
Document #41: About Support Groups .................................................................................................... 100
II | Essential Nutrition Actions and Essential Hygiene Actions

Document #42: Support Group Observation checklist ............................................................................. 103
Document #43: What is Integrated Management of Acute Malnutrition ................................................ 104
Document #44: Signs of Marasmus, Kwashiorkor, and Bilateral Edema .................................................. 105
Document #45: Acute Malnutrition Management and ............................................................................ 107
Inpatient Treatment Admission Criteria ................................................................................................... 107
Document #46: Food and Counseling for Outpatient Therapeutic Programs .......................................... 108
Document #47: Child MUAC Measurement ............................................................................................. 109
Document #48: Antenatal Care in Fourth, Sixth or Seventh, Eighth, and Ninth Months ......................... 111
Document #49: Delivery and Perinatal Care............................................................................................. 114
Document #50: Postnatal Care and Family Planning on the 7th and 45th Days after Delivery ............... 117
Document #51: Expanded Program on Immunization ............................................................................. 120
Document #52: Growth Monitoring and Well-Child Visits ....................................................................... 123
Document #53: Sick-Child Visits and Integrated Management of Neonatal and
Childhood Illnesses................................................................................................................................ 126
Document #54: Community Management of Acute Child Malnutrition in an
Outpatient Therapeutic Program.......................................................................................................... 129
Document #55: Comparison of Training Guides for Health Workers and Community Workers ............. 132
Document #56: Supervision Guidelines for Community Health Workers ................................................ 136
Document #57: Action Plan Template for Implementation of ENA & EHA Program ............................... 138
Document #58: Post-Assessment ............................................................................................................. 139
Document #59: Pre- and Post-Assessment: Answers ............................................................................... 141
Document #60: ENA&EHA: Course Evaluation ......................................................................................... 142
Reference Manual: Health Workers and Nutrition Managers | III

IV | Essential Nutrition Actions and Essential Hygiene Actions
Acronyms and Abbreviations
ANC antenatal care
ARV antiretroviral
BF breastfeeding
BMI body mass index
CV community volunteer
EBF exclusive breastfeeding
EHA Essential Hygiene Actions
ENA Essential Nutrition Actions
F75/F100 Formula 75 and Formula 100: Therapeutic milk to treat severe acute malnutrition
FADDUA Frequency, Amount, Density, Diversity, Utilization, Active feeding
GALIDRAA Greet, Ask, Listen, Identify, Discuss, Recommend, Agree, set follow-up Appointment
GMP growth monitoring and promotion
HFP homestead food production
IDD iodine deficiency disorder
IFA iron–folic acid
IMAM integrated management of acute malnutrition
IMNCI integrated management of neonatal and childhood illnesses
IPT intermittent preventive treatment
ITN insecticide-treated mosquito net
IU international units
IYCF infant and young child feeding
LAM lactation amenorrhea method
MAM moderate acute malnutrition
MTCT mother-to-child transmission (of HIV)
MUAC mid-upper arm circumference
OTP outpatient therapeutic program
PMTCT prevention of mother-to-child transmission (of HIV)
RUTF ready-to-use therapeutic foods
SAM severe acute malnutrition
SBCC social behavior change communication
SC stabilization Center
SFP supplementary feeding program
STI sexually transmitted infection
TOT training of trainers
TT tetanus–toxoid
Reference Manual: Health Workers and Nutrition Managers | V

VI | Essential Nutrition Actions and Essential Hygiene Actions
Global Nutrition Efforts
Around the world some 162 million children under five were stunted in 2012. ‘At current trends, the
number of stunted children under five is projected to be 128 million in 2025, against a target of 100
million. The current prevalence of anaemia in women of reproductive age is 29.4%, against the 2025
target of 14.7% (WHO, 2014)”.5 Beyond the scourge of the lack of food is the even more pervasive
problem of “hidden hunger,” or deficiencies in key micronutrients like vitamin A, iron, zinc and iodine.
Children affected by stunting and micronutrient deficiencies are more susceptible to sickness, fare poorly
in school, enter adulthood more prone to non-communicable diseases, and at work often earn less than
non-stunted coworkers. Children suffer, families suffer and nations suffer.
The world community is reacting with increasing urgency to the gravity of this situation and its effects for
the long term, focusing on global undernutrition, especially among pregnant women and children under
two years of age. It is also aligning and increasing resources and building partnerships to combat
suffering caused by undernutrition. Since 2010, more than 100 government, civil society, and university
groups have endorsed the framework and roadmap for the Scaling-Up Nutrition (SUN) Movement. There
is also broad recognition that a well-defined set of essential nutrition actions has proven effective in
combating malnutrition during the critical first 1,000 days.6
The landmark Lancet Series on Maternal and Child Undernutrition published in 2008 and updated in
20137 8 9 estimates that maternal and child undernutrition is the cause of 45 percent of under-five
deaths.1 These series reviewed global data from randomized control trials and confirmed that if
implemented at scale during the window of opportunity (from conception up to 24 months of age) this
package of nutrition-specific and nutrition-sensitive interventions can significantly reduce mortality and
related morbidity and disability.
In 2013, the World Health Organization (WHO) released a guide entitled, Essential Nutrition Actions:
improving maternal, newborn, infant and young child health and nutrition10, which also draws on the
findings of systematic reviews such as those of the Lancet to highlight the proven actions that need to be
taken to scale within the health sector.
5
http://www.who.int/nutrition/en/
6
http://www.thousanddays.org/
7
The Lancet. Maternal and Child Undernutrition. The Lancet, 2008, http://www.thelancet.com/series/maternal-and-child-undernutrition; and
2013, http://www.thelancet.com/series/maternal-and-child-nutrition. This landmark series estimated that effective, targeted nutrition
interventions to address maternal and child undernutrition exist, and if implemented at scale during the 1,000-day-long window of
opportunity, could reduce nutrition-related mortality and disease burden by 25 percent
8
Black, R. E., C. G. Victora, et al. (2013). “Maternal and child undernutrition and overweight in low-income and middle-income countries.” The
Lancet
9
Bhutta, Z. A., J. K. Das, et al. (2013). “Evidence-based interventions for improvement of maternal and child nutrition: what can be done and
at what cost?” Lancet.
10
World Health Organization. 2013. “Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition.”
Geneva: World Health Organization. http://www.who.int/nutrition/publications/infantfeeding/essential_nutrition_actions/en/.
Reference Manual: Health Workers and Nutrition Managers | 1

About the Essential Nutrition Actions
Operational Framework
The Essential Nutrition Actions (ENA) framework was originally developed with the support of USAID,
WHO and UNICEF, and has been implemented across Africa and Asia since 1997.11 The full ENA
framework is an approach for managing the advocacy, planning and delivery of an integrated package of
interventions to reach near universal coverage (>90%) in order to achieve public health impact.
It promotes a “nutrition through the life cycle” approach to deliver the right services and messages to
the right person at the right time using all relevant program platforms. It provides an operational
framework for reducing “missed opportunities” both within12 and outside the health system for
delivering nutrition messages and services.
The recommended practices are multiple and potentially complex. However, over years of experience
the program has evolved to distill the most important and practical aspects, and to organize delivery
mechanisms that refresh and reinforce the knowledge of implementers. In addition, in each setting
users can select priority elements from the full package for their context, and/or phase in components
over time to avoid overloading health agents, community workers and other cadres helping to roll out
nutrition strategies.
11
Guyon AB, Quinn VQ, Hainsworth M, Ravonimanantsoa P, Ravelojoana V, Rambeloson Z, and Martin L. (2009) Implementing an integrated
nutrition package at large scale in Madagascar: The Essential Nutrition Actions Framework. Food & Nutrition Bulletin 30(3):233-44.
12
Hampshire, R. D., V. M. Aguayo, et al. (2004). “Delivery of nutrition services in health systems in sub-Saharan Africa: opportunities in Burkina
Faso, Mozambique and Niger.” Public Health Nutr 7(8): 1047-1053.
2 | Essential Nutrition Actions and Essential Hygiene Actions

The Essential Nutrition Actions
Women’s Nutrition
For adolescents and women: the importance of the healthy timing and spacing of pregnancy,
consumption of diversified diet and/or of fortified foods (commercial and/or in-home fortification).
During pregnancy and lactation: increased protein, caloric and micronutrient (Vitamin A, Iron,
Calcium, Zinc) intake, dietary change to increase iron absorption, rest during pregnancy, and the lactation
amenorrhea method (LAM) of contraception.
Breastfeeding
Early initiation of breastfeeding (immediately after birth), exclusive breastfeeding for the first 6 months,
continued breastfeeding with complementary foods up to 2 years or beyond, and HIV and infant feeding.
Complementary Feeding
From 6 months (age-appropriate frequency, amount, density, diversity, utilization) with continued
breastfeeding for up to two years or beyond, consumption of fortified foods (commercial and/or in-home
fortification), responsive feeding, food hygiene.
Nutritional Care of Sick and Malnourished Children

Feeding more during and after illness, provision of vitamin A, and treatment of diarrhea with low-
osmolarity ORS and zinc supplements, and the integrated management of acute malnutrition (IMAM) for
moderate and severe acute malnutrition.
Prevention and Control of Anemia

Among women: increased dietary intake of iron-rich or enhancing foods, iron-folic acid
supplementation during pregnancy, post-partum and more routinely by women of childbearing age,
intermittent preventive treatment (IPT) for malaria and de-worming treatment during pregnancy, use of
insecticide-treated bed nets (ITNs), and delayed cord clamping at birth.
Among children: delayed cord clamping at birth, implementation of the Integrated Management of
Neonatal and Childhood Illness (IMNCI) algorithm and integrated Community Case Management (iCCM)
of malaria, diarrhea, pneumonia, anemia and acute malnutrition, use of ITNs, de-worming from age 12
months, increased dietary intake of iron-rich or enhancing foods from age 6 months, and iron
supplementation where indicated.
Prevention and Control of Vitamin a Deficiency

Among children and women: through breastfeeding, high dose supplementation of children ages 6-59
months and of women post-partum where appropriate, low dose supplementation during pregnancy
where indicated, and promoting the regular consumption of vitamin A-rich, fortified or bio-fortified
foods.

Prevention and Control of Iodine Deficiency
Among children and women: through promotion of iodized salt or through supplementation in the
absence of scaled up iodized salt programs.
In addition, mounting evidence suggests it is necessary to give more emphasis to the Essential Hygiene
Actions previously embedded within complementary feeding and feeding the sick child. These actions
include: household treatment and safe storage of drinking water (such as utilizing chlorine solution and
storing water in closed container with tap), hand washing at five critical occasions (after defecation;
after cleaning child who has defecated; before preparing food; before feeding child; before eating), safe
storage and handling of food, the safe disposal of feces through the use of latrines and promotion of
open defecation free communities, and creating barriers between toddlers and soiled environments and
animal feces.
The 2013 Lancet Maternal and Child Nutrition series emphasized that nutrition-sensitive programs,
such as those shown in the box below, can improve nutritional outcomes by addressing many of the
underlying determinants of malnutrition especially those related to food security, caregiving practices
and adequate health services, water and sanitation. These nutrition-sensitive programs also offer an
opportunity to integrate nutrition-specific interventions, such as the Essential Nutrition Actions (ENA)
and Essential Hygiene Actions (EHA), which in turn leads to their increased coverage and effectiveness.
As the Lancet authors note, “…nutrition-sensitive programs can help scale up nutrition-specific
interventions and create a stimulating environment in which young children can grow and develop to
their full potential”.13
The ENA & EHA training materials aim to provide skills on how to effectively implement nutrition-
specific ENA & EHA interventions during the first 1,000 days, as well as emphasizes how to integrate
these into a range of nutrition-sensitive programs including health services and community level
interventions in other sectors.
13
(Ruel M, Alderman H, and the Maternal and Child Nutrition Study Group. Nutrition-sensitive interventions and programmes. Lancet 2013;
published online June 6. http://dx.doi.org/10.1016/S0140- 6736(13)60843-0)

Nutrition Sensitive Interventions
Health and Family Planning Services
 Family planning
 Adolescent and women health

 Immunization
 Management of childhood illnesses
Food Security and Livelihoods

 Agricultural interventions
 Addressing seasonal food insecurity
 Early warning and resilience
 Social protection and safety nets
 Conditional and unconditional cash transfers
 Dietary quality and diversity
Water, Sanitation and Hygiene (WASH) interventions

 Environmental enteropathy
 Promotion of hygiene behaviors and practices
 Hygienic and sanitary environment
 Drinking water – quality, distance and source
 Improved sanitation facilities
 Reduction and elimination of open defecation
Early Childhood Development (ECD) and Positive Caregiving

Women’s Empowerment and Gender Equality
Maternal Mental Health
Child Protection
Classroom Education

The Framework to Integrate, Communicate and Harmonize
The ENA Framework includes ensuring that priority messages and services from this comprehensive list
are integrated into all existing health sector programs, in particular those that reach mothers and
children at critical contact points in the first thousand days of the life cycle: maternal health and
prenatal care; delivery and neonatal care; postpartum care; family planning; immunizations; well child
visits (including growth monitoring, promotion and counseling); sick child visits (including facility and
community IMCI and CCM); and IMAM.
The appropriate messages and services are also integrated to the greatest extent possible into programs
outside the health sector: agriculture and food security activities; education (pre-service for health,
primary and secondary schools for general education) and literacy programs; microcredit and livelihoods
enhancement; and water, sanitation, and hygiene (WASH). ENA messages and behavior change
communications are also delivered and reinforced by community groups.
Implementing the ENA framework entails building the widest possible network of partnerships across
sectors so that interventions, practices and messages are harmonized and all groups use similar
materials and jobs aids. Ideally, ministries and partners are brought together at the regional and/or
national levels to agree on these harmonized approaches. Such fora can also serve as a platform for
advocacy with policy leaders on the importance of nutrition to the nation’s economic as well as social
development.
Implementing the ENA Framework Entails Three Interconnected

Strategies
Develop a multi-channel social and behavior change communication (SBCC) plan to promote and
support the adoption of “small do-able” actions. Special emphasis is given to interpersonal counseling
(supporting individual mothers, especially in the context of their daily routines, to adopt optimal
practices) reinforced by group discussions, mass media, community festivals and other social
mobilization events. Health workers, other agents, and community workers are trained to employ the
counseling technique of “negotiation for behavior change,” to help mothers anticipate and overcome
barriers to carrying out new practices. Health workers can use these approaches with clients at clinics,
while community workers apply them during home visits or at community meeting places (markets,
chores, women groups meetings, etc.).
Tailor a capacity building strategy to enable program managers, health workers, other agents
(agriculture extension workers, teachers, credit groups, etc…) and community workers to acquire
knowledge and skills in delivering services and counseling through all relevant existing platforms and
contacts, therefore decreasing missed opportunities to deliver ENA and EHA.
Strengthen delivery systems (health, agriculture, water & sanitation, education, finance) to secure the
regular supply of nutrition related products, to include the monitoring of nutrition actions into
information systems, and to incorporate nutrition into supportive supervision and quality improvement
schemes.

2015 Updates, Compared to ENA 2011
The updated ENA-EHA training builds on the ENA 2011 training Trilogy keeping the overall format of the
materials. The 2015 revised version also:
 Includes the latest ENA recommendations from WHO14 across the life cycle; in particular,
nutrition for adolescents, non-pregnant and non-lactating women, revised micronutrient
protocols, and the importance of working beyond the health sector.
 Serves as an operational and practical tool for translating 2013 Lancet recommendations and
SUN aspirations into action on the ground
 Gives central focus to moving beyond nutrition education to promotion of social and
behaviour change. Includes exercises throughout to build participants’ skills in counselling and
negotiation to support caregivers to adopt improved practices, including role plays, field
practicums, using illustrations to animate group discussions and individual counselling,
facilitating community support groups, and applying these skills across both ENA and EHA.
 Equips health workers at health facilities to better deliver nutrition services and messages at
each health contact.
 Guides nutrition managers through practical exercises to build their training skills and provides
them with a tool to train community workers across all sectors to promote high impact
nutrition and hygiene.
 Includes the promotion of the Essential Hygiene Actions as inextricably linked to improved
nutrition, going beyond hand washing to food hygiene, animal hygiene, safe water, and
introduction to simple hand washing stations.
 Incorporates suggestions for ways that Homestead Food Production can contribute to improved
nutrition and how agriculture in general can be made nutrition-sensitive.
14
World Health Organization. 2013. “Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition.”
Geneva: World Health Organization. http://www.who.int/nutrition/publications/infantfeeding/essential_nutrition_actions/en/.

Reference Documents
Lancet References (2008 -2013)
Lancet Series on Maternal and Child Undernutrition (2008) Lancet Series on Maternal and Child Nutrition
(2013)
WHO References (2013)

WHO Essential Nutrition Actions Guide
ENA Training Materials (2015)

 ENA & EHA Training Guide - Health Workers and Nutrition Managers
 ENA & EHA Reference Manual - Health Workers and Nutrition Managers
 ENA & EHA Training Guide - Community Workers (all sectors)
 ENA & EHA Reference Materials on Key Practices - Community Workers (all sectors)
ENA State of the Art Training for Managers (English & French, 2006)
Includes nine modules on rational for the essential nutrition actions and large scale implementation
Technical Capacity Assessment tools (JSI, 2013)

These tools are designed to help an organization assess its ability to implement various nutrition
programs, looking holistically at personnel, documents, and systems in place at the organizational and
implementing partner levels.
 Essential Nutrition Actions Framework within the Health system
 Community-based Management of Acute Malnutrition
 Essential Nutrition Actions Framework within the context of HIV & AIDS
Quality Assessment of Nutrition Services-A How-To Guide (HKI. jnielsen@hki.org)

Surveying Nutrition-Related Services Offered to Pregnant Women, Postpartum Women, and Caregivers of
Children Under Five in Health Facilities
Supportive Supervision Tools

Quality Improvement Verification Checklists Partnership Defined Quality (Save the Children) Integrated
MNCH Supportive
Supervision (JSI) Supportive Supervision at key health contact points (JSI)
Care Group Guidance for Community

 Care Group Difference: Guide to Mobilizing Community-Based Volunteer Health Educators
(World Relief/CORE Group, 2004)
 Care Groups: A Training Manual for Program Design and Implementation (TOPS; Food for the
Hungry, 2014)
Formative Research Tools

 ProPAN 2.0 (PAHO, CDC, 2013)/Optifoods Focused Ethnographic Study Guide (GAIN, 2012)
 Designing for Behavior Change (CORE Group & Food Security & Nutrition Network, 201

About The Reference Manual
The goal of this Reference Manual is to provide information to health workers and nutrition managers to
conduct Community Workers training and to support the delivery of nutrition and hygiene practices.
This reference manual provides key information on the conceptual framework of nutrition, on contact
points to deliver essential nutrition actions and essential hygiene actions, on adolescents and women
nutrition, infant and young child feeding, nutrition in the context of HIV, protocols to prevent and control
micronutrient deficiencies, integrated management of acute malnutrition, guidelines to conduct
counseling and negotiation with mother and caregivers, facilitation skills to conduct community support
groups and guidelines to carry out supportive supervision at community level. Messages and additional
information for each of the ENA and EHA practices are targeted to improve health workers’ performance
in delivery of nutrition (and hygiene) during each health contact.
The Essential Nutrition Actions and Essential Hygiene Actions Reference Manual - Health Workers and
Nutrition Managers is distributed during the ENA & EHA training for health workers and nutrition
managers. It is to be used by health workers after the training, as it provides a summary of the
fundamental concepts of nutrition and hygiene in the health sector. Similarly it is to be used by
nutrition managers to build their capacity in carrying participative and quality training based on the
principles of adult learning.
In addition, complementary materials can be also provided:
The Essential Nutrition Actions and Essential Hygiene Actions Reference Materials on Key Practices -
Community Workers (all sectors) provides messages and information on each of the recommended ENA
and EHA practices, identifying “who is doing the action”, “what is the action”, and “the benefit of the
intended action.” Information about Homestead Food Production (HFP) that can support nutrition
practices in the first 1,000 days is also included in this reference handbook.

About Adapting the Reference Manual
Two training guides have been developed to strengthen the nutrition capacity of health workers and
community workers. Both include sessions introducing technical content while also enabling the practice
of counseling and negotiations skills through role plays and field practice and guiding providers in how
to deliver nutrition and hygiene through existing contacts using a life cycle approach.
While the content of the training guides remain generally fixed, the approach for communicating the
rationale and benefits of the practices may need to be adapted through formative research or testing of
the messages to ensure they fit specific country and regional cultures and contexts. Such research will
identify key behavioral determinants to be addressed, local terms and social norms to be taken into
account, and other strategies to tailor the general training modules and communications strategies to
the specific needs of each unique area. Similarly, protocols related to micronutrient supplementation
and treatments will have to be aligned with country recommendations.

Document #1: Learning Objectives for the ENA&EHA
Training
At the end of the training, participants will be able to:
 Describe the key nutrition practices and messages relating to:
o women’s nutrition (adolescents, and during pregnancy and lactation)

o breastfeeding from birth up to 6 months, including infant feeding and HIV
o complementary feeding from 6 up to 24 months: BF + FADDUA
o prevention and control of micronutrient deficiencies (vitamin A, anemia zinc, iodine, and
calcium).
o Assessment, treatment and referral of acute malnourished children
o Essential Hygiene Actions (use of latrines, handwashing, clean water, clean environment
and utensils)
 Explain which nutrition actions to deliver at each contact (facility and community)
 Perform the following skills:
o negotiate with mothers/fathers/caregivers to encourage them to try one improved practice

and reinforce correct behaviors
o facilitate participatory group discussions and community support groups that will stimulate
problem solving to overcome barriers to behavior change
o train and supervise community workers to strengthen their performance in promoting
optimal nutrition and hygiene actions

Document #2: Pre-assessment
Please read through the following statements. Select Yes if you agree with the statement or select No if
you disagree with the statement.
# PRE ASSESSMENT YES NO
1. When breastfeeding, the baby’s chin needs to touch the mother’s breast.
2. Vitamin A supplementation is necessary only for children under 1 year.
3. Even if a mother believes she does not have enough breastmilk, she can still be able
to adequately breastfeed her baby.
4. A mother can prevent sore and cracked nipples by correctly positioning and
attaching her baby at the breast.
5. Watery food is a better food for a 6-month old baby than soft porridge.
6. The mother or caregiver needs to play with the baby to encourage the baby to eat
all the food given.
7. Animal products, beans and legumes are the foods that help a child grow.
8. Young children should be breastfed for at least 1 year.
9. Mothers need support from the family or the community in order to feed their
children.
10. When a young child over 6 months has diarrhea, the mother needs to decrease the
frequency of breastfeeding, frequency of other liquids, and the frequency of foods
to give child’s stomach a rest,
11. A pregnant woman needs to eat more than a woman who is lactating.
12. Red meat, liver, and green leafy vegetables contain iron.
13. A malnourished mother is likely to give birth to a low birth weight child.
14. Breastfeeding benefits only the baby.
15. It is important to sleep under an ITN to prevent anemia in women and children.
16. Pregnancy and lactation are the only points in the lifecycle of females where
nutrition should be improved.
17. It is important to focus on pregnant and lactating women and children under two
year of age to improve nutrition outcomes.
18. When a mother is HIV-positive, she cannot breastfeed.

# PRE ASSESSMENT YES NO
19. Integration of nutrition into other sectors means reaching mothers, their babies and
children at critical contact points in that sector.
20. In traditional complementary foods, iron is almost always deficient.

Document #3: Role of Health Workers in Improving
Nutrition
WHO WHEN/WHERE/CONTACT NUTRITION AND HYGIENE PRACTICES
Adolescent  Schools  Adolescent nutrition

 Community-wide  Micronutrient supplementation and treatment
events
 WASH
Woman  Discussion groups  Woman’s nutrition

 Community Support  Micronutrient supplementation and treatment
Groups
 WASH
 Care groups
 Family planning
Pregnant  Antenatal and  One extra meal per day

Woman postnatal care
 Micronutrient supplements/treatment (or protein-energy
 Family planning supplements for undernourished mothers)
 Community support  Discuss the following:
Groups
o Importance of skin-to-skin with newborn
 Care Groups
o Good positioning and attachment
o Early initiation of breastfeeding (give colostrum)
o Exclusive breastfeeding from birth up to 6 months
(avoid other liquids and food, even water)
o Breastfeeding on demand – up to 12 times day and
night
o WASH
Newborn Delivery  Place baby skin-to-skin with mother

 Good positioning and attachment
 Early initiation of breastfeeding (give colostrum, avoid
water and other liquids)
Lactating  Postnatal care  Two extra meals per day

mother  Family planning  Micronutrient supplements/treatment
 Community support  Vitamin A supplementation (from birth to 6 weeks post-

WHO WHEN/WHERE/CONTACT NUTRITION AND HYGIENE PRACTICES
Groups delivery according to national protocol)

 Care Groups  WASH
Infant 0 up to Postnatal visits  Good positioning and attachment

6 months 
 Immunization Sessions Exclusive breastfeeding from birth up to 6 months
 Growth Monitoring  Breastfeeding on demand – up to 12 times day and night

Promotion (GMP)  Ensure mother knows how to express her breast milk
 Family planning  Breastfeeding difficulties (plugged ducts which can lead to
sessions mastitis, and not enough breast milk)
 Sick Child clinic  Increase breast milk supply
 Community follow-up  Maintain breast milk supply
 Continue to breastfeed when infant or mother is ill
 WASH
Infant &  GMP  BF + FADDUA: Frequency, Amount, Density, Diversity,

young child Utilization, Active or Responsive feeding
 Sick child Clinic
from 6 up to  At 6 months, begin to offer foods 2 to 3 times a day -
24 months  Community follow-up
gradually introduce different types of foods (animal foods,
staple, legumes, vegetables, and fruits) and continue
breastfeeding
 WASH
Infant &  Health facility  Screen for MAM and SAM

young child  IMAM program  Refer to in-patient if necessary
 Community outreach  WASH
Family  Discussion groups  Safe water

 Community Support  Hand washing
Groups
 Sanitation
 Care groups
 Clean environment
 Homestead Food
Production for dietary
diversity
 Community-Led Total
Sanitation for clean
environments

Document #4: Helping Health and Community Workers
Use All Available Platforms and Contact Points
Opportunities in Health Facilities
 At antenatal care clinics
 At delivery and post delivery
 During postpartum/family planning sessions
 During well-baby clinic sessions
 In immunization clinics
 During growth monitoring and promotion
 At sick-child visits
 During outpatient care for malnutrition
Opportunities at the Community Level

 During home visits
 During outreach for immunization
 During nutrition screening
 During market days
 While fetching water and working
 During visits to neighbors
 Around religious, cultural, social, or business-related gatherings (e.g., festivals, family
celebrations, savings and loan meetings, literacy groups, talks by religious leaders)
 During traditional gatherings for men or women
 Support Groups
Opportunities at School
 During health classes
 At parent–teacher association activities
Opportunities with Agriculture Platforms

 Conversations with extension or agricultural workers
 At farmers’ schools
 Discussions with seed traders
 Lectures or talks about Household Food Production (HFP): gardens, agroforestry or about small
husbandries
Encourage brainstorming to find as

many platforms as possible in volunteers’ communities.

Document #5: Stages of Change Model
Steps to Change Practices and behaviors, and Role
of the Support Person
Celebrate success Maintenance: “Yes, I can do it”
Action: I’m trying a new practice

Praise, discuss benefits, support
Intention: “I’m ready to Try”
Negotiate
Knowing: “There might be a problem”
Share/discuss
information, encourage
Identify Problem Not Knowing: “I don’t see a problem”
Changing behavior is VERY DIFFICULT! It is not a linear process.

Not knowing: Doesn’t know, has no knowledge of the problem, thus doesn’t think at all about making a
change. Or, maybe knows something and is aware of the problem, but is fixed not to change.
Knowing: Is aware of the problem. Thinks a bit about making the change; recognizes the importance of
changing, but is not sure that s/he will or can change; has doubts about the results, the approval of
other people.
Intention: Has decided to do something. Maybe has tried in the recent past without succeeding.
Planning to make a change, but only thinking about doing it.
Action: Changing but has not arrived at a permanent state of practicing the behavior.
Maintenance: The new behavior is now a habit.

Document #6: Stages of Change and Interventions
STAGE APPROPRIATE INTERVENTIONS
At each stage, the goal is to encourage the target audience to try a new practice—to provide support for a
mother’s choice and to change community norms.
Never Heard About the  Build awareness and provide information.

Behavior  Stage skits and plays; participate in fairs.
(Not Knowing)  Give talks for community groups.
 Participate in radio broadcasts.
 Offer individual counseling.
 Form and promote support groups.
Heard About the New  Encourage the behavior and discuss its benefits.
Behavior Or Know  Hold group discussions or talks.
What it is
 Disseminate information via the spoken or printed word.
(Knowing)
 Hand out counseling cards.
 Form and promote breastfeeding and young child feeding support groups.
Thinking About the  Negotiate with community members and help them overcome obstacles.
New Behavior  Make home visits, and use visuals.
(Intention)  Create activities for families and the community.
 Create structures for peer-to-peer support.
 Negotiate with husbands, mothers-in-law, or other influential family
members to support the mother.
Trying Out the  Praise the behavior and reinforce its benefits.
New Behavior  Congratulate the mother and other family members as appropriate.
(Action)  Suggest support groups to visit or join to provide encouragement.
 On radio programs and in other forums, encourage community members to
provide support.
Continuing the New Behavior  Reinforce the benefits of the behavior.

or Maintaining It  Praise the individual for making the change.
(Maintenance)  Tell others about adopting the new practices.

Document #7: Conceptual Framework for Nutrition

Document #8: Implementing the ENA & EHA to Prevent
Undernutrition
The focus is on preconception and during the 1,000-day window of opportunity from pregnancy to a
child’s second birthday.
Focus on Essential Nutrition Actions

 Promote adolescent’s nutrition.
 Promote women’s nutrition during pregnancy and lactation
 Promote and support breastfeeding practices.
 Advocate feeding child 6 up to 24 months complementary foods (“family foods”) while
breastfeeding.
 Urge nutritional care of sick or malnourished children.
 Control vitamin A deficiency.
 Control anemia.
 Control iodine deficiency disorders.
Focus on Essential Hygiene Actions

 Promote the use of sanitary latrines, including by children.
 Promote hand washing with soap and water after going to the bathroom and after cleaning
baby’s feces.
 Promote hand washing with soap and water before preparing food, before eating food, and
before feeding young children.
 Promote the installation of a tippy tap or other hand washing station next to the cooking area
and another next to the toilet.
 Encourage keeping all cooking containers and utensils clean, as well as water and food
containers clean and covered.
 Encourage reheating and sufficient cooling of any stored foods to ensure safety.
 Encourage families to keep animals away from homestead and child play areas clean and
protected.

Document #9: The Intergenerational Cycle of Malnutrition
CHILD WITH LOW

WEIGHT AND
HEIGHT (GROWTH
FAILURE)
LOW ADOLESCENT
BIRTHWEIGHT Teenage pregnancy GIRL WITH
LOW WEIGHT
AND HEIGHT
WOMAN
WITH LOW WEIGHT
AND HEIGHT
THE CYCLE
When a woman is malnourished, the next generation may also suffer from malnutrition and poor health.
Malnourished women are more likely to have been:
Low birthweight babies.
Underweight and stunted as girls.
Girls whose first pregnancy occurred during their adolescence.
Women whose pregnancies have been closely spaced.
Women who had heavy workloads during pregnancy and breastfeeding.
Consequences of malnourished mother:

Increased infection due to weakened immune system
Weakness, tiredness
Decreased productivity
Difficult labor
Increased risks of complications during labor and delivery
Increased risk of death if mother hemorrhages
Decreased ability to care for children

Document #10: Interventions to Break the
Intergenerational Cycle of Malnutrition
Child survival initiatives must start before conception by improving the health of adolescent girls and
women, addressing their economic and social problems.
Prevent Growth Failure (Low Weight and Height in a Child)

 Initiate breastfeeding early (immediately after birth).
 Practice exclusive breastfeeding from birth up to six months of age.
 Start complementary feeding at six months; continue to breastfeed until at least age two.
 Continue adequate complementary feeding 6 up to 24 months (Breastfeeding + FADDUA)
 Feed sick children more than usual while they are ill and for two weeks after recovery.
 Obtain vitamin A supplementation and consume a diet rich in vitamin A.
 Control anemia via iron–folic acid (IFA) supplementation, deworming, and consuming iron-rich
foods.
 Control iodine deficiency by consuming iodized salt.
 Obtain all needed immunizations.
 Practice family planning.
Prevent Low Weight and Height in Adolescent Girls

 Increase adolescents’ food intake.
 Delay first pregnancies until after age 20.
 Prevent and treat infections via:
o complete anti-tetanus immunizations for pregnant women (five injections in all)
o education on prevention of sexually transmitted infections (STIs) and HIV
o use of insecticide-treated nets (ITN)
 Prevent iron, vitamin A, and iodine deficiencies via consumption of:
o iron-rich foods (e.g., meat and liver, dark green leafy vegetables, beans, fortified foods)
o vitamin A-rich foods (e.g., liver, butter, milk, papaya, mangoes, carrots, pumpkins and
orange-flesh sweet potatoes)
o iodized salt and iodine-rich foods (e.g., fish and seafood)
 Prevent vitamin A and anemia via supplementation of :
o IFA supplementation and deworming
 Encourage parents to give girls and boys equal access to education. (Malnutrition drops when
girls and women receive more education.)

Prevent low weight and height in women.
 Assure women’s access to nutrient dense foods at every stage of life, especially during
adolescence, during pregnancy, and while breastfeeding. They should receive an additional
meal, more food than usual, and a varied diet.
 Prevent iron, vitamin A, and iodine deficiencies via consumption of:
o iron-rich foods (e.g., meat and liver, dark green leafy vegetables, beans, fortified foods)
o vitamin A-rich foods (e.g., liver, milk, butter, papaya, mangoes, carrots, pumpkins and
orange-flesh sweet potatoes)
o iodized salt and iodine-rich foods (e.g., fish and seafood)
 Prevent and treat infections via:
o complete anti-tetanus immunizations for pregnant women (five injections in all)
o use of insecticide-treated nets
o IFA supplementation, deworming and presumptive treatment of malaria for pregnant
women
o education on STIs and HIV transmission and prevention
 Prevent low birth weight (LBW) through good nutrition during pregnancy
o eat iron-rich foods
o eat vitamin A-rich foods
o use iodized salt
o eat one additional meal daily
o prepare for early initiation of breastfeeding and exclusive breastfeeding
Implement Family Planning

Women need to visit a family planning center offering multiple contraceptive options to
 Space pregnancies (3 years).
 Delay the first pregnancy until after age 20.
Decrease Energy Expenditure

 Encourage couples to use family planning for optimal birth spacing.
 Decrease the workload of pregnant and breastfeeding women.
 Allow women to rest more during pregnancy.

Encourage Men’s Participation
 Involve men in birth spacing and following up on pregnancy and delivery.
 Obtain husbands or partners’ involvement for a more nutritious diet and lighter workload for
their wives.
 Involve fathers in providing nutrient-rich foods for young children.

Document #11: Practices provided by Health Workers to
Adolescent Girls, Non-Pregnant Women, and Pregnant
and Lactating Women
Nutrition for Adolescent Girls and Non-pregnant Women
Girls between the ages of 10 and 20 years are still growing and need different types of food and an Iron
Folic Acid (IFA) supplement to fully develop their bodies. Non-pregnant women also need to build strong
bodies to prepare for future pregnancies and to take care of their families.
 Advise an adolescent girl to eat at least three meals daily; eating fish, chicken, eggs, or meat at
least once a day will help an adolescent girl develop strong bodies and help them develop into
healthy adults and prepare them for healthy future motherhood.
 Advise adolescent girls and non-pregnant women to eat many different types of colorful foods
to develop and maintain strong bodies. Some examples are amaranth and red amaranth,
country bean, yard-long bean, soybeans, peanuts, black beans, orange-flesh sweet potato,
pumpkin, African eggplants, moringa, okra, papaya, and spinach.
 Provide adolescent girls and non-pregnant women weekly IFA supplementation and twice yearly
deworming medicine to prevent anemia or weak blood. IFA and deworming medicines may be
available to adolescent girls at schools.
 Advise an adolescent girl to delay her first pregnancy until after age 20 to allow her body to fully
develop. A fully developed body will enable her to deliver a strong baby. Work to convince the
entire family of this fact.
Nutrition for Pregnant Women

Pregnant women need to eat more food than usual (one extra bowl of food every day) to give birth to
healthy and strong babies.
 Counsel a pregnant woman to get vitamins by eating a varied diet that consists of many
different types of colorful foods, to have healthy and strong babies. Examples of these foods are
amaranth and red amaranth, country bean, yard-long bean, potato greens, soybeans, peanuts,
black beans, orange-flesh sweet potato, pumpkin, African eggplants, moringa, okra, papaya, and
spinach. Pregnant women should also consume chicken, crayfish, eggs, fish, meat, peanuts, or
snails daily if possible.
o The list of nutritious foods will change with regions and seasons.
 Encourage husbands and partners to support their pregnant wives in these practices
 Urge a pregnant woman to rest and avoid carrying heavy loads. Husbands and partners should
support their pregnant wives to take these steps, so they can deliver strong, healthy babies.
 Counsel that to allow the body to rest, pregnancies need to be spaced by a minimum of three
years

Nutritional Supplements, Medicines, and Vaccines during Pregnancy
Iron–Folic Acid Supplements during Pregnancy
Anemia (“low or weak blood”) is a condition where the number of red blood cells in the body is too low.
This causes a person to feel very sick and very weak. Not getting enough iron will lead to anemia, and
pregnant women need extra iron.
 Provide IFA tablets to pregnant women to maintain their strength and health and to prevent
anemia.
o Pregnant women need to take IFA medicine throughout the pregnancy and after delivery.
o Depending on the country protocol, IFA tablets are consumed daily or two to three times
weekly.
o Husbands need to make sure their pregnant wives obtain IFA tablets as soon as possible to
keep them healthy and strong, and to have strong babies.
 Inform pregnant women that IFA tablets should be taken with food to avoid nausea and
vomiting, stomach pain, or constipation. Also, recommend they drink a lot of water to avoid
becoming constipated.
o Black stools are normal when taking iron medicine.
 Encourage the consumption of fish, meat, eggs, liver, and dark green leafy vegetables: good
sources of iron, daily if possible.
 Depending on the country protocol, provide low dose vitamin A consumed daily or two to three
times weekly.
Deworming Medicines during Pregnancy

Worms can cause anemia.
 Provide deworming medicine to pregnant women two times during a pregnancy to keep them
from becoming anemic.
o Husbands need to make sure their pregnant wives get deworming medicine.
Tetanus–Toxoid Vaccines during Pregnancy
 Give to pregnant women tetanus-toxoid immunization at the health facility.
o Husbands need to make sure their pregnant wives get these vaccinations.
Preventing Malaria during Pregnancy
Malaria causes anemia, which can be harmful for the unborn baby.
 Provide malaria medicine (intermittent preventive treatment [IPT]) to pregnant women at each
scheduled antenatal care visit after the first trimester. The dose should not be taken at the same
time as IFA.
 Advise pregnant women to sleep under an insecticide-treated mosquito net (ITN) to protect
herself from malaria and to keep her unborn baby healthy.

o Husbands need to make sure their pregnant wives get IPT at the clinic and that they sleep
under an ITN to prevent malaria and to keep the unborn baby healthy.
o Test and immediately treat a pregnant woman (or family member) who has fever.
Iodized Salt during Pregnancy
A pregnant woman needs to consume iodized salt to make sure her new baby is born healthy and will be
able to learn at school when they are older.
 Recommend that all family food be cooked using iodized salt, so all family members remain
healthy.
 The iodized salt has to be added to the pot at the end of the cooking.
 The iodized salt should be stored in a covered container or jar and away from heat.
Nutrition for Breastfeeding Mothers

Diet Quantity and Quality
 Counsel breastfeeding women to eat more food than usual and consume many different types
of colorful foods to remind strong and get vitamins, including amaranth and red amaranth,
country bean, yard-long bean, potato greens, soybeans, peanuts, black beans, orange-flesh
sweet potato, pumpkin, African eggplant, moringa, okra, papaya, and spinach. They also have to
eat chicken, crayfish, eggs, fish, meat, peanuts, or snails.
 Advise breastfeeding women to eat two extra bowls of food each day to maintain her strength
and health.
Vitamin A Supplementation Postpartum

Taking vitamin A enriches breastmilk, which helps babies fight illness.
 Give vitamin A supplement (200,000 IU) to a post-partum woman, as soon as possible after the
delivery, no later than eight weeks afterwards (check country protocol).

Document #12: Essential Nutrition Actions in the Context
of HIV Pregnant and Lactating Women and Their
Children Who Are HIV Negative or of Unknown Status
ADEQUATE
WOMEN’S
COMPLEMENTARY
NUTRITIONAL CONTROLLING NUTRITION
OPTIMAL FEEDING WITH CONTROLLING
CARE OF SICK OR CONTROLLING IODINE DURING
BREASTFEEDING CONTINUED VITAMIN A
MALNOURISHED ANEMIA DEFICIENCY PREGNANCY
(< SIX MONTHS) BREASTFEEDING DEFICIENCY
CHILD DISORDERS AND
(6 UP TO24
LACTATION
MONTHS)
• Early initiation • Complementary • Increased • Diversified diet • Delayed cord • Iodized salt, • One
of feeding starting at frequency of with vitamin A- clamping. when additional
breastfeeding six months with breastfeeding rich foods (e.g. available. meal daily
—within one mashed foods. during and ripe orange and • Diversified diet during
hour of birth. after illness. yellow with iron-rich pregnancy.
• Continued vegetables and foods (red meat
• Keep newborn breastfeeding to • Increased fruits, liver) and and dark green, • Two
warm and dry 24 months or frequency of fortified foods. leafy vegetables) additional
(skin to skin). beyond. complementar and fortified meals daily
y feeding • Vitamin A foods. during
• Exclusive • Increased feeding during and supplementatio lactation.
breastfeeding frequency with after illness for n for woman • Supplementatio
during first six age. children aged 6 after delivery n with IFA daily • Breast
months. up to 24 (as per national for six months health
• Increased amount for pregnant during
of food with age. months. protocol).
women and lactation.
• Increased density • Zinc • Vitamin A continuing after
supplementatio supplementatio delivery, if • Less
or thickness of workload
foods with age. n for children n twice a year needed.
with diarrhea. for children and more
• Enriched diet with between 6 and • Deworming for rest during
a variety of foods • Vitamin A 59 months of pregnant pregnancy.
and fortified supplementatio age. women and for
foods. n as children
recommended. between 12 and
• Active feeding. 59 months of
(Encourage and • Special care for age, twice a
play with the baby malnourished year.
while eating. child,
depending on • In malaria-
• Hand washing severity. endemic areas:
before feeding. sleep under ITN,
• Kangaroo care IPT for pregnant
• Food hygiene. for low birth women.
weight
newborns. • In areas where
malaria is not
endemic but
anemia
prevalence is >
50 percent: IFA
supplementatio
n daily for
children aged six
months and
above.
KEY CONCEPTS OF ESSENTIAL NUTRITION ACTIONS
Delay of first pregnancy. Child spacing. Immunization. Clean water, hygiene, and sanitation.
Developed by Agnes Guyon, Victoria Quinn, and Robert Mwadime. Revised 2013.

Additional Essential Nutrition Actions for HIV-Positive Adults,
Pregnant and Lactating Women, and Their Children
ADEQUATE
COMPLEMENTARY CONTROLLING CONTROLLING WOMEN’S
NUTRITIONAL
OPTIMAL FEEDING WITH DEFICIENCIES OF ANEMIA NUTRITION
CARE OF SICK OR
BREASTFEEDING CONTINUED VITAMIN A AND AND IODINE DURING ADULT’S HEALTH
MALNOURISHED
(< SIX MONTHS) BREASTFEEDING OTHER DEFICIENCY PREGNANCY AND
CHILD
(SIX UP TO 24 MICRONUTRIENTS DISORDERS LACTATION
MONTHS)
• Support infant • Early cessation • Counsel on • Supplementation • Follow ENA • Energy intake • Diversified
feeding of breastfeeding testing child at one for HIV- increased by 10 diet.
option: when breastmilk (depending on recommended negative percent if non-
exclusive can be replaced test daily allowance individuals. symptomatic; • Energy intake
breastfeeding by other milks availability). with multiple add one extra increased by
or exclusive (animal or micronutrients if feeding daily. 10 percent in
formula commercial); • Immediate diet is not adults if not
feeding. otherwise treatment of adequately • Energy intake symptomatic;
breastfeed for sickness. diverse. increased by 20 add one extra
• Encourage at least 1 year. to 30 percent if meal daily.
exclusive • Diet symptomatic or
breastfeeding • Energy intake management losing weight; • Energy intake
for 6 months increased by 10 of nausea, add two extra increased by
for infants percent if vomiting, and feedings daily. 20 to 30
confirmed to suspected HIV- oral sores, etc. percent if
be HIV- positive and not • BMI for symptomatic
• Energy intake nutritional or losing
positive. losing weight increased by
(one extra monitoring or weight; add
• Energy intake 50 to 100 MUAC for two extra
feeding per percent if
increased by day). pregnant feedings daily.
10 percent if losing weight women.
suspected • Use fortified, (double the • Evaluation of
HIV-positive blended foods, daily feedings). • Breastfeeding interaction of
and not losing when available. stopped on nutrition and
• Supplementary affected breast ARVs.
weight (one or therapeutic
extra feeding • Assess health if encounter
and growth of feeding for breast • Monitor
per day). moderate or weight and
child. problems.
• severely BMI.
malnourished • Dietary
child, per management • Dietary
international of nutrition- management
guidelines. related of vomiting,
symptoms. nausea, and
other
• Importance of nutrition-
malaria related
prevention and symptoms.
deworming. Physical
exercise to
• Counsel and build muscle
refer for mass.
PMTCT and
ART.
Be sure to assess the household food security situation and to treat all illnesses immediately.
Developed by Agnes Guyon, Victoria Quinn, and Robert Mwadime. Revised 2013.

Document #13: The Benefits of Breastfeeding for Infants
and Young Children and the Risks of Formula Feeding
How Breastmilk Helps Infants and Young Children
Breastmilk:
 saves infants’ lives
 is a complete food for infants because it contains balanced proportions and a sufficient quantity
of all the nutrients babies need during their first six months of life
 contains antibodies that protect against diseases, especially against diarrhea and respiratory
infections
 Infants benefit from colostrum, the yellowish “first milk,” which protects them from diseases.
The colostrum acts as a laxative, cleaning the infant’s stomach
 promotes adequate growth and development, preventing stunting
 is always clean
 is always ready and at the right temperature
 is easy to digest; its nutrients are well absorbed
 protects against allergies
 has antibodies that protect the baby’s gut, preventing harmful substances from passing into the
blood
 contains the right amount of water to meet a baby’s needs (up to 88 percent of breastmilk is
water)
 helps jaw and teeth development; suckling develops facial muscles
Frequent skin-to-skin contact with the mother improves the baby’s psychomotor, emotional, and social
development
How Breastfeeding Helps the Mother

Breastfeeding:
 reduces risks of bleeding after delivery
 immediately after birth stimulates breastmilk production
 is economical
 stimulates the bond between mother and baby
 reduces the mother’s workload. She does not have to spend time gathering fuel, boiling water,
or preparing milk to feed her baby, and
 reduces risks of breast and ovarian cancer.
 The baby’s suckling stimulates uterine contractions, so putting the baby to the breast
immediately after birth facilitates expulsion of the placenta.

 Immediate and frequent suckling prevents engorgement.
 Exclusive breastfeeding is more than 98 percent effective as a contraceptive method during the
first six months, provided that periods do not return.
How Breastfeeding Benefits the Family

 No money needs to be spent to buy formula, firewood, or other fuel to boil water or milk. The
money saved can be used to meet the family’s other needs.
 No medical expenses are incurred due to sickness that could be caused by formula.
Breastfeeding mothers and their breastfed children are healthier.
 With fewer illnesses, the family encounters fewer emotional stresses.
 Breastfeeding’s contraceptive effect spaces births.
 Breastfeeding saves time and reduces the family workload—breastmilk is always available and
ready.
How Breastfeeding Is Good for the Community

 With no need to import formula and the utensils necessary for its preparation, hard currency is
saved and can be used elsewhere.
 Healthy babies make a healthy nation.
 Savings are made in the health sector. Decreased child illnesses reduce the national cost of
treating them.
 Breastfeeding improves child survival and reduces child morbidity and mortality.
 Breastfeeding benefits the environment—no trees need to be used for firewood to boil water or
milk. Breastmilk is a natural renewable resource.
Risks of Formula Feeding

 Risk of mortality increases for formula-fed children.
 Risk of gastrointestinal infections and acute respiratory disease increases for formula-fed
children.
Formula-fed children:
 are at increased risk for infection. Infant formula can become contaminated in the factory with
heat-resistant, pathogenic, and highly contagious bacteria such as Enterobacter sakazakii.
 are more likely to suffer from asthma
 are at increased risk for allergies
 cognitive development and educational attainment are reduced

 are at increased risk for childhood cancers such as leukemia and for chronic diseases
 are at increased risk for obesity, Type 1 and Type 2 diabetes, and cardiovascular disease

Document #14: Breastfeeding Practices from Birth up to
Six Months
Early Initiation of Breastfeeding
 At delivery, put the newborn on the breast immediately after birth (even before expelling the
placenta) to help the mother expel the placenta.
o The first yellowish milk (colostrum) is rich in vitamins and is important for babies’ health: It
makes the babies strong. It cleans their stomachs, and helps them get rid of their first dark
stool (meconium). Also, it acts as an infant’s first vaccination, which helps keep the baby
from getting sick and protects from infection.
o Breastfeeding right away helps milk come in and helps mothers expel the placenta, reduce
postpartum bleeding, and avoid swollen breasts.
 Help the mother to support her breast with her whole hand; explain that putting fingers around
the nipple in a scissors-like position risks stopping the milk flow.
 Feeding the baby sugar water, honey, water, palm oil, butter, powdered milk, cow’s milk, or
goat’s milk instead of breastfeeding may interfere with establishing good breastfeeding
practices. It also could lead to diarrhea, pneumonia, or other illness in the baby. Only feed the
baby breastmilk.
 If a mother thinks the baby is thirsty, advise mother to drink water; breastmilk will quench her
baby’s thirst.
Exclusive Breastfeeding from Birth up to Six Months of Age

 Advise a new mother to feed her baby only breastmilk. The baby should not be given water or
other liquids or food, so she can grow healthy and strong during first six months of life.
o Explain that frequent breastfeeding helps milk flow and keeps the baby growing big and
strong. When a mother gives her baby water or other liquids, the child will suck less on the
breast. This may hinder the baby’s growth
o Breastmilk contains all the food and water the baby needs for the first six months. It is
clean and safe. It also protects babies from diarrhea, colds, and coughs.
 Counsel that it is important to empty one breast before switching to the other to enable the
baby to get the water and the nutrients of breastmilk. The breastmilk at the beginning of the
feeding is full of water and helps quench the baby’s thirst. Later during the feeding the milk is
richer, thicker, and full of nourishment. It will satisfy the baby’s hunger.
 During first six months breastmilk sufficiently satisfies the baby’s thirst—even in hot weather.
An important part of the breastmilk is water, so the mother needs to always drink enough
water.
o Giving babies sugar water, traditional medicine, infant formula, milk powder, or other
liquids or other foods can make them sick.

 Recommend not to use a bottle to feed the baby. Bottles are hard to keep clean and may
become contaminated and cause illness.
How Often to Breastfeed

 The more a baby suckles, the more milk is made. Mothers need to breastfeed as often as the
baby wants—at least 10 to 12 times over a 24-hour period. Breastfeeding often helps milk
production and gives the baby enough food to grow healthy and strong. One breast needs to be
emptied before the mother offers the other breast.
 Assure the mother that if she allows her baby to suckle frequently, she should not worry about
having enough breastmilk.
o At around three months, the baby is likely to have a rapid growth spurt; therefore, the
baby may cry more or want to feed more often. This is normal and temporary. Be sure that
the baby suckles frequently and longer
 While a woman is breastfeeding, she is also practicing family planning, i.e., the lactation
amenorrhea method (LAM). This is effective as long as she is not having her menses and the
baby is less than six months old and only breastfeeds.
How to Express Breastmilk

 Explain and demonstrate with the mother:
 Put her thumb on the breast above the areola, the dark area around the nipple, and the first
finger below the nipple and areola. She can support her breast with her other fingers.
 Gently press toward her chest wall with her thumb and finger.
 To continue to compress the breast while moving her hand away from the chest wall. This
should not hurt. If it does, she is not doing it right.
 Press the same way on each side of the dark area around the nipple to empty all parts of the
breast.
o She should not squeeze the nipple or rub her fingers over the skin.
 She can express one breast for between three and five minutes until the flow slows down; she
then switches to the other breast. Finally, do both breasts again. Change hands when one hand
gets tired. It usually takes 20 to 30 minutes to express all the milk.
 The breastmilk is stored in a clean, covered container in a cool place (up to 8 hours) until she is
ready to warm it and feed it to the baby.
 Advise to feed the baby using an open cup; never feed the baby with a bottle. (Bottles are hard
to clean and can give baby diarrhea.)

Document #15: How Health Workers Can Support
Maternal and Child Health
Help Mothers to Achieve Breastfeeding Practices
 Discuss the benefits of breastfeeding and birth spacing with mother, husband, and family.
 Help the mother breastfeed immediately after delivery (whether done by a midwife, at the
hospital, or at home) to give the baby colostrum.
 Explain the benefits of giving colostrum.
o Colostrum will protect the infant from disease by providing first vaccine.
o Suckling will aid the mother in expelling the placenta more rapidly, helping her reduce
blood loss.
o Colostrum will help the baby expel meconium, the infant’s first stool.
o Giving colostrum will stimulate production of breastmilk.
o Giving colostrum requires skin-to-skin contact, which will keep the baby warm.
 Promote EBF from birth to six months. Inform the mother about the following:
o Breastmilk contains all the water and nutrients infants’ need to grow and satisfy their
hunger and thirst.
o Give no other foods or liquids during the babies’ first six months because their immature
systems cannot digest them.
o Exclusively-breastfed infants likely have fewer diarrheal, respiratory, and ear infections.
o Exclusive breastfeeding helps space births by delaying the return of fertility (LAM).
 Mention the importance of introducing complementary foods at six months while breastfeeding
at least until the baby’s second birthday. Inform the mother about the following:
o After six months, breastmilk alone cannot meet all of the baby’s nutritional needs.
o Complementary foods can include available, affordable, local foods.
o Giving breastmilk to children for two years will continue to protect them from illness.
 Congratulate and encourage the mother (or caregiver); answer her questions.
 Urge her to seek out community support group meetings for breastfeeding support.
 For family planning help, provide appropriate methods and counseling or refer her to Family
Planning consultation.
 Remind her to immunize the child (see below).

Ask Pregnant Women Nutrition-Related Questions
 How will you feed your baby? (If she does not plan to breastfeed, ask why not.)
 Have you heard of exclusive breastfeeding and why it is essential? (Reinforce key messages on
EBF from birth to six months of age).
 Did you encounter difficulties breastfeeding other children? If so, what were they?
 Have you been to a health facility for prenatal (antenatal) care?
 Did you get iron–folic acid (IFA) supplements at the health facility? Do you take them daily?
 Did you get your tetanus vaccination? Did you get your deworming medicine?
 If malaria is endemic in the area: Do you sleep under an insecticide-treated mosquito net? Did
you get the intermittent preventive treatment?
 If HIV testing is available nearby: Have you been tested for HIV?
When is the best time for clamping the baby umbilical cord?
 The clamping of the baby umbilical cord needs to be done when the pulsations have stopped
(two to three minutes).
 It helps to prevent mother’s heavy bleeding.
 It increases blood flow to the newborn and builds infant’s body iron storage, preventing infant
anemia.
 There is no risk for HIV transmission.
Encourage Iron–Folic Acid Supplementation after Delivery

 Mothers need IFA supplementation for three months after delivery to prevent iron-deficiency
anemia. All together the pregnant woman needs IFA supplementation for 6 months, no matter
when she starts (including post-partum).
 Because mothers lose blood during delivery, they need to increase their iron stores for their
own health and that of their babies. (Iron passes into breastmilk.)
 Breastfeeding mothers need to eat food rich in iron, including dark green leafy vegetables,
meat, liver, and legumes.

Give Mothers of Three-Month-Olds the Information They Need
 Breastfeeding frequency needs to be increased because the baby is growing fast.
 The mother needs to empty one breast before switching to the other. (Milk at the beginning is
full of water to quench the baby’s thirst; milk at the end is richer, thicker, and full of nutrients
and fat content.)
 No food or drink should be given to the infant—the child’s system is not mature enough.
 A mother will have enough milk if she gives the baby no other food or drink. The more the baby
sucks, the more breastmilk the mother will produce.
Explain the Care of a Sick Child under Six Months of Age

 Counsel the mother to breastfeed more often when her baby is sick to help the child gain
strength and weight. She should continue breastfeeding more often for two weeks after baby
recovers. She should give the baby no other liquids.
Provide Immunizations for Babies before Their Six-Month Birthday

BCG + Polio 0 Polio 2 + Penta 2 + Pneumococcus + Rota
Vaccines
Polio 1 + Penta 1 + Pneumoccocus + Rota
Vaccines Polio 3 + Penta 3 + Pneumococcus + Rota
Vaccines
Remind the mother to come back at six months for vitamin A supplementation (IU 100,000)
and at nine months for measles and yellow fever (if applicable) vaccines.

Document #16: Proper Breastfeeding Positioning and
Attachment
Positioning
 The mother is comfortable.
 The mother holds the infant so the child’s face is at her breast level, with nose pointing straight
toward mother’s nipple. The baby should have a direct view of the mother’s face, not her chest
or abdomen. The infant should be close to the mother, and the child’s stomach should be
against the mother’s stomach. The infant’s head, back, and buttocks should be in a straight line.
 The mother brings the infant’s body to her breast and supports the child’s whole body, not just
the head and shoulders.
 The mother holds her breast with her fingers in a C shape, with the thumb above the dark part
of the breast (the areola) and the other fingers below. Fingers are not in a scissor hold around
the nipple (i.e., with two fingers on either side of it); this method puts pressure on the milk
ducts and can stop the milk flow and pull the nipple out of the baby’s mouth.
 To stimulate the infant to open the mouth wide, the mother teases the infant’s lower lip with
her nipple.
Good Attachment
 Good attachment enables the infant to suckle effectively, to remove the milk efficiently, and to
stimulate an adequate supply.
 The baby’s mouth covers a large part of the areola; more of the areola shows above the nipple
than below. The infant’s chin touches the breast.
 Baby’s lower lip is turned outwards.
 The areola and the nipple stretch and become longer in the infant’s mouth. (If attachment is not
good, milk will not be completely removed, which can lead to sore nipples, inflammation of the
breast, and mastitis.)

Signs of Efficient Suckling
 Slow and regular sucking is good, with one swallow following
each two sucks.
 The infant’s sucks are slow and deep with occasional pauses.
 Suckling is comfortable and pain free for the mother.
 The mother hears her baby swallowing.
 The breast is softer after the baby has finished feeding.
Common Breastfeeding Positions

Regardless of position, the mother must be comfortable. In every position, she should draw the infant
toward her rather than leaning toward the child.
Sitting
 This is the position most breastfeeding mothers use. The mother’s back may be resting on the
chair’s back and her feet crossed or raised on a stool.
 Make sure infant’s and mother’s stomachs are facing each other.
Side-Lying
 More comfortable for the mother after delivery, this position enables her to rest while
breastfeeding.
 Both mother and infant are lying on their sides, facing one another.
American Football
 This position is best used:
o after a Caesarean section
o when the nipples are painful
o to breastfeed twins
 The mother is comfortably seated with the infant under her arm. The infant’s body passes by
the mother’s side and the child’s head is at breast level.
 The mother supports the infant’s head and body with her hand and forearm.

BREASTFEEDING POSITIONS

Document #17: Feeding Recommendations for HIV
positive mother
 Mothers exclusively breastfeed their infants for the first 6 months, introduce appropriate
complementary foods thereafter, and continue breastfeeding for the first 12 months of life.
 The recommendation is for 12 months breastfeeding (instead of 24 months for the general
population) because in the first 12 months of a baby’s life breastfeeding provides major
protection against death from diarrhea, pneumonia and malnutrition, in the same way as it does
for babies of HIV negative mothers. After this time the risk of the baby dying from these
conditions is lower, but the risk of being exposed to HIV still remains.
 Continued breastfeeding beyond 12 months may be recommended if a woman is not able to
provide a safe replacement for breast milk or is unsure of her HIV status. In this case feeding
recommendations are the same as for the general population. Mothers in these situations may
need reassurance that breastfeeding is the safest option for their babies
 When mothers stop breastfeeding at or before 12 months, it is recommended to be done
gradually over the course of one month. (Stopping breastfeeding abruptly is NOT advisable.)
 If infants and young children are known to be HIV positive or are of unknown status, mothers
are strongly encouraged to exclusively breastfeed for the first six months of life and continue
breastfeeding, as per the recommendations for the general population; that is, up to two years
or beyond. It is recommended that infants and young children known to be HIV positive should
all be started on lifelong antiretroviral treatment as soon as possible after testing positive for
HIV.
 The risk of transmission is greater if a baby is given other foods or drinks at the same time as
breastfeeding during the first months of life. This is known as mixed feeding. Other food or
drinks may cause diarrhoea and damage the gut, which might make it easier for the virus to
enter the baby’s blood.
Note: Where wet-nursing is acceptable, an HIV positive mother could consider this as long as a
set of criteria are met.
FEEDING RECOMMENDATIONS FOR HIV-POSITIVE MOTHERS

Following the recommendation of the National Health Authority, an HIV-positive mother either
breastfeeds exclusively or exclusively uses replacement feeding.
HIV transmission is increased by mixed feeding—that is, breastfeeding plus replacement feeding.
She introduces complementary feeding at six months.
After six months, if she has been breastfeeding, she continues to breastfeed up to 12 months.

At Each Visit
 Ask the mother how she is feeding her baby.
 Check on the baby’s growth and health.
 Ask how the mother is coping with her health and whether she has any difficulties.
Follow Breastfeeding Practices

 Ask the mother what other foods and liquids, including milk or water, she is giving her baby.
 Ask how often she feeds the baby during the day and during the night.
 Ask whether she uses both breasts at each feeding.
 Ask how often the baby urinates each day (should be at least six times).
 Observe the mother breastfeeding, check the mother’s breasts and suggest any needed
improvements in technique.

Document #18: How to Transition to Replacement
Feeding after 12 months
The infant’s well-being is the most important factor in deciding whether to keep breastfeeding or to
transition to replacement feeding. Replacement feeding means that the infant is no longer exposed to
HIV through the mother’s breastmilk. If the mother cannot replace breastmilk with another type of milk
(animal or formula), she should continue breastfeeding to make sure her child gets enough food to
grow, develop, and be healthy.
Transitioning
 If suitable breastmilk substitutes are not available or not provided appropriately, the infant risks
becoming malnourished.
 If breastmilk substitutes are not prepared safely, the infant may be at increased risk of diarrhea.
 If breastfeeding cessation is too rapid and infants are not prepared for the transition, they can
become dehydrated, anxious, disoriented, and unhappy. They may cry excessively or refuse
food, making the transition more difficult for themselves and their families.
 Infants need to learn to cup feed before breastfeeding cessation. Cup feeding requires the
caregiver’s patience and time.
o Teach the baby to drink from a cup while you are still breastfeeding.
o Start by replacing one breastfeeding with a cup of formula; increase the frequency of cup
feeding every few days.
o Stop breastfeeding completely once the baby can drink from a cup.
o Gradually replace the breastmilk with formula or animal milk.
 To avoid breast engorgement, express and discard milk when your breasts feel too full.
 Early breastfeeding cessation is not recommended for HIV-infected infants.
 Do not dilute animal milks or add sugar. However, special preparation is still required for fresh
and powdered milk.
o Fresh animal’s milk must be boiled to kill any bacteria.
o To powdered or evaporated milk, add clean, boiled water, following the directions on the
tin.
Breastmilk Substitute Requirements after 12 Months
AGE AVERAGE AMOUNT OF MILK PER DAY
12 up to 24 months 500 ml

Document #19: Replacement Feeding with Commercial
Infant Formula
 If replacement feeding from birth is necessary, commercial infant formula milk should be used
for the first six months because it provides appropriate nutrients for the baby’s growth and
development. After that boiled cow’s milk or commercial infant formula can be given until 12
months, and thereafter un-boiled cow’s milk can be given.
 The negative aspects, concerning the higher risk of infection or malnutrition, could be reduced
by ensuring that the recommended conditions to safely formula feed are fully met.
 For the mother who is switching from breastfeeding to replacement feeding, it is important that
she stops breastfeeding gradually while introducing her baby to replacement feeding.
Commercial infant formula must be prepared carefully according to the instructions on the label, and
given in quantities appropriate for the child’s weight and age. Information about the volume of feeds is
also included on the label.
Formula is expensive, and a continuous supply is needed to prevent malnutrition.
Commercial Infant Formula Requirements during the First Six Months
MONTH 500G TINS NEEDED PER MONTH 450G TINS NEEDED PER MONTH
First month 4 tins 5 tins
Second month 6 tins 6 tins
Third month 7 tins 8 tins
Fourth month 7 tins 8 tins
Fifth month 8 tins 8 tins
Sixth month 8 tins 9 tins
How to Prepare Commercial Infant Formula for Feedings

 Using soap and clean water, wash hands as well as all utensils, containers, and cups.
 Read or have someone read directions for mixing the formula given on the formula tin.
 Boil water for five minutes then let it cool.
 Measure the milk powder needed for one feed; mix it with the correct amount of cooled boiled
water; use a cup to offer the infant an appropriate amount of formula.

Daily Formula Amounts: Six Months
# DAILY FEEDS X
AGE IN MONTHS DAILY TOTAL
FEED QUANTITY
0 to <1 8 feeds x 60 ml/feed 480 ml
At Each Visit
 Ask the mother how she is feeding her baby.
 Check on the baby’s growth and health.
 Ask how the mother is coping with her health and whether she has any difficulties.
Follow how Mother Is Using Replacement Feeding

 Ask what kind of milk she is feeding her baby.
 Ask to see the tin to learn whether she is using a commercial formula or canned milk.
 Ask how many tins of formula or milk she buys each month.
 Ask how much the milk or formula costs per month and whether she has money for the next
month’s supply. If she expresses concerns, find an appropriate referral of support services.
 Ask her to show you how she prepares a serving of formula or milk.
 Observe the quantity used and the cleanliness.
 Ask how often she feeds the baby during the day and during the night.
 Ask her what container she uses to feed the baby with the replacement feeding.
 Ask whether she is breastfeeding, and how often.
 If the mother is preparing infant formula incorrectly, demonstrate the proper method.

Document #20: Family Planning, Nutrition, and
Breastfeeding
Timing Pregnancy to Improve Nutritional Status of Women and Child
Survival
 Delaying first pregnancies gives adolescents and young women the opportunity to reach their
full adult growth before becoming pregnant, protecting their health and that of their children.
 Spacing children at least three years apart allows each baby to grow well and the mother to
recover fully before she undergoes another pregnancy.
 Spacing the next pregnancy at least 36 months after the last birth reduces the risk of stunting
and child mortality.
 Spacing also permits the mother to give her full attention and care to a young child until the
child is three years old.
 Having fewer children means better access to more food for the entire family.
Other Family Planning Methods

Prior to Six Months Post Delivery
 LAM
After Six Weeks Post Delivery

 Minipills
 Progesterone-only injectables
 Implants
After Six Months Post Delivery

 Combined oral contraceptives
At Any Point
 Barrier methods
 Intrauterine devices
 Sterilization of either partner
 Natural family planning methods

Document #21: Messages on the Lactation Amenorrhea
Method
Introducing the Lactation Amenorrhea Method
 The lactation amenorrhea method uses breastfeeding to space births.
 Birth spacing by three years or more is vital for maternal and child health and survival. It:
o helps save lives
o gives the mother’s body time to replenish its nutritional stores
 The lactation amenorrhea method is more than 98 percent effective at preventing pregnancy, if
three criteria are met:
o Amenorrhea—that is, a woman has no menstrual periods.
o Exclusive breastfeeding. (The mother must breastfeed at least every four hours, with an
interval of no longer than six hours at night.)
o The infant is under six months of age.
 When a woman no longer meets one of the three criteria, she needs to use another family
planning method to prevent pregnancy.
Benefits
 The lactation amenorrhea method is universally acceptable.
 It is more than 98 percent effective.
 It is started immediately after delivery.
 It promotes maternal and child health.
 It does not require products or devices.
 It is accepted in most cultures.
 It acts as a preliminary step to using other contraceptive methods.
Disadvantages
 The method can only be used during a limited period of time (six months after birth).
 It does not protect against HIV or other STIs.
 It can only be used by breastfeeding women, and exclusive breastfeeding may be difficult to
maintain.

Who Can Use the Lactation Amenorrhea Method
 All breastfeeding women up to six months postpartum can use LAM.
 Working women can use LAM, however, LAM’s effectiveness is reduced if between-feeding
intervals extend more than four hours during the day or more than six hours at night. Expressing
milk (up to 10 percent of nursing time) counts as feeding. Mothers who are separated from their
babies during the day may try more frequent feeding at night.
Messages on the Lactation Amenorrhea Method and Other Family

Planning Options
For Mothers and Fathers
 When the baby is older than six months or if the mother does not meet one of the LAM criteria,
wives and their husbands should visit the health facility or a community-based reproductive
health agent to obtain another family planning method.
 Do not wait until the baby is six months old to decide on a family planning method

Document #22: The Diarrhea Transmission Cycle:
The Fecal–Oral Route
Pathogens and parasites found in human excreta, if ingested, can result in illness, including diarrhea.
Diarrhea leads to both malnutrition and death, particularly in small children.
How Feces Enter the Human Mouth:15
The Faecal-Oral Transmission Diagram (F-Diagram)
Block the
Transmission
 Use a sanitary latrine and
have your children do so
 Properly dispose of
children’s feces
 Do not use dirty water
 Wash your hands
 Cover Food
 Keep animals away from
compound
 Fluid/water. When you drink water that has been contaminated by feces.
 Fingers. By direct transmission: when hands are not washed after defecation or after contact
with feces on the ground (e.g., when small children are crawling) and then are put into the
mouth. Or by indirect transmission, as when food is prepared or eaten with contaminated,
unwashed hands or using dishes, cups, or utensils handled with contaminated, unwashed hands.
 Flies. Because flies sit on feces and then sit on food.
 Food. When people eat food that flies have been sitting on.
 Field. When soil contains feces due to direct defecation or other means; unwashed hands that
have worked the soil and improperly cleaned and cooked crops from the fields can enable feces
to be ingested.
15
Preventing Moderate Acute Malnutrition (MAM) through nutrition-sensitive interventions. CMAM Forum Technical Brief, Dec 2014.

Document #23: Building a Hand Washing Device
A tippy tap helps you wash your hands when you should—even with scarce
water. And making one is easy:
1. Decide on the design of your hand washing station: Will it sit, hand, or
hang and tip?
2. Find a vessel and spout—a hollow tube such as a pen casing or pawpaw
stem. Wash vessel and spout.
3. Poke a hole in the vessel for the tube. Use a sharp knife, nail, or screw
driver, heating it first. Make the hole small (a bit smaller than the tube)
and as low on the container as you can (about two finger widths from the
bottom). Slowly and carefully push the tube into the hole. Be careful not to
push the hole so big that it leaks.
4. Test the water flow. When using a Highland bottle: Water flows when the
cap is unscrewed and stops when the cap is tightly shut. With a Jerry can
or gourd: Water flows when the cap on the pen or plug in the tub is
removed. If you don’t have the original cap, just find an old stick to plug up
the flow.
5. Set up the washing station. Put one tippy tap by the latrine and another
near where you cook and eat; tie a string around its neck and hang. Or set on a stable shelf. Hang or
place an old shallow can or plastic bowl for soap or ash for washing.
How To Wash
1. Wet hands with running water.
2. Rub with soap or ash for the time it takes
to sing “Happy Birthday” (about 30 seconds).
3. Clean between fingers, under fingernails, up to
wrists. Scrubbing and soap or ash dislodges and
remove germs.
4. Rinse hands with water poured from jug or tippy
tap. Then air-dry—don’t pick up germs from a
dirty towel!
IMPORTANT! You can wash your hands with “dirty” water and still get them clean—
as long as you use soap and pour water over your hands—no dipping into a bowl!
The soap or ash lifts the dirt; water flushes off germs

Document #24: Discussion Using an Illustration
Why Use Picture Stories?
 They permit impersonal discussions of issues that may be personal.
 They open the door for indirect questions—and more accurate answers—about behaviors. They
are particularly useful in sensitive situations where, if asked a direct question, the mother or
caregiver may answer what she thinks that person wants to hear.
 They make it easier to probe for more information: You can ask what might happen next.
Representative Questions to Ask to Open a Dialogue

ORPA
Ask for Observations
 What is happening in the picture? How old do you think the baby is?
 What are the characters in the picture doing?
 How does the character feel about what he was doing? Why did she do that?
Ask for Reflections

 Who do you agree with? Why?
 Who do you disagree with? Why?
 Are there other behaviors that the character(s) should be sure to do or not do?
 What is the advantage of adopting the practice shown in the picture?
Personalize
 What would people in this community do in the same situation? Why?
 What would you do in the same situation? Why?
 What difficulties might you experience? Would you be able to overcome them? How?
Repeat Key Messages, Then Explore Actions

 If you were the mother (or another character), would you be willing to try the new practice?
 Can you tell me what difficulties that character might have? What would you recommend to
remove these difficulties? How would you overcome any barriers to trying the new practice?
 What doable actions can you try? (Together with the mother or caregiver, explore the person’s
ideas.)

Document #25: Listening and Learning Skills, and
Building Confidence and Giving Support Skills
Use helpful nonverbal communication
 Keep your head level with the mother’s.
o Pay attention.
o Nod your head.
o Take your time.
o Use appropriate touch.
 Ask open-ended questions—that is, ask questions that start with what, why, how, or where
rather than questions that require merely a yes or no answer.
 Use responses and gestures that demonstrate your interest.
 Reflect back on what the mother said—that is, repeat her ideas back to her using your own
words.
 Empathize: Demonstrate that you understand how she feels.
 Do not use words that sound judgmental (e.g., words that suggest you believe what she is doing
is wrong or bad).
Building Confidence and Giving Support skills

 Accept what a mother/father/caregiver thinks and feels (to establish confidence, let the
mother/ father/caregiver talk through her/his concerns before correcting information)
 Recognize and praise what a mother/father/caregiver and baby are doing correctly
 Give practical help
 Give brief, relevant information
 Use simple language
 Use appropriate counselling card or cards
 Make one or two suggestions, not commands

Document #26A: GALIDRAA Negotiation Checklist
Greet the mother and be friendly. Establish her confidence.
Ask the mother about feeding practices, her children’s ages, and their feeding status.
Listen to the mother.
Identify feeding challenges and their causes. With the mother, choose one challenge to overcome.
Discuss different feasible options with the mother.
Recommend and negotiate doable actions. Present options and negotiate with the mother to help her
choose one practice to try.
Agree on which practice the mother will try; ask her to repeat the agreed-upon practice back to you.
Appointment made for follow-up visit.

Document #26B: Observation Checklist of GALIDRAA
Counselling Steps
Name of Counsellor: ___________________________________________________
Name of Observer: ____________________________________________________
Date of visit: _________________________________________________________
(√ for yes and × for No)
Did the Counsellor
Use Listening and Learning skills:
 Keep head level with mother/parent/caregiver
 Pay attention (eye contact)
 Remove barriers (tables and notes)
 Take time
 Use appropriate touch
 Ask open questions
 Use responses and gestures that show interest
 Reflect back what the mother said
 Avoid using judging words
 Allow mother/parent/caregiver time to talk
Use Building Confidence and Giving Support skills:

 Accept what a mother thinks and feels
 Listen to the mother/caregiver’s concerns
 Recognize and praise what a mother and baby are doing correctly
 Give practical help
 Give brief, relevant information
 Use simple language
 Make one or two suggestions, not commands
GALIDRAA Counselling Steps

Did the counsellor
 GREET the mother/caregiver
 ASK and LISTEN to mother/caregiver
Ask mother or caregiver:
 Child’s age
 Checking child’s growth curve (if GMP exists in area)
 Checking recent child illness

Breastfeeding (with mother):
 Not breastfeeding
 Assess the current breastfeeding practice
 Check for breastfeeding difficulties
 Observe a breastfeed
Fluids:
 Assess ‘other fluid’ intake
Foods:
 Assess ‘other food’ intake
Active Feeding:
 Ask about whether the child receives assistance when eating
Hygiene:
 Check on hygiene related to feeding
Did the counsellor?

 IDENTIFY any feeding difficulty
 Prioritize difficulties (if there is more than one)
Record prioritized difficulty: _____________________________________
DISCUSS, RECOMMEND
Did the counsellor?
 Praise the mother/caregiver for doing recommended practices
 Address breastfeeding difficulties e.g. poor attachment or poor breastfeeding pattern with prac-
tical help.
 Discuss age-appropriate feeding recommendations and possible discussion points
 Present one or two options that are appropriate to the child’s age and feeding behaviours
 Help the mother/caregiver SELECT AGREED UPON BEHAVIOUR that she or he can try to address
the feeding challenges
 Discuss appropriate practices from Reference Materials relevant to the mother or child’s situa-
tion
 Ask the mother/caregiver to repeat the agreed-upon new behaviour
Record agreed-upon behaviour: __________________________________________
 Ask the mother/caregiver if she or he has questions/concerns
 Refer as necessary
 Suggest where the mother/caregiver can find additional support
 Agree upon a date/time for a FOLLOW-UP APPOINTMENT
 Thank the mother/caregiver for her or his time

Document #26C: Initial Visit Negotiation Record
COMMENT
Name
Age
Feeding Difficulty(ies) Identified
Options Suggested
What Mother Agreed To Try

Document #27: Negotiation Checklist for Follow-Up
Visits
The full process of negotiation requires at least two visits: the initial visit and a follow-up visit a week or
two after the first one. If possible, schedule a third visit to maintain the practice or to negotiate another
practice.
Second Visit: Questions to Ask

 For visits after the initial one, cover these topics:
 Ask whether the mother tried the agreed-upon practice or continued it. (If she did not try the
practice, ask why not.)
 Congratulate the mother for trying or continuing the new practice.
 Ask what happened when she tried or continued the new practice. What did she think of it?
 Ask whether she made any changes to the new practice, and if so, why and what?
 Ask what problems or difficulties she had and how she solved or overcame them.
 Listen to the mother’s questions, concerns, or doubts.
 Ask whether she likes the practice and whether she thinks she will continue it.
 Praise the mother; motivate her to continue the practice.
 Remind the mother to take the child to be weighed (i.e., to attend the well-baby clinic).
 Tell the mother where she can get support from community-based health workers, health
centers, and mother groups.
 If necessary, encourage her to try a new practice and agree on the one she will try; have her
repeat the agreement in her own words.
 Agree on a date for the next visit.
Third Visit: Questions to Ask

 Before making the visit, check on the age of the child. Based on that information, decide
whether the mother should continue the current practice or try a new one.
Maintain the New Practice

 Ask the mother whether she has continued the new practice.
 Congratulate her if she has.
 If she has not, ask why not.
 Did she make any changes to the new practice, why, and what?
 Find out what difficulties she had and how she solved them.

 Listen to the mother’s questions, concerns, or doubts.
 Discuss the recommendations made during the second visit. For example, if the new practice
was exclusive breast feeding, remind the mother that when her baby reaches the age of six
months, she must give the child other foods besides breastmilk.
Negotiate a New Practice

 Encourage the mother to try another new practice.
 Ask her which recommendation she thinks she can carry out.
 Find out whether she thinks she can practice it every day.
 If she thinks she can implement this new practice twice a week and the previous for the rest of
the week, encourage her to give it a try.

Document #28: Practice Case Studies: Adolescents and
Women’s Nutrition
Case Study 1
The Situation: Kebbet is four months pregnant but has not yet visited the health clinic.
The Visit: The health worker asks Kebbet about her pregnancy and listens carefully. The fact that Kebbet
has not attended the antenatal clinic is a problem. (A participant should explain that visiting the prenatal
clinic is important to ensure the pregnancy is going well and to receive tetanus–toxoid vaccines and
iron–folic acid [IFA] supplementation.) The health worker also reminds Kebbet that is important for her
to eat well—one additional meal each day, including as much meat as possible, as well as colorful fruits
and vegetables. Kebbet should also use iodized salt to season not only her own food but also the
family’s food.
Case Study 2
The Situation: Hawa is a recently married 18-year-old woman.
The Visit: The health worker has to find out about Hawa’s eating habits and overall nutrition. The health
worker also has to listen carefully to Hawa to identify problems and their causes. Specifically, Hawa
needs to understand her body is still developing and she has to eat well to allow her body to develop
more. At each meal, she needs to eat animal-source foods, as well as brightly colored fruits and
vegetables. The health worker should urge her to delay her first pregnancy while her body continues to
develop. Finally, the health worker should suggest that Hawa go the health facility for advice on family
planning and to be checked for anemia.
Case Study 3
The Situation: Queta has three daughters between the ages of 12 and 16.
The Visit: The health worker needs to ask questions about the nutrition practices of the mother and her
daughters, listen carefully, and then identify problems and their causes. After deducing that Queta’s
children were spaced closely, the health worker should explain the importance of good nutrition. Queta
should eat well and encourage her daughters to do so as well. Queta needs to learn that this means
eating animal-source foods as much as possible, dark green leafy vegetables, and orange and yellow
fruits and vegetables. The health worker needs to explain how important it is that Queta’s daughters
delay pregnancy until after age 20 and to space their own pregnancies at least three years apart. Birth
spacing ensures bodies are strong enough to have healthy infants. Finally, the health worker should urge
Queta and her daughters to go to the health clinic to be checked for anemia.

Case Study 4
The Situation: Thirty-five-year-old Betty has five children and is breastfeeding her youngest, who is 18
months of age.
The Visit: The health worker should ask Betty questions about her nutrition practices and should listen
carefully to understand any problems and their causes. The main problem is that Betty, having had many
children, is probably weak from the many pregnancies and many months of breastfeeding. The health
worker needs to explain to Betty the importance of eating well. Betty should have two additional meals
each day that contain meat and animal-source products as often as possible, as well as colorful fruits
and vegetables. The health worker should also urge Betty to use iodized salt when preparing her food
and her family’s. She should also counsel her (and her husband if possible) on the importance of using
contraception to defer or prevent additional pregnancies for her health and that of her family, and
advise her on appropriate choices.
Case Study 5
The Situation: Faith is in her last month of pregnancy and does not know where she will give birth.
The Visit: The health worker should ask Faith questions about her plans for delivering and feeding her
baby. The health worker should then listen carefully and identify any problems that may affect Faith’s
nutritional status and their causes. The main challenge is to convince Faith to deliver her baby at a
health facility. Faith also needs to be checked for anemia and to be given IFA supplementation. Faith
should also be counseled on early initiation of breastfeeding (within an hour of birth, before the
placenta is expelled) and should be advised on the advantages of breastfeeding exclusively until the
baby is six months old.
Case Study 6
The Situation: Queta, 21, has three daughters between the ages of two and six.
The Visit: The health worker should learn about community practices regarding pregnancy and child
rearing, listen carefully to Queta, then identify the potential problems in Queta’s situation, as well as
their causes. The main issue is that Queta’s pregnancies were too close to one another and started
when she was very young. The health worker should stress the importance of eating well to help her
body recover from the pregnancies, and suggest she try to eat red meat as often as possible. She should
check Queta for anemia. The health worker should suggest Queta wait at least three years before having
her next child so her body can fully recover. The health worker should also recommend that Queta
speak with her husband about family planning to delay another pregnancy.

Document #29: Practice Case Studies: Infants from Birth
up to Six Months
Case Study 1
The Situation: You make a home visit to a new mother, Betty, who has a newborn son. She is
breastfeeding, and her mother-in-law insists that she give water to her grandson.
The Visit: In visiting mothers, the first job of the health worker is to find out what practices are common
among other mothers in the community; to listen carefully to the mother being visited; and then to
identify any problems current and potential and their causes. Here, the main problem is the mother-in-
law’s insistence that Betty give water to the baby. The health worker has to ask why the grandmother
thinks that the baby should take water and if Betty also thinks so. The health worker needs to explain
that if Betty breastfeeds correctly and feeds every two or three hours the baby will have all the liquid he
needs. One way for her to know is that he will pass urine six or more times in 24 hours, but she should
be assured that breastmilk has everything the baby needs, including water. Betty needs to understand
that feeding water puts her baby at risk for diarrhea or potential weight loss: That’s because water will
carry germs that can make the baby sick. In addition, with a stomach full of water, he may feed less.
Less feeding will lower breast-milk production, leading to more weight loss.
The health worker should negotiate with Betty and persuade her to agree to practice exclusive
breastfeeding for two to three days, and make an appointment to meet again soon after that. The
health worker also needs to talk to the grandmother. The health worker should be sure to praise the
mother and thank her for her time.
Case Study 2
The Situation: Yamah is breastfeeding her 10-week-old daughter but has decided to give her some
porridge to accustom her to eating food.
The Visit: Giving food to a baby before her six-month birthday puts her at risk for malnutrition, diarrhea,
and other illnesses; and puts Yamah at risk for too-soon pregnancy and reduced breast-milk production.
But before making recommendations, the health worker needs to gently probe about local practices and
listen carefully to Yamah. The fact that Yamah wants to give her daughter complementary food before
she has reached six months of age is the main issue. The health worker needs to stress that this
complementary feeding of porridge before the age of six months is not only risky but is also
inappropriate because the baby’s body is not ready for family foods. And Yamah needs to understand
that for a baby of ten weeks of age, breastmilk alone is sufficient to meet all her needs for food and
water. Moreover, EBF brings the baby many health benefits, including resistance to diseases.
The health worker needs to negotiate with Yamah to get her to agree to EBF for several days to see the
effect. The health worker should praise Yamah and fix a time for a follow-up visit.

Case Study 3
The Situation: Queta does not think she has enough milk for her four-month-old baby. She and her
husband are seeking advice on what they should give to their baby.
The Visit: Why do the parents believe that Queta’s milk is not sufficient for the baby? The health worker
should ask about: breastfeeding frequency; on-demand feeding, night feeding, emptying one breast
before switching to the other, and any additional feedings; the baby’s health and weight; frequency of
passing urine over 24 hours; and other issues related to Queta’s health or concerns. The health worker
should also find out about community practices, and then identify potential problems and their causes.
The health worker should definitely explain the role of frequent suckling in breast-milk production: The
breast is like a factory: The greater the demand for milk, the greater the supply will be. The health
worker should also make sure that Queta and her husband understand all the benefits of exclusive
breastfeeding until six months of age. The health worker should recommend that Queta continue EBF
until her baby is six months old and should arrange a follow-up visit after few days.
Case Study 4
The Situation: Massa works very hard and does not always have time to breastfeed her three-month-old
son by day but does breastfeed him at night.
The Visit: As a working mother, Massa has many stresses. The health worker should find out more about
these as well as about how other mothers in the community with similar challenges handle the stress.
Massa’s nighttime breastfeeding should be recognized and praised, and she should be encouraged to
keep it up. Further, the health worker needs to recommend that Massa breastfeed before leaving the
house in the morning; look into the feasibility of someone else bringing the baby to her workplace; and
negotiate with her employer for breastfeeding breaks.
The health worker can also suggest that Massa express her breastmilk so that it can be given to her baby
in a cup while she is at work if bringing the baby to her during the day is impossible. The health worker
will need to explain how to express breastmilk and how to store it safely. If the health worker cannot
teach Massa how to express her milk, she should provide a referral to a place where Massa can learn the
techniques.
Case Study 5
The Situation: Mercy says she gives only breastmilk to her four-month-old daughter. But in visiting
Mercy, the health worker sees her give the daughter some water. When that observation is mentioned
to Mercy, she explains that water is not food or milk. The health worker should address the issues
mentioned in practice case study #1, above.

Case Study 6
The Situation: HIV-positive Orphelia, living in a village and nine months pregnant, is confused about
what to feed her baby after delivery.
The Visit: Orphelia is uncertain about how to feed her child in the context of her HIV status. The health
worker should find out more about what Orphelia is thinking and what she knows about how other
mothers in her community handle the situation. The health worker should listen carefully to Orphelia.
The health worker knows that where Orphelia lives, access to safe water is difficult. For that reason, the
health worker advises Orphelia to exclusively breastfeed her baby—to start immediately after birth and
give only breastmilk until the baby is six months old. The health worker must emphasize that EBF is very
important; that is because mixed feeding—mixing breastfeeding with other drinks or foods—is very
dangerous for the baby of an HIV-positive mother and will increase the risk of HIV transmission.

Document #30: Preventing and Controlling Vitamin A
Deficiency
Background
Among the serious public health problems of developing countries is deficiency in vitamin A, one of six
vitamins (the others being A, D, E, K, B, and C). The impact of avitaminose A is most profound during the
first three years of life and during a pregnancy, as women need more vitamins and minerals for
themselves and the fetus.
Causes
 Low consumption of vitamin A
 High burden of infections, which burn up vitamin A
Multisystem Effects of Vitamin A Deficiency

Vision: The most common manifestation is night blindness: people have trouble seeing at night. Another
disease is xerophthalmia: a dry, thickened, lusterless condition of the white part of the eye. Bitop’s spot,
a spot-like, white foam, is one of the symptoms. Dryness affects the cornea that eventually starts to
“melt, and permanent vision loss follows. Milder forms of deficiency are invisible but also damaging to
the health.
Immunity: Lowered immunity puts vitamin A–deficient children at higher risk of infection and thus
higher mortality.
Physical Growth: Vitamin A deficiency retards children’s physical growth
Anemia: Vitamin A–deficient patients suffer from iron deficiency and anemia.
Reproductive System: Its effectiveness is maintained by vitamin A.

Strategies to Prevent Vitamin A Deficiency
1. Promote Breastfeeding as Source of Vitamin A
Vitamin A in the mother’s body passes into the breastmilk, so breastfeeding women must obtain vitamin
A supplementation and eat a vitamin A-rich diet. (Women should also get enough vitamin A prior to
pregnancy.)
2. Promote Consumption of Vitamin A-Rich Foods
This is especially important in pregnant and lactating women and in children under five. Animal sources
are the richest and most fully absorbed by the body.
Representative Vitamin A-Rich Foods
ANIMAL-SOURCE
LEAFY VEGETABLES OTHER VEGETABLES FRUIT
FOODS
Spinach Coriander leaves Pumpkin Jackfruit Liver
Water spinach Halencha leaves Sweet potato Mango Fish oil
Mint leaves Gourd leaves Carrot Ripe papaya Egg yolk
Sweet potato leaves Radish leaves Butter
3. Provide High-Dose Vitamin A Supplements to Lactating Women and Children

Under Five
AGE OR STATUS QUANTITY DOSE
1 capsule 10,000 IU Daily

Pregnant woman*
1 capsule 25,000 IU Weekly
Aged 6–11 months 1 capsule 100,000 IU Once
Aged 12 months and above 1 capsule 200,000 IU Every four to six months
Postpartum mother* 1 capsule 200,000 IU Within 42 days of delivery

*Refer to country protocol
 Supplementation may be provided during routine health services, national immunization days,
child health days, or micronutrient days.

4. Treat Conditions and Diseases with Vitamin A
Guidelines for Treatment with Vitamin A*
CONDITION PATIENT AGE DOSAGE AND FREQUENCY
Severe and Moderate Children 6–11 months 100,000 IU on Day1, Day 2 and Day 14
Acute Malnutrition
Children 12–59 months 200,000 IU on Day 1, Day 2 and Day 14
HIV Infection Children 6–59 months Every 6 months
Persistent Diarrhea Children 6–11 months 100,000 IU once
Children 12–59 months 200,000 IU once
Measles Children 6–11 months 100,000 IU on Day 1, Day 2, and Day 14
Children 12–59 months 200,000 IU on Day 1, Day 2, and Day 14
Xerophthalmia Children birth to 6 months 50,000 IU on Day 1, Day 2, and Day 14

* Refer to national integrated management of childhood illnesses guidelines.
5. Fortified Foods
Populations in industrialized countries get an abundant supply of vitamin A, not just in the natural diet,
but also through industrial fortification of foods, such as margarines and vegetable or canola oil. Many
Central American countries, including Guatemala and Honduras, have fortified sugar. West African
countries are fortifying cooking oil and wheat flour.

Document #31: Preventing and Controlling Anemia
Background
Anemia is a condition in which the red cells in the blood are too few in number to meet the body’s
physiological needs (which vary by age, sex, altitude, and smoking and pregnancy status). Almost 2
billion people globally—over 30 percent of the world’s population—are anemic; all anemia contributes
to an estimated 20% of maternal deaths (WHO), and that IDA is the third ranking cause of global DALYs
(Global Burden of Disease 2010). The most vulnerable, the poorest, and the least educated—including
women and children—are affected disproportionately. According to the World Health Organization, the
health consequences are “steady but devastating.”
Hemoglobin Values Defining Anemia for Population Groups
AGE OR SEX GROUP HEMOGLOBIN VALUE DEFINING ANEMIA (G/DL)
children 6–59 months <11.0
children 5–11 years <11.5
children 12–14 years <12.0
nonpregnant women older than age 15 <12.0
pregnant women <11.0
men older than age 15 <13.0
Types and Causes

 Iron deficiency due to inadequate iron intake or poor iron absorption is a major cause of
anemia. Deficiency of vitamin B12, folic acid, zinc, and vitamin A and eating foods that are poor
sources of iron are also associated with iron deficiency.
 Iron deficiency resulting from infection—specifically by hookworm or from schistosomiasis or
malaria—is the second major cause of anemia. Almost 80 percent of children in rural areas of
less developed countries have hookworm.
Signs and Symptoms

 physical weakness, poor mental concentration at work
 burning and pain in upper and lower limbs
 dizziness, drowsiness, and a high rate of palpitation when standing from sitting or lying position
 pale appearance, especially in the hands, whites of the eye, and underneath tongue

 sores in the corner of the mouth and cracks in the tongue
 tiredness and loss of appetite
Consequences
During Pregnancy: The baby’s birth weight may be low. The risk of maternal death from excessive
bleeding increases. Delay in delivery may result in the newborn’s death. Twenty percent of all maternal
deaths are associated with anemia.
Children: Anemia impairs physical and cognitive development in children; the World Health
Organization estimates that 40 percent of preschoolers are anemic. School performance suffers.
Adults and Older People: Decreased productivity and lowered immune capacity are consequences in
adults. Severe anemia causes deposition of water in lower limbs and heart attack.
Strategies to Prevent Iron Deficiency

1. Increase Iron Intake
Advocate for consumption of iron-rich foods, particularly among pregnant and lactating women and
children under the age of five.
Encourage iron–folic acid (IFA) supplementation and treatment. In malaria endemic areas
supplementation of children under 5 years should be implemented in conjunction with measures to
prevent, diagnose and treat malaria.
Iron Supplementation and Treatment Dosage and Duration by Vulnerable Group
TARGETS DOSAGES DURATION
PREVENTIVE SUPPLEMENTATION
pregnant and lactating women Iron: 60 mg/day At least six months. Take IFA from
conception until three months postpartum
Folic acid: 400 mcg/day
TREATMENT
children under 2 Iron: 25 mg/day Three months

Folic acid: 100–400 mcg/day
children aged 2–12 Iron: 60 mg/day Three months

adolescents and adults Iron: 120 mg/day Three months


2. Control Infection
Helminthiasis Control and Deworming
TARGETS TREATMENT WHEN
pregnant women Mebendazole 500 mg OR One dose in the second trimester of

pregnancy and another dose in the third
Albendazole 400 mg trimester
children older than 12 Mebendazole 500 mg OR Routine dose every six months
months
Albendazole 400 mg

Document #32: Preventing and Controlling Zinc and
Calcium Deficiencies, and Iodine Deficiency Disorders
Preventing and Controlling Zinc Deficiency
Background
According to Lancet 2013, 17% of the world population is at risk of deficiency on the basis of analysis of
dietary intake. Pregnant women and young children are at higher risk of zinc deficiency. Zinc deficiency
is very hard to assess and there are very limited data for global estimates.
Causes
 low consumption of zinc
 high burden of infections, which use up zinc
 high zinc needs during growth
Consequences
Children may be vulnerable to zinc shortages during infancy and adolescence; these shortages may be
associated with deficits in cognitive development. Mild to moderate deficiency accounts for some 16
percent of lower respiratory tract infections, 18 percent of malaria infections, and 10 percent of
diarrheal disease.
Strategy
Advocate for consumption of zinc-rich foods, such as animal source products, particularly among
pregnant and lactating women and children under the age of five.
Treat all cases of diarrhea with zinc in addition to low osmolarity oral rehydration therapy.
Zinc Treatment for Diarrhea
GROUPS DOSING DURATION
children under six months 10 mg 10–14 days
children older than six months 20 mg 10–14 days

Preventing and Controlling Calcium Deficiency
Background
In pre-eclampsia there are often problems with the placenta, along with increased blood pressure, that
can reduce blood flow and therefore oxygen and nutrient supply to the baby. These conditions may
result in intra-uterine growth retardation and possibly early delivery, which represents, in lower-income
settings, a leading cause of infant mortality.
Pre-eclampsia may also pose serious risks to the mother, such as kidney and liver problems, potentially
progressing to stroke or seizures (eclampsia). Hypertensive disorders of pregnancy are associated with
preterm birth, low birth weight and maternal mortality.
Causes
 low consumption of calcium
 Calcium is an essential mineral that assists with many of the body’s processes, such as
maintaining cell membranes in nerve as well as muscle contraction
Consequences
Pre-eclampsia is a hypertensive disorder that develops in approximately 5% of all pregnancies, usually
after about 20 week gestation. Low calcium intake is thought to cause high blood pressure.
Strategy
During pregnancy and lactation calcium supplementation is often recommended to meet the
body’s increased demands and for the overall health of mother and child.
Calcium Supplementation during pregnancy
1.5 g
pregnant woman (3 tablets, 3 times daily Entire pregnancy
with meals)

Preventing and Controlling Iodine Deficiency
Background
Globally, more than 1.9 billion people (Lancet 2013) may be at risk for iodine deficiency; recent
estimates point to more than 1 billion people experiencing some degree of goiter, one of iodine
deficiency’s effects. Pregnant women and young children are most at risk of iodine deficiency.
Causes
Inadequate intake of iodine causes iodine deficiency disorder (IDD), particularly in regions where
quantity of iodine in the soil is low.
Consequences
Iodine deficiency is one of the most common preventable causes of mental retardation and brain
damage, with “endemic cretinism”—a profound mental retardation—at the severe end of the spectrum
of IDDs. Lower mean birthweight, higher infant mortality, hearing impairment, impaired motor skills,
and neurological dysfunction are also associated with IDD.
Other Effects of Iodine Deficiency Disorder
IN CHILDREN IN WOMEN
Impaired physical growth Goiter

Delay in pregnancy
Chilling Irregular menstruation
Stillbirths
Apathy Fatigue, dementia, and apathy
Strategies
 Make available iodized salt for entire population.
 Encourage the consumption of iodized salt for the entire family and of foods rich in natural
iodine, such as seafood.
 In regions where the access to iodized salt is less than 20 percent, iodized capsules may be
distributed to pregnant women and children under five.
USE AND PRESERVATION OF IODIZED SALT

Preserve iodized salt in a covered glass jar in a darkened place or in a covered clay or plastic pot.
Keeping iodized salt in a wet container or brightly lit place may reduce its iodine content.
Use the salt within six months of the iodine’s addition to the salt.
Add the iodized salt after cooking the food.

Document #33: Complementary Feeding Practices for
Children Aged 6 up to24 Months
Complementary feeding means giving other foods in addition to breast milk.
About Complementary Feeding

Introduce Complementary Food
 At six months of age, breastmilk alone is not enough for a young child to continue to grow and
stay healthy and strong.
 Advise the mother or caregiver to introduce pureed or mashed food twice a day when the baby
is six months.
o Porridge can be made from rice, plantain, cassava, corn, sorghum, sweet potatoes, eddo, or
yam.
o The baby’s food should be put in a separate bowl, so the mother or caregiver knows how
much the child is eating.
o Do not add pepper or chili to the baby’s food. The pepper kills the appetite and discourages
the baby from eating.
o At 12 months, the baby may start to feed himself or herself; the child needs help to eat all
the food served.
 Recommend her to wash her hands and the baby’s hands with soap before each meal and
snack.
 Encourage the mother or caregiver to help the baby learn how to eat by taking the time and
feeding the child patiently. Explain to the mother that she should play with and sing to the child
and encourage easting all the food offered. Force feeding or stuffing may discourage the baby
from eating and can be harmful.
 Explain that the porridge is just right and good for the baby when it is thick enough to slowly fall
off the spoon. A watery or thin porridge is not healthy for the baby; it does not provide enough
nutrients for the baby to grow strong and healthy.
o A sticky porridge is difficult for the baby to swallow, making it unhealthy for the child.
o Porridge should get thicker as the baby grows older; making sure the child is still able to
easily swallow it without choking. To thicken porridge, add more flour or paste.
Continue Breastfeeding—and Space Your Pregnancies
 Breast milk supplies ALL of the ‘energy needs’ of a child from birth up to 6 months, about 60% of
‘energy needs’ of a child from 6 up to 12 months and 40% of ‘energy needs’ of a child from 12
up to 24 months. (This fact can be posted throughout the training.)

 Counsel the mother to continue breastfeeding until the baby is two years old to make sure the
baby grows strong and stays healthy.
o From 6 up to 24 months of age, give the child breastmilk as often as he or she wants (at
least eight times) during the day and night.
 Advise the mother to space pregnancies at least three years apart for her health and the health
of the baby.
o When the baby is six months old, the mother can no longer use LAM and needs to adopt
another family planning method.
o Mothers should not wait until the baby is six months old to decide on which family
planning method to use.
o Having sex will not spoil breastmilk. A pregnant woman can breastfeed safely.
Consume a Varied Diet

 For women, children, and other family members to get the vitamins they need, their diet needs
to be varied.
 Counsel the mother to enrich the baby’s food at each meal with two to three different types of
colorful foods to help the baby grow and get strong.
o Colorful foods enrich the baby’s diet. They include vegetables and fruits that are orange
and red, such as carrots, orange-fleshed sweet potatoes, and ripe mango and papaya; dark
green leafy vegetables, such as kale and chard; and avocado, beans, eggs, peanuts, and
peas or lentils.
o Animal-source foods such as fish, eggs, chicken, liver and other meat, and milk should be
mashed as needed and added to the diet whenever they are available. Animal-source foods
are especially important to allow babies and children to grow healthy and strong.
o A little butter, spoon oil, palm oil, vegetable oil, sesame seed, or peanut paste can be
added to the baby’s food.
o Advise giving the baby a little bit of fruit every day. In addition to fruit listed above, babies
can have bananas, butter pears, plum mangoes, or watermelons. Fruit needs to be well
washed and, for younger babies, well mashed or squeezed into juice.
o Advise that calcium-rich foods such as milk and dairy products, legumes and dark green
leafy vegetables can be consumed daily.
o Other family foods need to be mashed to make them easy for the child to chew and
swallow.
Feeding Frequency and Quantity for Children between 6 - 11 Months
 Young children have small stomachs and can eat only small amounts at each meal, so feed
young children frequently throughout the day.
 Advise the mother or caregiver to wash hands before feeding the child, and to wash the child’s
hands, to avoid diarrhea.
 For children between the ages of six and 11 months, explain that the baby needs to eat two to
three times each day plus have one or two nutritious pureed or mashed snacks. This will help
the baby grow healthy and strong.

o Tell the mother to encourage the baby to eat everything that is given to the child. All foods
should be mashed, so the baby can swallow without choking.
o Every day, the baby needs to eat a variety of different foods along with porridge to make
sure the child gets all the nutrients he or she needs to grow well.
o Start by giving a 6 up to 9month-old baby half of a 250 ml bowl of colorful food twice daily
(three times daily as the baby gets older).
o If the baby is 6 up to 9 months old, mix two tablespoons of porridge with one tablespoon of
other foods.
o If the baby is 9 up to 12 months old, mix three tablespoons of porridge or family staple
with three tablespoons of other foods.
 Inform the mother/caregiver that by eight months, the baby is usually able to begin eating with
his or her hands, thus it is necessary to wash the baby’s and mother’s hands before feeding. The
child should be given small pieces of finger foods, e.g., soft-cooked vegetables or soft ripe fruit,
such as bananas, papaya, ripe plum mango, avocado or butter pear; or bread, . Calcium-rich
foods like dairy are also important. Caregivers need to remember to help the baby eat all the
food that it is served to him or her.
 Tell the mother not to use a baby bottle to feed the baby, as it is difficult to
clean and the baby can get diarrhea.
 Recommend using iodized salt to prepare food for the whole family, including
the baby.
 Offer 1 to 2 snacks: between meals offer extra foods that are easy to prepare,
clean, safe and locally available and can be eaten as finger foods. Snacks can be
pieces of ripe mango, papaya, banana, avocado, other fruits and vegetables,
fresh and fried bread products, boiled potato, sweet potato
Note: 'Biscuits', package foods such as chips, tea and coffee are not appropriate
complementary foods, and therefore are not recommended for young children. No coffee or tea with
meals (or to soften food for baby).
Representative One-Day Menu for Children Aged 6 up to12 Months
Morning Meal  Serve rice porridge.

 Add an egg, oil, or small piece of butter and avocado or papaya, if available.
Morning Snack  Give child one half of a mashed ripe mango or an equivalent amount of mashed
papaya, banana, or mango; bread,; or roasted or fried plantain or yam.
Midday Meal  Serve yam porridge.

 Add a tablespoon of vegetable oil, a tablespoon of mashed beans, and one-half
tablespoon of green leafy vegetables.

Afternoon Snack  Same as the morning snack.
Evening Meal  Serve cassava porridge.

 Add a piece of cooked sweet potato or roasted soft plantain, a tablespoon of palm
oil, a tablespoon of dried fish or mashed chicken, and mashed vegetables (e.g.,
carrots, pumpkins, or okra).
Feeding Frequency and Quantity for Children Aged 12 up to24 Months

 Young children have small stomachs and can eat only small amounts at each meal, so feed the
baby frequently throughout the day.
 Always wash hands with soap before feeding and eating.
 Counsel the mother that to ensure healthy growth, the baby needs be fed a meal of family foods
plus one or two snacks at least three to four times a day.
o At 12 months, the baby can begin to eat family foods, such as rice, yam, plantain, cassava,
or sweet potato.
o From the family bowl, a portion can be kept for the baby and be enriched with one or two
additional foods—for example, sesame seeds or cassava leaves or other dark leafy
vegetables; and milk, meat, fish, egg, mashed beans, peanuts, or other nuts.
o Whenever available, animal-source foods (e.g.., fish, eggs, chicken, liver and other meat,
and milk) should be included for the child to get strong. Calcium-rich foods are also
important.
o At each meal, mix a cup of staple or family foods with three tablespoons of other foods.
o To support the baby’s growth, the child can be given more food if he or she asks for it.
 Advise that the baby also be given snacks at least twice a day between main meals, such as
bread, banana, roasted or fried plantain, or yam; the child is growing and needs more food.
 Recommend iodized salt to cook all family food.
Representative One-Day Menu for Children Aged 12 up to 24 Months
Morning Meal  Serve rice porridge.

 Add half a small butter pear and a banana.
Morning Snack  Give child half a plum mango or fried plantain.
Midday Meal  To family food, add a tablespoon of palm oil and dried fish.
Afternoon Snack  Give child one banana
Evening Meal  Add an egg and a small piece of pumpkin to family food.

About Vitamin A and Medicine for Malaria and Worms
Vitamin A
 Vitamin A is important for the baby’s eyesight and to help the child fight illness.
 Remind the mother to obtain vitamin A supplementation for the child when he or she turns six
months old (and every six months after that until fifth birthday).
o To obtain child’s vitamin A supplementation, look for vitamin A supplementation sessions
on national immunization days or at similar events
 Recommend that everyone in the family, including the baby, needs to eat foods rich in vitamin
A, such as papaya, mango, and other orange and yellow fruits, as well as orange-fleshed sweet
potatoes, dark green leafy vegetables, red meat, liver, and milk.
o Vitamin A–rich foods enrich breastmilk with vital nutrients to keep babies healthy and
strong.
o Pregnant and breastfeeding women in the household, as well as children aged six months
to two years, should get as much animal-source food (i.e., fish, eggs, chicken, liver and
other meat, and milk) as possible.
 Advise the mother/caregiver that fortified foods should be eaten when they are available for
purchase in stores.
Malaria Prevention
 Malaria causes anemia (“low blood”), which makes family members weak and sick.
 Recommend that all members of the family, especially pregnant women and young children
sleep under an insecticide-treated mosquito net to prevent malaria.
 Children and any family member with fever should be brought to the health center to be tested
for malaria and treated as early as possible.
Deworming
 In young children, worms cause anemia, which makes them weak and sick.
 Remind the mother that when the child is a year old, he or she needs to be treated with worm
medicine every six months until the fifth birthday to maintain healthy growth and prevent
anemia.
o Deworming medicine can also be obtained during national immunization days or similar
events.
Hygiene
 Good hygiene and sanitation is important to prevent a runny stomach, worms, and other
sickness. It also keeps families healthy.

 Explain that the mother has to wash her hands with soap and water before cooking, handling
food, eating, and feeding her child.
 Hands should be washed with soap and water after visiting the toilet or cleaning a child.
 The home and its surroundings should be kept clean.
 Keep the Animals away from living quarters as their manure can cause illness.
 If possible, Give to the child a safe and clean place to play, protected from dirt, animal feces and
objects that could be put into the mouth.
 Shoes should be worn to prevent worms.
 A clean cup or bowl should be used to feed the baby. Bottles are hard to clean and germs may
cause diarrhea.

Document #34: Active Feeding
What does it mean for mothers, fathers, or caregivers to “actively feed” a
young child?
 Active or responsive feeding is a method that encourages the child to eat and to finish his or her
meals.
 When feeding himself, a child is easily distracted. Distractions may lead to the child not eating
enough, putting him or her at risk for malnutrition
 Let the child eat from his or her own plate, so you will know how much he or she has consumed.
 Sit down with the child and encourage him or her, if needed.
 Offer the child food he or she can hold; young children often want to feed themselves.
Encourage self-feeding, but make sure most of the food goes into the child’s mouth.
 After washing your hands and your child’s hands, use your fingers to feed the child, if that is
your preference.
 Feed the child as soon as he or she starts to get hungry.
 Have the child eat in his or her usual mealtime or snack time setting.
 As much as possible, have the child eat with the family to create an atmosphere promoting his
or her social and emotional development.
 Do not insist on feeding the child if he or she does not want to eat; wait a bit or put eating off
until later.
 Talk to the child or play with him or her while he or she eats.
 Congratulate the child when he or she eats.
 Be sure to involve parents, older children and other family members, and child caregivers in
active feeding.

Early Childhood Development
In addition to good nutrition and hygiene, a child needs loving care and communication to grow up
strong and happy and smart.
Message for Mothers and Fathers

Children have many things to learn in their first two years: to talk, to walk, to run, to feed themselves.
Even newborns are ready to use their eyes and ears and develop loving bonds with their families. Be
sure you play and communicate with your baby even before she has words to reply, as this will help her
learn and develop.
More Information
 Babies need clean and safe places to explore and play, as they often put things into their
mouths. Putting them on a clean mat will help protect them. Remove dirty objects and replace
them with clean things they can explore and cannot swallow.
 Pots and cups and spoons are all toys for small children, who learn by grabbing, banging,
stacking and watching and copying others.
 When they are ready, children should be allowed to feed themselves although they also need to
be encouraged with patience and good humor to eat a variety of different foods.
 At each age children need the opportunity to learn new things, and as they grow and develop
they will be able to build on what they know to gain more advanced skills.
 Give your child affection and show love.
 Be aware of your child’s interests and respond to them.
 Praise your child for trying to learn new skills.

Document #35: What Health Providers Can Teach
Parents or Caregivers about Complementary Feeding
Which questions should be asked of mothers whose babies will soon be
six months old?
 Do you know why it is important to wait until your baby is six months old before feeding the
child anything besides from breastmilk?
 How often will you need to feed your six- to eight-month-old child?
 How much food should you give your child aged six to eight months?
 What should be the consistency of your baby’s first foods?
 What should you feed your child?
 Where can you obtain vitamin A supplements that your child needs when he or she is six
months old?
 After your baby has his or her first vitamin A supplementation at the age of six months, when
will you return for the second supplementation?
 What immunizations has your child received?
Why encourage mothers, fathers, or caregivers to use iodized salt for the
whole family, including children who have begun complementary
feeding?
 To ensure the physical and intellectual development of not only the child but also the whole
family.
 To prevent goiters and their complications.
 To prevent poor work performance in adults.
 In pregnant women: to prevent miscarriage, stillbirth, low birth weight, and cretinism in the
baby.
Which foods are rich in vitamin A in your community?

 Colostrum and breastmilk are important sources of vitamin A.
 Red meat, eggs and liver are the richest food sources of vitamin A.
 Ripe orange and yellow fruits (e.g., papaya and mangoes) are good sources of vitamin A.
 Orange and yellow vegetables (e.g., carrots and pumpkins) as well as liver and green leafy
vegetables are good sources of vitamin A.

Why should a baby eat foods rich in iron?
 To gain strength.
 To reinforce the baby’s health, as well as the child’s physical and intellectual development.
Which foods are rich in iron?

 Red meats and small fish are the richest sources; among plants: lentils, legumes and dark green
leafy vegetables are also good sources, especially if combined with foods rich in vitamin C, like
tomato and lemons and papayas.
What foods are rich in calcium?

 Milk and dairy products are the richest sources of calcium; legumes and dark green leafy
vegetables and some fish are also good sources.
Why should vitamin A be administered to children every six months from

the age of six months to five years?
 Vitamin A supplementation ensures the child’s growth.
 Vitamin A reinforces the child’s health.
 Vitamin A protects the child from severe forms of infection, such as diarrhea and respiratory
diseases, thus reducing the risk of death.
 Vitamin A improves the child’s sight and prevents night blindness, which can lead to childhood
blindness.
Why should children be dewormed every six months starting at two

years of age?
 Some worms feed exclusively on blood. If the child has these worms, he or she becomes anemic
(thin and weak).
What other nutrition services should be provided by health centers?

 Persistent diarrhea (over 14 days) should be treated with zinc supplements, oral rehydration
solution and an extra dose of vitamin A, as recommended in IMCI protocol.
 Check children for anemia and treat as recommended in IMCI protocol
 Provide immunizations for children
Check Provide
Polio 2 + Penta 2 + Pneumococcus + Rota
Measles
Vaccines
Yellow Fever (if applicable)
Polio 3 + Penta 3 + Pneumococcus + Rota
Vaccines

What nutritional advice to give a mother and child (birth up to 24
months) to stay healthy?
 Use family planning to ensure that pregnancies are spaced—minimum 3 years
 Eat a diversified diet and two additional meals while breastfeeding
 During pregnancy and lactation take iron-folic acid supplementation for six months(provide
tablets for at least one month)
 Keep the environment of the compound free from the feces of animals and children
 Wash hands with soap before preparing foods, eating and feeding the child
 Use latrines and wash hands with soap after each use
What are the essential nutrition supplies and how can health workers
maintain adequate stocks?
 Capsules of vitamin A
 Iron–folic acid
 Mebendazole or Albendazole
 Iron syrup
 Ready to use therapeutic foods (RUTF) (if applicable)
 Middle-upper arm circumference (MUAC) tapes
 Scales (refer to country guidelines)
 Order drugs and supplies several months before your stocks run out as you do with other
essential drugs. Consider your leftover stocks. For campaigns, order in relation to the target
coverage; use the results of the previous supplementation.
How can health workers help mothers, fathers, or caregivers make sure
that their children are properly fed and that they obtain the nourishment
they need?
 Discuss age-appropriate feeding recommendations with the mother or caregiver and, if possible,
with the father, grandmother, and the rest of the family.
 Congratulate and encourage mothers to continue breastfeeding for two years.
 Encourage parents to give their children many different types of food, including foods rich in
vitamin A and iron. Emphasize that even small quantities of animal foods are especially
important for growth.
 Encourage parents to have a garden and to grow different green leafy vegetables and orange
and yellow vegetables and fruits and to raise poultry.
 Raise awareness among the population to use only salt that has been iodized.

 Encourage parents to bring their children to the health center in the case of illness, malnutrition,
weight loss, or edema.
 Encourage parents to go to health centers or community outreach to obtain needed
immunizations (e.g., measles at nine months); for vitamin A supplementation at six months; and
for deworming beginning at the age of two.
 Encourage families to space births at least three years apart. Explain that the lactation
amenorrhea method (LAM) can be effective for six months after birth if the mother has no
menses and is exclusively breastfeeding. After six months other methods are needed. Advise
parents to come to the health center to learn about other family planning methods.
 Encourage families, including their children, to sleep every night under mosquito nets treated
with long-lasting insecticides to protect against malaria.
 Encourage parents to call on support groups when they face difficulties.

Document #36: Seasonal Food Calendar
JANUARY FEBRUARY MARCH
HOME HOME HOME
MARKET MARKET MARKET
APRIL MAY JUNE
HOME HOME HOME
JULY AUGUST SEPTEMBER
HOME HOME HOME
OCTOBER NOVEMBER DECEMBER
HOME HOME HOME

Document #37: Illness, Feeding, and Recovery
WEIGHT LOSS WEIGHT LOSS

LESS APPETITE EATS MALNOURISHED
LESS LONG ILLNESS
NOT HUNGRY
BURNS CALORIES
SICK CHILD
(DIARRHEA, ARI,
MEASLES, FEVER)
DISABILITY
DEATH
LENGTHENS ILLNESS
WHY FEEDING DURING SICKNESS AND RECOVERY IS

CRITICAL TO A CHILD’S HEALTH
Although a sick child usually does not feel like eating, she needs strength to fight the illness. Strength
comes from the food the child eats, and she needs to eat more food and breastfeed more than when
she is well—if she does not, recovery time will be longer. The baby may become chronically sick or
malnourished. If the child’s condition worsens, she may develop a nutrition-related physical or
intellectual disability or even die.

Document #38: Nutritional Care during and After Illness
During Illness
 Breastmilk contains water and nutrients in the quantities the baby needs to get better quicker.
In addition, breastfeeding comforts a sick child.
From Birth up to 24 Months

 Encourage the mother to breastfeed more often and for longer each time when the baby is sick
and after the child recovers. Breastmilk helps the baby recover faster and prevents weight loss.
 The mother has to continue breastfeeding even if she is sick.
Aged Six Months and Up

 Advise the mother to keep giving her child complementary foods during illness along with
breastmilk to maintain the child’s strength and reduce weight loss. (The mother should also
breastfeed more frequently.)
o A extra bowl or one extra meal of her favorite food
o Meals should be frequent and small; this works better for sick children.
o Be patient when encouraging the sick child to eat—illness may have taken away his or her
appetite.
 If the child cannot eat, breastfeeding should be increased and additional food given after his
appetite has returned.
After Illness
 Each time babies are sick, they lose weight, so it is important to give breastmilk as often as
possible after and during an illness. Breastmilk is the safest and most important food offered to
the baby to restore the child’s health and help him or her regain lost weight.

 Advise the mother to continue giving breastmilk more often for two weeks after the illness.
o The mother has to continue breastfeeding even if she is sick.

 Recommend that the mother give one extra bowl of food each day for two weeks after illness to
restore the baby’s strength and help him or her regain lost weight.
o The recovering baby should continue getting family foods, the meals being more frequent
and smaller, which is easier for recovering children to consume.
o The mother or caregiver should be patient when encouraging the baby to eat. After illness,
it may take the child a while to regain his or her appetite.

Feeding a Child Who Has Moderate Acute Malnutrition
 The child should get breastmilk more often to ensure he or she gets vitamins and other
nourishment. This will help improve the child’s condition quicker.

 Recommend that the mother give the baby one additional bowl of family foods each day—or it
may be easier to give smaller but more frequent meals - to speed recovery and help a child with
moderate acute malnutrition regain his strength.
o If the child receives a ration of supplementary foods, it must be given to that child for his
regular feeding as well as the additional bowl.
o The mother selects the baby’s favorite foods
o She needs to be patient when encouraging the child to eat, as he may have lost his
appetite.
 Encourage the mother to breastfeed more often until the child recovers.
Nutritional Care of Infants and Children with Diarrhea

 Advise the mother to breastfeed the child even if he or she has diarrhea and to breastfeed the
child more frequently to replace the lost liquid.
o If the baby’s diarrhea is severe and he or she shows signs of dehydration, the mother must
continue breastfeeding, give oral rehydration therapy (ORT), and come back to the health
center.
 Advise that when the child has diarrhea, the mother must continue giving complementary
foods, as well as breastmilk, and breastfeed more frequently. This will help maintain the child’s
strength and reduce weight loss.
o Advise the mother to be patient when encouraging the child to eat, as the illness may have
taken away his or her appetite; to select the child favorite foods, and to give in small
quantities throughout the days; smaller, more frequent meals are easier for a sick child to
eat.
 Recommend water, rice water, or ORT, to ensure the child does not become dehydrated.
 Give the child zinc medicine with ORT; provide instructions to continue the treatment for 10 to
14 days (as recommended), even after the runny stomach has stopped
Zinc Treatment for Diarrhea
Children Under Six Months 10 Mg 10–14 Days

Children Older Than Six Months 20 Mg 10–14 Days

Document #39: What Health Providers Can Teach
Parents or Caregivers about Feeding During and
After Illness
How should you counsel parents or other caregivers on child feeding
during and after illness?
 A sick child usually does not feel like eating, but he or she needs even more strength to fight
illness. Strength comes from the food the child eats. If the child does not eat or breastfeed
during sickness, it will take him or her more time to recover.
 If the child does not eat, he or she will be in a chronic state of sickness and malnutrition and
may end up with a physical or intellectual disability as a result. Sometimes, if the child takes
longer to recover, his or her condition will worsen, which could lead to death.
 A sick child should be encouraged to eat even if he or she does not feel like it. Also, the child
should eat even more during recovery to regain strength more quickly.
What is the best way to help mothers, fathers, and caregivers prevent
diarrhea?
 Urge exclusive breastfeeding from birth to six months of age.
 Initiate complementary feeding in a timely fashion, emphasizing FADDUA (correct frequency,
amount, density, diversity, utilization, and active feeding).
 Wash hands with soap and water before preparing food.
 Wash hands with soap and water before feeding infants and young children.
 Wash hands with soap and water after using the toilet or cleaning the baby.
 If food is stored ensure it is in a covered container and reheated (then cooled) sufficiently
before serving to ensure its safety.
 Dispose of waste appropriately.
 Observe correct personal and environmental hygiene.
 Have an adequate supply of safe water and protect it.
 Ensure the child has all necessary vaccinations.
 Obtain vitamin A supplementation for the child starting at age six months and repeating every
six months until age 59 months.
 Avoid bottle feeding; use cups and bowls instead.

What is the best way to help mothers, fathers, and caregivers manage a
child with diarrhea?
 Advise them to continue exclusive breastfeeding and increase frequency if the child is younger
than six months of age.
 If the child is six months or older, offer more liquids and more food; breastfeed more often.
 Increase the frequency of feedings.
 Never feed your baby using a bottle.
 If the child is becomes dehydrated she should be brought immediately to the health center.
What signs of severe dehydration should all parents and caregivers be

aware of?
 Eyes are dry and sunken.
 Skin, when pinched, returns very slowly to its original state.
 The child is lethargic or unconscious.
 The child fails to suckle, drink, or feed.
What general danger signs of illness should all parents and caregivers be
aware of?
 The child is unable to drink and eat.
 The child experiences loss of consciousness or is lethargic.
 The child vomits up everything.
 The child has convulsions or history of convulsions
If you note severe dehydration or danger signs of illness,

go to the nearest health clinic.

Document #40A: Practice Case Studies: Complementary
Feeding for Children 6 up to 24 Months
Case Study 1
The Situation: You visit Korpo, whose baby, Anik, is six and a half months old. Korpo tells you that Anik is
too young for food because his stomach is too small. She says she will continue exclusively breastfeeding
him until he is older. Her husband and mother-in-law agree with her.
The Visit:
Greet, Ask, Listen
 Greet Korpo and ask questions that encourage her to talk, using listening and learning, building
confidence and giving support skills.
 How is breastfeeding going; how is eating other foods going?
 Listen to Korpo’s concerns, and observe Anik and Korpo
 Accept what Korpo is doing without disagreeing or agreeing
Identify
 Korpo is exclusively breastfeeding Anik
 Korpo has not started complementary foods; she believes Anik’s stomach is too small for food
 Think: beginning complementary foods, frequency, amount, and density
Discuss, Recommend, Agree on Action, Follow-up Appointment

 Praise Korpo for breastfeeding
 Explain how important it is for Anik’s growth and development that Korpo keep breastfeeding
 Talk with Korpo about beginning complementary foods and why it is necessary for Anik at this
age
 Talk with Korpo about the characteristics of complementary feeding: frequency, amount,
density (thickness/consistency), diversity, responsive feeding, and hygiene
 Present options/small do-able actions (time-bound) and help Korpo select one or two that she
can try, (FADDUA) e.g. begin with a small amount of staple food (porridge, other local
examples); begin with tastes and increase to 2 - 3 tablespoons; increase feeding frequency to 3
times a day; talk about appropriate density (thickness/consistency) of staple; assist Anik during
feeding times; and discuss hygienic preparation of foods
 Answer questions
 If available, counsellor will select an illustration that is most relevant to Anik's situation -- and
discuss it with Korpo

 Ask Korpo to repeat the agreed upon behaviour – elements of BF + FADDUA
 Arrange with Korpo a time for a follow-up visit
 Suggest where Korpo can find support (attend an ENA-EHA Support Group in community,
Supplementary Food Programme, and refer to Community Worker).
 Refer as necessary
 Thank Korpo for her time
Case Study 2
The Situation: Hawa has a nine-month-old daughter, Tesfa, who is eating plain gruel once a day. Hawa is
also breastfeeding Tesfa.
The Visit:
Greet, Ask, Listen
 Greet Hawa and ask questions that encourage her to talk, using listening and learning, building
 How is breastfeeding going; how is eating other foods going? (How often is Hawa giving plain
gruel, how thick, and how many times?)
 Listen to Hawa’s concerns, and observe Tesfa and Hawa
 Accept what Hawa is doing without disagreeing or agreeing
Identify
 Hawa is breastfeeding Tesfa
 Hawa is giving Tesfa plain gruel once a day
 Think: frequency, amount, density and diversity

 Praise Hawa for breastfeeding and giving other foods to Tesfa
 Explain how important it is for Tesfa’s growth and development that Hawa give foods other than
breastfeeding
 Talk with Hawa about the characteristics of complementary feeding: frequency, amount, density
(thickness/consistency), diversity, responsive feeding, and hygiene
 Present options/small do-able actions (time-bound) and help Hawa select one or two that she
can try, (FADDUA) e.g. increase feeding frequency to 3 – 4 times a day; talk about appropriate
density (thickness/consistency) of gruel; use foods prepared for the family to add to gruel; assist
Tesfa during feeding times, provide separate plate for Tesfa; and discuss hygienic preparation of
foods

 If available, counsellor will select an illustration that is most relevant to Tesfa's situation -- and
discuss it with Hawa
 Ask Hawa to repeat the agreed upon behaviour – elements of BF + FADDUA
 Arrange with Hawa a time for a follow-up visit
 Suggest where Hawa can find support (attend an ENA-EHA Support Group in community,
 Thank Hawa for her time
Case Study 3
The Situation: Yamah’s gives her 12-month-old baby, Abdul, bites of family food at mealtime only.
Yamah is continuing to breastfeed.
The Visit:
Greet, Ask, Listen
 Greet Yamah and ask questions that encourage her to talk, using listening and learning, building
 How is breastfeeding going; how is eating other foods going? (How often is Abdul eating, what
kinds of foods is he eating, and how much?)
 Listen to Yamah’s concerns, and observe Abdul and Yamah
 Accept what Yamah is doing without disagreeing or agreeing
Identify
 Yamah is breastfeeding Abdul
 Yamah is giving Abdul bites of food at mealtime only
 Think: frequency, amount and diversity including snacks

 Praise Yamah for breastfeeding and giving other foods to Abdul
 Explain how important it is for Abdul’s growth and development that Yamah give foods other
than breastfeeding
 Talk with Yamah about the characteristics of complementary feeding: frequency, amount,
 Present options/small do-able actions (time-bound) and help Yamah select one or two that she
can try, (FADDUA) e.g. increase feeding frequency of 3 – 4 times a day; give a variety of foods to
Abdul; Abdul needs to receive about a cup of food at each meal; offer snacks to Abdul between
meals; assist Abdul during feeding times, provide separate plate for Abdul; and discuss hygienic
preparation of foods

 If available, counsellor will select an illustration that is most relevant to Abdul's situation -- and
discuss it with Yamah
 Ask Yamah to repeat the agreed upon behaviour – elements of BF + FADDUA
 Arrange with Yamah a time for a follow-up visit
 Suggest where Yamah can find support (attend an ENA-EHA Support Group in community,
 Thank Yamah for her time
Case Study 4
The Situation: Kaisha’s son, Faith, 15 months old, eats a family meal with her parents two times a day.
Kaisha has stopped breastfeeding her, and she seems small for her age.
The Visit:
Greet, Ask, Listen
 Greet Kaisha and ask questions that encourage her to talk, using listening and learning, building
 How is breastfeeding going; how is eating other foods going? (How often is Faith eating, what
kinds of foods is she eating, and how much?)
 Listen to Kaisha’s concerns, and observe Faith and Kaisha
 Accept what Kaisha is doing without disagreeing or agreeing
Identify
 Kaisha is no longer breastfeeding Faith
 Kaisha is giving Faith food twice a day at mealtime
 Faith seems small for her age
 Think: frequency, amount and diversity including snacks

 Praise Kaisha for giving family foods to Faith at mealtimes
 Talk to Kaisha about the possibility of re-lactating Faith
 Explain how important it is for Faith’s growth and development that Kaisha give different kinds
of foods to Faith especially since she is no longer breastfeeding Faith
 Talk with Kaisha about the characteristics of complementary feeding: frequency, amount,

 Present options/small do-able actions (time-bound) and help Kaisha select one or two that she
can try, (FADDUA) e.g. increase feeding times to 3 – 4 times a day; give a variety of foods to
Faith; offer 2 snacks during the day; Faith needs to receive a cup of food at each meal; add a
little oil Faith’s food; assist Faith during feeding times, provide separate plate for Faith; and
discuss hygienic preparation of foods
 If available, counsellor will select an illustration that is most relevant to Faith's situation -- and
discuss it with Kaisha
 Ask Kaisha to repeat the agreed upon behaviour – elements of BF + FADDUA
 Arrange with Kaisha a time for a follow-up visit
 Suggest where Kaisha can find support (attend an ENA-EHA Support Group in community,
 Screen with MUAC and refer to health facility/supplementary feeding program
 Thank Kaisha for her time

Document #40B: Practice Case Studies:
Feeding the Sick Child
Case Study 1
The Situation: Hannah’s three-month-old baby, Ben, has diarrhea and is vomiting. Although still
breastfeeding, Hannah has also been giving her baby water in a bottle.
The Visit:
Greet, Ask, Listen
 Greet Hannah and ask questions that encourage her to talk, using listening and learning,
building confidence and giving support skills.
 How is breastfeeding going? (How often is Ben breastfeeding; when did diarrhea start; when did
Ben begin receiving water?)
 Listen to Hannah’s concerns, and observe Ben and Hannah
 Accept what Hannah is doing without disagreeing or agreeing
Identify
 Hannah is breastfeeding Ben
 Hannah is giving Ben water in a bottle
 Ben has diarrhea and is vomiting
 Think: frequency, on-demand feeding day and night; duration of breastfeeding; Ben releasing
breast; check positioning and attachment; use of bottles

 Praise Hannah for breastfeeding Ben
 Talk with Hannah about the recommended breastfeeding practices: importance of exclusive
breastfeeding; frequency, on-demand feeding day and night; duration of breastfeeding; Ben
releasing breast on his own; check positioning and attachment; risk of using of bottles
 Present options/small do-able actions (time-bound) and help Kaisha select one or two that she
can try, e.g. breastfeed exclusively, increase breastfeeding frequency day and night; breastfeed
until Ben releases breast; supply and demand; risks of bottle feeding
 Advise Hannah to take her baby to the health center as soon as she can
 If available, counsellor will select an illustration(s) that is most relevant to Hannah's situation --
and discuss it with Hannah
 Ask Hannah to repeat the agreed upon behaviour – recommended practices of breastfeeding
 Arrange with Hannah a time for a follow-up visit

 Suggest where Hannah can find support (attend an ENA-EHA Support Group in community,
 Thank Hannah for her time
Case Study 2
The Situation: Joyce’s daughter, Diane, who is nine months old, has a mild fever and cough and refuses
to eat food.
The Visit:
Greet, Ask, Listen
 Greet Joyce and ask questions that encourage her to talk, using listening and learning, building
 How is breastfeeding going; how is eating other foods going? (When did fever and cough start;
when did Diane lose her appetite?)
 Listen to Joyce’s concerns, and observe Diane and Joyce
 Accept what Hannah is doing without disagreeing or agreeing
Identify
 Joyce is breastfeeding Diane
 Diane has a mild fever and cough, and she is refusing to eat
 Think: increase frequency of breastfeeding, on-demand feeding day and night; feeding favorite
foods; offering more liquids

 Praise Joyce for breastfeeding Diane
 Talk with Joyce about the importance of increasing frequency of breastfeeding; on-demand
feeding day and night; feeding smaller portions of favourite foods more often; offering other
liquids more frequently
 Present options/small do-able actions (time-bound) and help Joyce select one or two that she
can try, e.g. increase breastfeeding frequency day and night; offer smaller quantities of favourite
foods more frequently; offer other liquids; encourage Diane to eat; for the two weeks after she’s
better, to give Diane one additional meal each day while maintaining increased breastfeeding
frequency
 Advise Joyce to take Diane to the health center as soon as she can
 If available, counsellor will select an illustration(s) that is most relevant to Joyce's situation --
and discuss it with Joyce
 Ask Joyce to repeat the agreed upon behaviour
 Arrange with Joyce a time for a follow-up visit

 Suggest where Hannah can find support (attend an ENA-EHA Support Group in community,
 Thank Hannah for her time
Case Study 3
The Situation: Betty’s baby boy, Andy, was sick last week and is now recovering. He is five months old.
Betty continues to breastfeed as usual, but her baby is losing weight.
The Visit:
Greet, Ask, Listen
 Greet Betty and ask questions that encourage her to talk, using listening and learning, building
 How is Andy doing? How is breastfeeding going? Is Andy getting anything else to eat or drink?
 Listen to Betty’s concerns, and observe Andy and Betty
 Accept what Betty is doing without disagreeing or agreeing
Identify
 Betty is exclusively breastfeeding Andy
 Andy was sick last week and lost weight
 Think: increase frequency of breastfeeding, on-demand feeding day and night; duration of
breastfeeding; Andy receiving other foods or drinks?; preparation for giving complementary
foods; active feeding; WASH

 Praise Betty for breastfeeding Andy
 Talk with Betty about the importance of exclusive breastfeeding; frequency, on-demand feeding
day and night; increased frequency after sickness; number of wets during a 24-hour period;
duration of breastfeeding; Andy releasing breast on his own; risk of using of bottles; active
feeding; WASH practices
 Present options/small do-able actions (time-bound) and help Betty select one or two that she
can try, e.g. increase breastfeeding frequency day and night; breastfeed until Andy releases
breast; supply and demand; risks of bottle feeding; beginning of complementary foods around 6
months
 Advise Betty to take Andy to the health center regularly for growth monitoring
 If available, counsellor will select an illustration(s) that is most relevant to Betty's situation -- and
discuss it with Betty
 Ask Betty to repeat the agreed upon behaviour
 Arrange with Betty a time for a follow-up visit

 Suggest where Betty can find support (attend an ENA-EHA Support Group in community,
 Thank Betty for her time
Case Study 4
The Situation: Celeste, whose daughter, Albina, is 18 months old, tells a health worker that her baby is
recovering from an illness and has started eating well but is still losing weight.
The Visit:
Greet, Ask, Listen
 Greet Celeste and ask questions that encourage her to talk, using listening and learning, building
 How is Albina doing; how is breastfeeding going; how is other feeding going?
 Listen to Celeste’s concerns, and observe Albina and Celeste
 Accept what Celeste is doing without disagreeing or agreeing
Identify
 Celeste is breastfeeding Albina
 Albina is recovering from a sickness
 Albina is still losing weight
 Think: extra food for 2 weeks after sickness; frequency, amount and diversity of foods; active
feeding; WASH

 Praise Celeste for breastfeeding Albina
 Talk with Celeste about the importance of giving extra food for 2 weeks after sickness; offer 3 –
4 meals a day and 1 – 2 snacks such as banana, avocado or orange flesh sweet potato; foods at
home or in market; more active feeding; WASH practices frequency
 Present options/small do-able actions (time-bound) and help Celeste select one or two that she
can try, e.g. continue breastfeeding; increase frequency, amount and variety of foods; offer food
in smaller, more-frequent meals; assist Albina more in eating; put into practice WASH
 Advise Celeste to take her Albina to the health center regularly to check on weight gain
 If available, counsellor will select an illustration(s) that is most relevant to Celeste's situation --
and discuss it with Celeste
 Ask Celeste to repeat the agreed upon behaviour
 Arrange with Celeste a time for a follow-up visit
 Suggest where Celeste can find support (attend an ENA-EHA Support Group in community,
 Thank Celeste for her time

Document #41: About Support Groups
Definition
A support group a group of mothers and caregivers who gather together to discuss themes of Essential
Nutrition Actions and/or Essential Hygiene Actions and provide mutual support. The group meets
periodically and is facilitated by experienced mothers who know about optimal practices and who,
ideally, have mastered group dynamic techniques. Group participants share their experiences and
information and support each other to adopt best practices.
The Facilitator
 Sits in a circle at the same level as the rest of the group.
 Introduces himself or herself and asks participants to introduce themselves.
 Introduces the meeting’s purpose and theme.
 Explains that the support group meeting will last 60 to 90 minutes.
 Asks open-ended questions to encourage participation and active debate of the ideas.
 Encourages all to share experiences and ideas, including difficulties and challenges, even quieter
participants.
 Repeats key messages.
 Asks participants to summarize what they learned.
 Decides, with participants, on meeting length, frequency, timing, and topics.
Potential Community Support Group Facilitators

 Experienced mothers and health workers.
 Formally trained health workers.
 Community workers.
Characteristics of a Community Support Group

 Provides a safe environment of respect and trust.
 Allows participants to:
o Share information and personal experiences about different nutrition, health and hygiene
themes.
o Mutually support each other through their own experiences.
o Become persuaded of the value of trying to improve nutrition practices.
o Strengthen or modify certain attitudes and practices.
o Learn from each other’s experiences.

 Allows participants to reflect on their experiences, doubts, and difficulties, as well as on popular
beliefs and myths, common information, and adequate nutrition practices. In this safe
environment, the mother has the knowledge and confidence needed to decide to either
strengthen or modify her practices.
 Is not a lecture or a class. All participants play an active role.
 Focuses on the importance of interpersonal communication to allow all women to express their
ideas, knowledge, and doubts; share experiences; and receive and give support.
 Has a seating arrangement that allows all participants to have eye-to-eye contact (generally a
circle).
 Varies in size between three and 15 participants.
 Is usually facilitated by a trained, experienced caregiver whose role it is to listen and guide the
discussion.
 Is open, allowing the admission of all interested pregnant women, mothers who are
breastfeeding, women with older toddlers, and other interested people.
Participants: Nutrition Support Group

 Adolescent nutrition.
 Breastfeeding mothers.
 Mothers who have breastfed in the past.
 Pregnant women.
 Community workers.
 Caregivers and parents.
 Formally trained health workers.
Possible Topics for a Community Support Group

 Benefits of exclusive breastfeeding (for mother, child, family, and community).
 Breastfeeding techniques and challenges (position, attachment; insufficient breastmilk
production and sore, cracked nipples; babies separated from their mothers, twins; maternal or
child sickness).
 Adolescent and women’s nutrition.
 Complementary feeding beginning at six months (how to ensure a variety of food, active
feeding, how to vary feeding, why keep on breastfeeding, snacks, and how to increase amount,
frequency, and density).
 Feeding a sick child (how to encourage a sick child to eat or breastfeed, how to vary and enrich
feeding during and after sickness, why continue breastfeeding during a child’s sickness, why give
extra food during recuperation).
 Optimal water, sanitation and hygiene practices and their importance to nutrition and health.
 How to develop homestead food production to support family nutrition.

Community Groups and Gatherings as Basis for Support Groups
 People living with HIV and AIDS—where PMTCT sites are available.
 Food distribution sites.
 Therapeutic feeding centers.
 Community growth monitoring and promotion.
 Agricultural and similar groups.
 Around the market.
 At school meetings and traditional ceremonies.

Document #42: Support Group Observation checklist
COMMUNITY
PLACE
DATE TIME # OF ATTENDEES
THEME
GROUP FACILITATOR(S)
WHAT THE FACILITATOR DOES DURING THE MEETING COMMENTS
Introduces self to group.
Clearly explains the day’s theme.
Asks questions that generate participation.
Motivates quiet women to participate.
Applies communication skills.
Adequately manages content.
Shares tasks (if more than one facilitator).
Fills out the information sheet on the group.
Thanks women for attending the support group.
Invites women to attend the next support group (provides

place, date, and theme).
Asks women to talk to a pregnant or breastfeeding woman

before the next meeting, and report back.
WHAT MOTHERS DO DURING THE MEETING COMMENT
Share their experiences.
Sit in a circle.
Supervisor/mentor: provide feedback and support to Facilitator(s):

Document #43: What is Integrated Management of
Acute Malnutrition
Introduction
The Integrated management of Acute Malnutrition (IMAM)16 allows community engagement in
identifying and referring cases as early as possible through regular screening, especially with simple
tools like Middle-Upper Arm Circumference (MUAC) tapes.
Only the most severe cases (severe acute with medical complications) require in-patient care, saving
resources and family costs.
Innovations like ready to use therapeutic foods (RUTF) made home-based care possible and are highly
effective.
Components of Integrated Management of Acute Malnutrition

Community Outreach
 IMAM’s community element must be strong to mobilize mothers and caregivers to bring their
children to the OTP or supplementary feeding program (SFP) for screening before medical
complications arise from SAM.
 Outreach workers will search for children who have dropped out of care and will follow up with
home visits.
 Health workers and community health volunteers should do this in their communities.
An Outpatient Therapeutic Program
 OTPs will assess and treat the majority of severely malnourished children.
 OTP staff will have specific IMAM training and support.
A Stabilization Center
 The stabilization center (SC) will only admit as inpatients malnourished children with medical
complications who are not well enough to be treated as outpatients.
 These children will remain inpatients (five to seven days on average) until their condition is
stable enough for discharge to outpatient care for treatment.
A Supplementary Feeding Program
 The SFP treats and supports all moderately malnourished children, lactating mothers with have
infants under six months of age with MUAC of less than 21 cm, and pregnant women with
MUAC of less than 21 cm.
 SFPs usually provide corn–soy blend and oil to supplement the diets of moderately
malnourished children, although increasingly lipid-based ready-to-use foods are being used
16
Many settings still refer to this as community-based management of acute malnutrition (CMAM)

Document #44: Signs of Marasmus, Kwashiorkor, and
Bilateral Edema
A small percentage of children may suffer from SAM and have complications such as marasmus and
kwashiorkor. During times of severe food shortages, it can be expected that a larger percentage of
young children will develop marasmus and kwashiorkor; feeding-related behaviors as well as disease
and other factors also result in high rates during non-crisis times.
Clinical Manifestations of Marasmus

 quiet, apathetic demeanor
 flabby muscles
 easily-seen ribs and bones
 wrinkled buttocks
 “old man” face
 sunken eyes
Clinical Manifestations of Kwashiorkor

 bilateral pitting edema—usually on the lower limbs but
also sometimes on the child’s feet, hands, eyelids, belly,
or even over the whole body
 difficulty walking
 moon face or hanging cheeks
 loss of appetite
 lack of interest in surroundings, little energy
 skin changes
 straightening of hair and presence of different color bands
in the hair, indicating periods of malnourishment and improved nourishment (a red flag)
 hair is easy to pluck out, and straightening at the bottom and
curling on the top, which looks like a forest (a so-called “forest sign”)
Marasmic Kwashiorkor
 Bilateral pitting edema
 Severe wasting

IMPORTANT
Do not wait for any of these signs to appear before acting. After complications have
become apparent, the child is in great danger and may require intensive care.
Signs of malnutrition’s onset often go unrecognized.
LOOK FOR recurrent or prolonged illness or diarrhea, growth issues or weight leveling off or
decreasing, and feeding issues (e.g., fussy baby or breastfeeding problems).
How to Recognize Bilateral Pitting Edema

 Bilateral pitting edema (BPE) is a sign of kwashiorkor—always a severe form of malnutrition.
 To assess BPE, apply normal thumb pressure to both feet for three seconds. If a shallow print
persists on both feet, the child has nutritional edema.
 There is no need to take another anthropometric measurement of children with bilateral
edema; this condition is evidence enough of severe malnutrition with complications.
 These children are at high risk of mortality and urgently need to be treated in a Stabilization
Center.

Document #45: Acute Malnutrition Management and
Inpatient Treatment Admission Criteria
SEVERE ACUTE MALNUTRITION (SAM)
MODERATELY ACUTE WITH MEDICAL COMPLICATIONS

WITHOUT MEDICAL BILATERAL EDEMA NEGATIVE APPETITE
MALNUTRITION COMPLICATIONS
TEST OR ONE OF THE FOLLOWING
AND POSITIVE APPETITE TEST
MUAC
< 120 MM • PNEUMONIA
• MUAC < 115 MM
AND WITH LENGTH > 65 CM • HIGH FEVER (≥ 38 )
> 115 MM • NO EDEMA • PERSISTENT DIARRHEA

• POSITIVE APPETITE • DYSENTERY
TEST • LOW BLOOD SUGAR
• CLINICALLY WELL • HYPOTHERMIA (< 35.5)
• ALERT
SFP OUTPATIENT
CORN–SOY BLEND INPATIENT TREATMENT
THERAPEUTIC
AND OIL AT STABILIZATION CENTER
PROGRAM F75 AND F100
& IMPROVED DIET RUTF

Document #46: Food and Counseling for Outpatient
Therapeutic Programs
Management of Severe Acute Malnutrition without Complications
Food
 Provide a one-week supply of Ready to Use Therapeutic Food (RUTF) based on the child’s
weight. The most common RUTF is Plumpy'Nut®.
Messages for Caregivers of OTP Children

 Follow the Breastfeeding + FADDUA recommendations to encourage the mother to improve
feeding practices of the child.
 Explain that RUTF is a food and medicine for malnourished children only. It should not be
shared.
o It is given before other foods. Encourage the mother or caregiver to offer small regular
meals of RUTF and to get the child to eat often.
o The child has to drink plenty of clean water while he or she is eating RUTF.
 If the mother is breastfeeding, urge her to consistently give breastmilk before the RUTF and to
breastfeed on demand.
 Recommend the mother to use soap for washing a child’s hand and face before feeding.
 All food should be clean and kept covered.
 Sick children get cold quickly. Always keep the child covered and warm.
 When the child has diarrhea, never stop feeding. Offer extra breastmilk or extra food and clean
water or oral rehydration solution.
Managing Moderate Acute Malnutrition: Diet, Treatment, and Care

 Provide supplementary foods or refer the child to the Supplementary Feeding program (SFP) for
food, counseling, and follow-up, if there is one nearby.
 Assist the mother or caregiver to use the food received appropriately.
 Assess current feeding practices.
 Use nutritional counseling messages for the sick child.
 Emphasize optimal breastfeeding and complementary feeding, especially enriching with animal
source foods whenever possible.
 Encourage the mother or caregiver to use active feeding, so child finishes his or her food.
 Encourage the mother to take the child to monthly weigh-in visits, providing they are available.
 Encourage the mother to make sure the child is immunized and receives vitamin A and
deworming.

Document #47: Child MUAC Measurement

How to Take MUAC Measurement in a child <5 years
 The mid-upper arm circumference is used to measure “thinness.” The World Health
Organization recommends it as the preferred method for screening for moderate or severe
acute malnutrition.
 The MUAC tape has a number of different parts.
o It has a wide section and a narrow section.
o In the middle of the wide section, there is a hole with an arrow on each side.
o The tape’s narrow end has three colored sections: green, yellow, and red.
 MUAC measurement reflects health status: Green indicates good nutrition. Yellow points to
sickness or a lack of proper feeding, with nutrition in the danger zone (Moderate acute
malnutrition). Increased feeding and follow-up are essential. Red alerts you to very poor
feeding, with nutrition at a very dangerous level (Severe acute malnutrition): with complications
have highest risk of death; without complications needs immediate referral. Immediate
attention is needed to prevent death in cases of severe acute malnutrition.
 Take measurements on the middle of the upper arm—and always on the left arm.
 To measure a child under five, use only the child MUAC tape.
o Remove clothing covering the left arm.
o Find the midpoint of left upper arm with the following techniques:
1. Locate the tip of the child’s shoulder with your fingertips.
2. Bend the child’s elbow to make a right angle.
3. Measure the tip of the shoulder to the tip of the elbow using a string (or the MUAC
tape), and fold the string in half. Use a marker or pen to mark the midpoint on the
child’s arm.
o Straighten the child’s arm, have him or her keep it relaxed, and wrap the tape around the
arm at the midpoint. Make sure the tape has the proper tension—it should be neither too
tight nor too loose.
o Read the number between the two arrows to the nearest 0.1 cm. Immediately record the
measurement and identify the color of the tape between the two arrows flanking the hole.
 For patients who have passed their fifth birthday, use the adult MUAC tape.
COMMON MISTAKES
Wrapping the tape too tightly or too loosely
Not taking the measurement at the midpoint between shoulder and elbow
Measuring the MUAC with a bent elbow or an arm that is not relaxed
Measuring the right arm rather than the left

Document #48: Antenatal Care in Fourth, Sixth or
Seventh, Eighth, and Ninth Months
Evaluate for Danger Signs
Ask the mother to come back if she has any of these signs; refer immediately for follow up, if necessary.
Vaginal bleeding Excessive weight gain Breathing difficulty
Severe headache/blurred Foul-smelling or Ruptured membrane without
vision yellowish/green/brown onset of labor within 18
vaginal discharge hours
Convulsions/loss of
consciousness Loss of fetal movement Severe abdominal pain
Fever History of leakage of No weight gain
amniotic fluid for more than
Swollen hands and legs
18 hours
Check the Mother’s Tetanus–Toxoid Immunization

Complete if Necessary
TT1: as soon as possible TT3: six months later TT5: one year later
TT2: one month later TT4: one year later
Assess Health Indicators

 Weigh the mother and check that she is gaining weight (norm: 1kg/month in the second and
third trimesters).
 Measure mid-upper arm circumference (MUAC) and check for underweight (norm >23 cm).
 Check blood pressure (norm <140/90), Hb (norm >11gm/dl), albumin, and blood sugar (norm,
negative).
 Check blood group and venereal disease and HIV statuses.
Advise to Take and Continue Iron–Folic Acid Supplementation

(Check national guideline)
 Advise patient to take one tablet daily (iron 60 mg, folic acid 400 mcg) for six months starting in
pregnancy and continuing until completed.
 Explain side effects (e.g., difficult to digest, black stools, constipation), how to take it (i.e.,
between meals with fruits), and where to get more tablets.
 Screen for anemia (e.g., check color of palm) or Hb <12 gm/dl and treat (iron 120 mg, folic acid
400 mcg daily for three months).

Give Vitamin A Supplementation
Give 10,000 IU daily or 25,000 weekly.
Counsel on the Need for Diversified Diet during Pregnancy

 Advise women to eat one extra meal—i.e., an extra bowl of food—each day.
 Emphasize importance of using iodized salt for herself and the whole family.
 Recommend a varied diet containing animal-source foods: egg, liver, and other meats; Vitamin
A: palm oil, pawpaw, plum, pumpkin, red and yellow sweet potato, carrot, and dark green leafy
vegetables; Iron: beans, meat, liver, and dark green leafy vegetables; Vitamin C: citrus fruits.
Treat and Counsel on Malaria Prevention and Treatment

 Urge the importance of sleeping under a mosquito net to prevent malaria.
 Advise the mother to obtain antimalarial treatment—specifically, one dose of sulfadoxine-
pyrimethamine 500 mg + 25 mg (three tablets) at each scheduled visit in the antenatal care
schedule after completion of the first trimester, each treatment at least one month apart.
Counsel on Breastfeeding Practices

 Put the baby to the breast immediately after birth, even before the placenta has been expelled.
 Check for and demonstrate correct positioning and attachment.
 Give baby colostrum, not pre-lacteals (e.g., pepper water, water, butter, traditional medicine, or
other liquids).
 Breastfeed exclusively (no water, rice water, coconut water, or other liquids or foods) until baby
is six months of age.
 Breastfeed on demand at least 10 times, day and night, each 24-hour period (every two to three
hours).
 Empty one breast completely before switching to the other to give the baby the nutritious milk.
 Come back if any breast or nipple problems or other breastfeeding difficulties occur.
Review Status on Sexually Transmitted Infections

 Identify and treat STIs.
 Counsel the mother to use a condom during sexual intercourse to prevent HIV infection during
breastfeeding.
 Counsel for HIV testing and refer to sites offering prevention of mother-to-child transmission
(PMTCT) services.

Counsel on Family Planning
 Advise the mother to delay any new pregnancy at least 24 months after the delivery for the
health of the mother and baby; explain family planning options.
SHORT-TERM OPTIONS LONG-TERM OPTIONS PERMANENT OPTIONS
Natural family planning Injectables: IUD Male and female

medroxyprogesterone or voluntary surgical
LAM Norplant
Depo-Provera contraception
Standard day method
Mini pills
Spermicides and condoms
Offer General Advice

 Rest at least an hour a day during the third trimester.
 Avoid heavy lifting and heavy work.
 Attend the antenatal clinic four times during pregnancy, if possible (optimally, the fourth, sixth
or seventh, eighth, and ninth months).
 Deliver in a health facility.
 Return for a postnatal visit on the 7th and 45th days and in between, as needed.

Document #49: Delivery and Perinatal Care
Evaluate Danger Signs Requiring Immediate Referral
Watch for labor lasting more than 12 hours. Spot excessive vaginal bleeding.
Watch for labor before the completion of 37 Check for severe fever or foul-smelling
weeks of pregnancy. vaginal discharge.
Watch for baby in abnormal position (breech, Watch for headache/visual
transverse). disturbances/convulsions/fits.
At Birth, be sure to:

 Cut the umbilical cord after pulsation has stopped (two to three minutes).
 Cut the umbilical cord with clean instruments and cover it with a clean gaze (nothing else).
 Dry and warm the newborn.
 Clean the newborn’s airway if the baby does not cry immediately.
 Ensure skin-to-skin contact with the mother.
 Put baby to the breast immediately after birth (within one hour) even before the placenta has
been expelled.
 Weigh the baby and record the weight on growth chart or health card.

 Give baby colostrum, not pre-lacteals (e.g., pepper water, water, butter, traditional medicine,
other liquids).
 Breastfeed exclusively (no water, rice water, coconut water, or other liquids or foods) until baby
is six months of age.
 Breastfeed on demand at least 10 times, day and night, each 24-hour period (or every two or
three hours).
 Empty one breast completely before switching to the other to give the baby the nutritious milk.
 Come back if any breast or nipple problems or other breastfeeding difficulties occur.
 Help the mother on correct positioning and attachment.
 Explain to the mother how to express her breastmilk; demonstrate.
 Let her know she can store her milk safely up to eight hours at room temperature.

 Give 200,000 IU to the mother once within eight weeks after delivery.

Advise to Continue Iron–Folic Acid Supplementation
 Advise one tablet daily (iron 60 mg; folic acid 400 mcg) for six months starting in pregnancy and
continuing until completed.
 Explain side effects (e.g., difficult to digest, black stools, constipation) and how to take it (i.e.,
between meals with fruits) and where to get more tablets.
 Screen for anemia (e.g., color of palm) or Hb <12 gm/dl and treat (iron 120 mg; folic acid 400
mcg daily for three months).
Counsel on the Need for Diversified Diet during Lactation

 Advise women to eat two extra bowls of food each day.
A: palm oil, papaya, plum, pumpkin, red and yellow sweet potato, carrot, and dark green leafy
Counsel on Malaria Prevention and Treatment

Prevention
 Urge the importance of sleeping under a mosquito net to prevent malaria, especially for
pregnant and lactating women and young children.
Treatment
 Advise the mother to get antimalarial treatment if she has fever.
o Malaria with no complications: Give artesunate + amodiaquine.
o Malaria with complications: Give quinine.
Review and Administer Immunizations

 Check the mother’s immunization tetanus– toxoid (TT) status and complete if necessary.
 Give the baby BCG and oral polio vaccine.

breastfeeding.
(PMTCT) services.
Advice on Postnatal Practices

 Bring the baby back for a postnatal visit on the 7th and 45th days and in between, as needed.
 Observe the baby’s immunization schedule.
 Check the baby’s weight monthly.
 Avoid heavy work and lifting for two weeks after delivery.

 Choose a family planning practice.
 Advise on lactation amenorrhea method.
 Advise at least 3 years delay between two pregnancies.

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Document #50: Postnatal Care on 7th and 45th Days
after Delivery and Family Planning
Evaluate Danger Signs in Mothers Requiring Immediate Visit to Health
Facility
Heavy vaginal bleeding Convulsions (fits)
Breathing difficulty Severe headache or visual disturbances
Fever or foul-smelling vaginal discharge Hot, red, and painful areola or lump on the
breast
Abdominal pain
Pain in calf, with or without swelling
Watch for Danger Signs in Newborns Requiring Immediate Visit to

Health Facility
Breathing problems (slow or fast breaths; Jaundice or yellow skin
grunting)
Convulsions
Feeding difficulties or not sucking well
Lethargy
Feels cold to touch
Diarrhea
Fever
Persistent vomiting or abdominal distension
Umbilical pus

 Assess and demonstrate correct positioning and attachment.
 Breastfeed exclusively until baby is six months of age—no water, rice water, coconut water, or
other liquids or foods.
 Breastfeed on demand, at least 10 times day and night during each 24-hour period.
 Empty one breast completely before switching to the other in order to get the nutritious milk.
 Come back if any breast or nipple problems or other breastfeeding difficulties.
Expressing Breastmilk

 Advise women to eat two extra bowls of food each day as side meals.

 Check status. If not given at delivery, give 200,000 IU to the mother within eight weeks.
Advise to Continue Iron–Folic Acid Supplementation

 Advise one tablet daily (iron 60 mg; folic acid 400 mcg) for six months starting in pregnancy and
continuing until completed.
 Explain side effects (e.g., difficult to digest, black stools, constipation) and how to take it (i.e.,
between meals with fruits) and where to get more tablets.
 Screen for anemia (e.g., color of palm) or Hb <12 gm/dl and treat (iron 120 mg; folic acid 400
mcg daily for three months).
Counsel on Malaria Prevention and Treatment

Prevention
 Urge the importance of sleeping under an insecticide-treated mosquito net, especially for
Treatment
 Advise the mother to get antimalarial treatment if she has fever.
o Malaria with no complications: Give artesunate + amodiaquine.
o Malaria with complications: Give quinine.
Review and Administer Immunizations

 Check the mother’s immunization TT status and complete.
 Give the baby BCG and oral polio vaccine as needed.

breastfeeding.
(PMTCT) services.

 Advise the mother to delay any new pregnancy at least 24 months after the delivery; explain
family planning options.

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 Advise the mother to expose the baby (undressed below the waist) to morning sunlight every
day for 20 to 30 minutes.
 Advise the mother to return for postnatal visit on the 7th and 45th days and in between, as
needed.
 Observe the baby’s immunization schedule.
 Check the baby’s weight monthly.
 Avoid heavy work and lifting for up to two weeks after delivery.

Document #51: Expanded Program on Immunization
Assess the Child’s Immunization Status
 Check before the baby’s first birthday and update as needed.
 Advise the mother to follow the baby’s immunization schedule and weigh the baby monthly.
IMMUNIZATION WHEN IMMUNIZATIONS PROTECTS FROM
BCG Tuberculosis
FIRST IMMUNIZATION At birth
Oral polio Polio
Pentavalent I
Oral Polio 1
SECOND IMMUNIZATION Sixth week
PCV Diphtheria
Rota Hepatitis B
th Pentavalent II Haemophilus influenza
10 week
Oral Polio 2 Tetanus
THIRD IMMUNIZATION (Four weeks after
PCV Pertussis
Pentavalent I)
Rota Polio
th Pentavalent III Pneumococcus
14 week
Oral Polio 3 Rotavirus
FOURTH IMMUNIZATION (Four weeks after
PCV
Pentavalent II)
Rota
Measles and yellow
Nine months Measles, yellow fever,
FIFTH IMMUNIZATION fever
of age vitamin A deficiency
Vitamin A
Screen the Mother’s Status

 Evaluate the mother’s immunization status; complete as necessary; remind her of the next
session.
 Check the mother’s vitamin A supplementation status; administer 200,000 IU, if needed within
eight weeks after delivery.
 Screen for anemia (check color of palm) or Hb <12gm/dl) and treat (iron 120mg, folic acid
400mcg daily for three months.
Update the Child’s Vitamin A Supplementation Status

 As needed, for children 6 through 11 months, administer 100,000 IU vitamin A during measles
immunization (once).
 For children 12 through 59 months, administer 200,000 IU vitamin A every six months.

Update the Child’s Deworming
 As needed, for children from 12 to 59 months, provide a single 500 mg dose of Mebendazole (or
Albendazole) every four to six months.
Check for and Treat the Child’s Anemia

 For children under two years of age: iron 25mg, folic acid 100–400 mcg daily over three months.
 Simultaneously, treat malaria: amodiaquine 153 mg + artesunate 50 mg for three days.
Assess and Counsel on Breastfeeding Practices for Children under Six

Months
 Review and correct positioning and attachment if the child is less than three months of age.
 Breastfeed exclusively until the baby is six months of age—no water, rice water, coconut water,
or other liquids or foods.
Assess and Counsel on Adequate Complementary Feeding from 6 to 24

Months
 Continue breastfeeding child until he or she is 24 months old (at least eight times during a 24-
hour period).
 Beginning at six months, feed infants two to three meals of porridge each day, plus one or two
other snacks in addition to breastmilk. Quantities can increase as the infant grows.
 Beginning at 12 months of age, offer family food to the baby four times a day; also, give the
child one or two snacks in addition to breastmilk.
 Enrich the baby’s diet with varied foods: Animal-source foods: egg, liver, and other meats;
Vitamin A: palm oil, papaya, plum, pumpkin, red and yellow sweet potato, carrot, and dark
green leafy vegetables; Iron: beans, meat, liver, and dark green leafy vegetables; Vitamin C:
citrus fruits; Oil or butter.
 Wash your hands and your baby’s before preparing food and before feeding him or her.
 Encourage the child to eat from his or her plate; encourage and assist him or her to finish all
food.

 Advise women to eat two extra bowls of food each day as side meals.
Counsel on Malaria Prevention

 Urge the importance of sleeping under an insecticide-treated mosquito net, especially for

breastfeeding.
(PMTCT) services.

family planning options

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Document #52: Growth Monitoring and Well-Child Visits
Growth Monitoring and Promotion
 Record the child’s birth weight onto the growth card if that information is available.
 Determine the child’s age in months.
 Calibrate the scale to zero and weigh the child (after removing heavy clothing); record weight on
the growth chart.
 Evaluate the direction and position of the baby’s growth curve; compare with the reference
curves on the card.
 Most importantly, explain the child’s growth curve to the mother.
 Congratulate the mother if the child is growing well; assess feeding practices; offer relevant
counseling.
 If the child is not growing well, counsel mother on appropriate feeding; measure height; check
for acute malnutrition and edema; and refer for treatment, if necessary.
 Advise the mother to weigh the baby monthly.
Counsel on Breastfeeding Practices for Children under Six Months

 Assess and demonstrate correct positioning and attachment if the child is less than three
months of age.
 Assess and Counsel on Adequate Complementary Feeding from 6 up to 24 Months
 Continue breastfeeding at least up to 24 months (at least eight times during each 24-hour
period).
 Beginning at 6 months, feed infants two to three meals of porridge each day, plus one or two
other snacks in addition to breastmilk.
 Beginning at 12 months of age, offer family food to the baby four times a day; also give one or
two snacks in addition to breastmilk.

 Enrich the baby’s diet with varied foods: animal-source foods: egg, liver, and other meats;
citrus fruits; oil or butter.
 Wash your hands and your baby’s before preparing food and before feeding.
 Encourage the child to eat from her own plate, and encourage and assist her to finish all her
food.
During and after Illnesses

 Counsel the mother to increase breastfeeding frequency during and after illnesses.
 During recovery, for children older than six months of age, advise the mother to give one
additional bowl of food every day for two weeks in addition to breastmilk.
Assess Immunization Status

 Complete immunizations as appropriate.
 Advise the mother to follow the baby’s immunization schedule.

 As needed, for children 6 to 11 months, administer 100,000 IU vitamin A during measles
 For children 12 to 59 months, administer 200,000 IU vitamin A every six months.
Update the Child Deworming

Check for and Treat the Child’s Anemia

 For children under two years of age: iron 25 mg; folic acid 100–400 mcg daily over three
months. In areas of endemic malaria, iron supplementation should be accompanied by diagnosis
and treatment of malaria.
 Simultaneously, treat malaria: amodiaquine 153 mg + artesunate 50 mg for three days.

 Advise women to eat two extra bowls of foods as side meals.
Counsel on Malaria Prevention

 Urge the importance of the entire family sleeping under an insecticide-treated mosquito net,
especially for pregnant and lactating women and young children.

breastfeeding.
(PMTCT) services.


medroxyprogesterone or Depo- voluntary surgical
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 Urge the mother to expose the baby (undressed below the waist) to morning sunlight every day
for 20 to 30 minutes.

Document #53: Sick-Child Visits and Integrated
Management of Neonatal and Childhood Illnesses
Check for Danger Signs and Refer, If Necessary
 Assess, classify illness, and treat according to the IMNCI algorithms (e.g., for cough, difficult
breathing, diarrhea, fever, ear problems).
 Refer if danger signs are found. They include:
o Lethargy or unconsciousness o Vomiting everything
o Convulsing in past or now o Unable to eat or drink
Assess the Child’s Nutritional Status

 Determine the child’s age in months.
 Check for visible and severe wasting with weight for height (or MUAC if height is impossible to
measure); refer for treatment of acute malnutrition, if necessary.
 Check for swelling (edema); refer for treatment, if necessary.
 Weigh child (remove heavy clothing) and record weight on the growth chart.
 Evaluate the direction and position of the baby’s growth curve; compare with the reference
curves on the card.
 Most importantly, explain the child’s growth curve to the mother.
 Urge the mother to come to the health center to have someone weigh the baby monthly to
ensure he is growing well.
 Counsel the mother on appropriate feeding during and after illness.
Counsel on More-Frequent Breastfeeding during and after Illness

 For a child older than six months of age, urge the mother to breastfeed more often and to give
him or her one extra meal every day for two weeks after recovery from an illness.

months of age.
 Breastfeed on demand, at least 10 times day and night during each 24-hour period, every two to
three hours.

Assess and Counsel on Adequate Complementary Feeding from 6 up to 24

Months
period).
 Beginning at six months, feed infants two to three meals of porridge each day, plus one or two
other snacks in addition to breastmilk.
 Wash your hands and your baby’s before preparing food and before feeding her.
food.
If the Child Has Diarrhea

 For children under six months, give zinc 10 mg daily for 10 to 14 days with low osmolarity oral
rehydration solution.
 For children aged six months to five years, give zinc 20 mg daily for 10 to 14 days.
Check for Anemia in the Child and Treat

 For children under two years of age, give iron 25 mg and folic acid 100–400 mcg daily over three
months.
 For children aged two to five years, give iron 60 mg and folic acid 400 mcg daily over three
months.
 Where malaria is endemic, treatment with iron should be accompanied by appropriate diagnosis
and treatment of malaria.
 Simultaneously treat malaria with amodiaquine 153 mg + artesunate 50 mg over three days.

 Add vitamin A to treatment for other conditions according to IMNCI protocol. (See table below.)
6 THROUGH 11 MONTHS 12 THROUGH 59 MONTHS

DISEASES
(100,000 IU) (200,000 IU)
Persistent diarrhea Day 1 Day 1
Severe malnutrition (eye lesions) Day 1 Day 1
Measles Day 1, Day 2, Day 14 Day 1, Day 2, Day 14
Xerophthalmia (night blindness, eye lesion) Day 1, Day 2, Day 14 Day 1, Day 2, Day 14

Check the Mother’s Tetanus–Toxoid Immunization Status and Complete,

If Necessary
TT1: as soon as possible TT3: six months later TT5: one year later
TT2: one month later TT4: one year later

Document #54: Community Management of Acute Child
Malnutrition in an Outpatient Therapeutic Program
Measure Mid-Upper Arm Circumference and Weight for Height and
Classify
 How to Classify
o Moderate acute malnutrition if MUAC < 12 cm > 11.5 cm or wt/ht >-3 < -2 z score
o Severe acute malnutrition if MUAC < 11.5 cm or wt/ht < -3 z score
 Identify complicated SAM and refer to stabilization center for inpatient treatment, if there is:
o Presence of bilateral pitted edema
o Failed appetite test
o Other medical complications (diarrhea, pneumonia, fever)
On Admission, If Severe Acute Malnutrition, Provide Counseling and

Medical Treatment
 Vitamin A, depending on age
 Folic acid if there are signs of anemia (5 mg or 2.5 mg in endemic malaria areas)
 Antibiotic therapy for seven days (amoxicillin, ampicillin, or gentamycin) , if necessary
 Malaria treatment and insecticide-treated mosquito nets
 Measles immunization
 RUTF by weight (following national guidelines)
If Moderate Acute Malnutrition, Refer to Supplementary Feeding

Program (SFP)
 In the SFP, obtain appropriate food rations (corn–soya blend, sugar, and oil or ready to use
supplementary foods –RUSF).
 Provide counseling, as relevant and as noted below.
Counsel on More-Frequent Breastfeeding during and after Illness

 For a child older than six months of age, urge the mother to breastfeed more often and to give
him or her one extra meal, every day for two weeks after recovery from an illness.

months of age.
 Empty one breast completely before switching to the other to get the nutritious milk.
 Try to reinitiate breastfeeding if the child is less than 24 months of age.
Assess and Counsel on Adequate Complementary Feeding from 6 up to 24

Months
period).
 Beginning at six months, in addition to breastmilk, feed infants two to three meals of porridge
each day plus one or two other snacks.
 Wash your hands and your baby’s before preparing food and before feeding her.
food.
Check on Immunization Status

 Complete immunizations as needed.
 Advise the mother to observe the appropriate immunization schedule and weigh the baby
monthly.
Check for Child’s Anemia and Treat

 For children under two years of age, give iron 25 mg and folic acid 100–400 mcg daily over three
months.
 For children aged two to five years, give iron 60 mg and folic acid 400 mcg daily over three
months.
o Simultaneously treat maria with amodiaquine 153 mg + artesunate 50 mg over three days.




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Document #55: Comparison of Training Guides for
Health Workers and Community Workers
TRAINING GUIDE FOR HEALTH WORKERS TRAINING GUIDE FOR COMMUNITY WORKERS
# of Sessions = 24 # of Sessions = 14
Length of Training = 5 days Length of Training = 3 days
Session 1: Why are we here? Session 1: Why are we here?
Session 2: About social behavior change Not included

communication
Session 3: Women and child nutrition Activity 1.2: Explore how to stay well-nourished
Activity 3.1: Recognize key factors that contribute to a
healthy, well-nourished woman and child
Session 4: ENA & EHA Activity 1.3: Identify how community health workers
Activity 4.1: Describe the Routine Nutrition Practices can improve nutrition and hygiene
that the HW Shares with Women to Improve Their
Own and Their Children’s Health; and Where/When
Can the HW Share These Messages with Women?
Session 5: Women’s nutrition: the malnutrition cycle Session 2: Adolescent girls and women’s nutrition
and strategies to break it during pregnancy, and the importance of
Activity 5.1: Explain the Intergenerational Cycle of micronutrients
Malnutrition Activity 2.1: Explain why nutrition for women is
important through the life cycle
Reference Handbook Practices:
Practice 1: Nutrition for Adolescent Girls and Non-
Pregnant women
Practice 2: Nutrition for Pregnant Women
Practice 3: Preventing Anemia and Malaria during
Pregnancy
Practice 4: Using Iodized Salt
Session 6: Nutrition in the context of HIV Not included
Session 7: Breastfeeding Advantages, Beliefs, and Not included

Myths and the Risks of Formula Feeding
Session 8: Breastfeeding practices from birth up to six Session 3: Breastfeeding up to 6 months

months Reference Handbook Practices:
Practice 5: Early Initiation of Breastfeeding
Practice 6: Exclusive Breastfeeding birth from up to 6

Months of Age
Practice 7: Positioning your baby correctly for
breastfeeding
Practice 8: Nutrition for Lactating Mothers
Session 9: Infant feeding and HIV Not included
Session 10: Family planning and nutrition Not included
Session 11: Essential Hygiene Actions Session 7: Essential Hygiene Actions

Reference Handbook Practices:
Practice 17: Keeping the Environment Clean
Practice 18: Handwashing
Practice 19: Washing a Child’s Hands before Feeding
Practice 20: Washing Your Hands Easily Using
Minimum water
Practice 21: Keeping Food and Food Containers Clean
Session 12: Using pictures to discuss practices Session 4: Using pictures to discuss practices
Session 13: Negotiation with mothers, fathers, Session 5: Negotiation with mothers, fathers,
grandmothers, or other caregivers: women’s nutrition grandmothers, or other caregivers: women’s nutrition
during pregnancy and breastfeeding practices during pregnancy and breastfeeding practices
Session 14: Preventing and controlling micronutrient Reference Handbook Practices:

deficiencies Practice 3: Preventing Anemia and Malaria during
Activity 14.2: Identify health problems caused by Pregnancy
micronutrient deficiencies and how to remedy them Practice 4: Using Iodized Salt
Practice 15: Importance of vitamin A
Practice 16: Preventing Anemia
Session 15: Complementary feeding practices Session 6: Complementary feeding and feeding a sick
Activity 15.2: Describe how health workers can child
support complementary feeding practices Activity 6.1: Practices in complementary feeding and
Activity 15.4: Name local, available and seasonal feeding a sick child
available foods appropriate for infants and young Activity 6.2: Name local, available and seasonal foods
children and Activity 15.5: Make a calendar of appropriate for infants and young children
seasonal foods A Reference Handbook:
Practice 9: Introducing complementary foods
Practice 10: A varied diet
Practice 11: Feeding frequency and quantity for
children aged 6 - 11 months
Practice 12: Feeding frequency and quantity for
children aged 12 up to 24 months

Practice 17: Keeping the environment clean
Practice 18: Hand washing
Practice 19: Washing a child’s hands before feeding
Session 16: Feeding the sick child and danger signs in Session 6: Complementary feeding and feeding a sick
illness child
A Reference Handbook:
Practice 13: Feeding sick children during and after
illness
Practice 14: Nutritional care of infants and children
with diarrhea or moderate malnutrition
Session 17: Negotiation with mothers, fathers, Session 9: Negotiation with mothers, fathers,
grandmothers, or other caregivers: complementary grandmothers, or other caregivers: complementary
feeding and the sick child feeding and the sick child
st
Session 18: 1 Field Practice Session 11: Field Practice
Session 19: Community Support Groups Session 13: Community Support Groups
nd
Session 20: 2 Field Practice Session 11: Field Practice
Session 21: Integrated Management of Acute Session 8: Screening for malnutrition and referring a
Malnutrition child who is malnourished
Session 22: The ENA and contact points (only for

health workers)
Session 23: Improving nutrition at community level Session 14: Implementation and action plans
and developing action plans
Session 24: Post assessment and course evaluation Session 14: Implementation and action plans
Not included Session 10: Gender Roles
Not included Session 12: Homestead food production and nutrition

A Reference Handbook:
Practice 22: Raising diverse crops and small animals,
and consuming a varied diet
Practice 23: Diversifying crops for a varied diet
Practice 24: Importance of a varied diet for pregnant
and lactating farmers
Practice 25: Raising and eating fish
Practice 26: having small-animal products
Practice 27: Taking care of poultry or small livestock
Practice 18: Composting

Practice 29: Water management through mulching
Practice 30: Farmers’ role in providing a varied diet to
their pregnant and lactating wives and children under
two

Document #56: Supervision Guidelines for Community
Workers
Objectives
 Reinforce the importance of supporting community workers in their ongoing activities to assure
quality of their work and continued motivation
 Mentor community workers in promoting nutrition, hygiene, and homestead food production.
 Provide further opportunities for learning and exchanging experiences.
Time
2 hours 15 minutes
Frequency of supervision
 For community workers: At most one month after training, then every two to three months, as
needed.
 For community groups functioning well: Every three to four months.
Activity 1: Problems and Solutions in Breastfeeding, Complementary

Feeding, Sick Children, and Women’s Nutrition and Micronutrients
(45 minutes)
 Each participant writes (or thinks of) two questions relating to breastfeeding, complementary
feeding, sick children, and women’s nutrition and micronutrients.
 Have participants form three groups.
 Have group members list all their questions and then as a group, discuss answers to shared
questions.
 In plenary, pose the questions, with facilitators to help provide answers.
Activity 2: Assessment of Negotiation Field Practice

(1 hour 30 minutes)
 Divide participants into pairs.
 Ask participants to practice negotiation sessions (four to six mothers per team).
 Divide the tasks for each team as follows:
o One participant negotiates with a mother while other participants observe, using the
negotiation observation checklist (see Document #26B, Observation Checklist for GALIDRAA
Counseling Steps, above). Then participants provide feedback.

o Reverse roles until each team has negotiated with four to six mothers.
o When all the teams have had a chance to practice negotiation skills, review feedback in
plenary.
 In plenary, have each team present the strong points and points to be improved.
 Summarize key points and reinforce important ones.
Activity 3: Experience Sharing

(45 minutes)
 Divide participants into three groups.
 Have each group describe its community work.
 Discuss the strong points, problems encountered, and solutions undertaken to solve those
problems.
 For each unsolved problem, ask group members to suggest potential appropriate solutions. The
goal is for group members to see how to improve their way of working, choose which activities
to maintain, and decide on optimal next steps.
Closing
 Present and summarize group thoughts and highlights.
 Set a date for the next meeting.

Document #57: Action Plan Template for Implementation of
ENA & EHA Program
NUMBER OF RESPONSIBLE TARGET

RESOURCES/MATERIALS
ACTIVITY WHO PARTICIPAN WHEN WHERE FOLLOW-UP
REQUIRED
TS

Document #58: Post-Assessment
Please read through the following statements. Select Yes if you agree with the statement or select No if
you disagree with the statement.
# POST ASSESSMENT YES NO
1. When breastfeeding, the baby’s chin needs to touch the mother’s breast.
2. Vitamin A supplementation is necessary only for children under 1 year.
3. Even if a mother believes she does not have enough breastmilk, she can still be able
to adequately breastfeed her baby.
4. A mother can prevent sore and cracked nipples by correctly positioning and
attaching her baby at the breast.
5. Watery food is a better food for a 6-month old baby than soft porridge.
6. The mother or caregiver needs to play with the baby to encourage the baby to eat
all the food given.
7. Animal products, beans and legumes are the foods that help a child grow.
8. Young children should be breastfed for at least 1 year.
9. Mothers need support from the family or the community in order to feed their
children.
10. When a young child over 6 months has diarrhea, the mother needs to decrease the
frequency of breastfeeding, frequency of other liquids, and the frequency of foods
to give child’s stomach a rest,
11. A pregnant woman needs to eat more than a woman who is lactating.
12. Red meat, liver, and green leafy vegetables contain iron.
13. A malnourished mother is likely to give birth to a low birth weight child.
14. Breastfeeding benefits only the baby.
15. It is important to sleep under an ITN to prevent anemia in women and children.
16. Pregnancy and lactation are the only points in the lifecycle of females where
nutrition should be improved.
17. It is important to focus on pregnant and lactating women and children under two
year of age to improve nutrition outcomes.

# POST ASSESSMENT YES NO
18. When a mother is HIV-positive, she cannot breastfeed.
19. Integration of nutrition into other sectors means reaching mothers, their babies and
20. In traditional complementary foods, iron is almost always deficient.

Document #59: Pre- and Post-Assessment: Answers
# PRE AND POST ASSESSMENT YES NO
1. When breastfeeding, the baby’s chin needs to touch the mother’s breast. X
2. Vitamin A supplementation is necessary only for children under 1 year. X
3. Even if a mother believes she does not have enough breastmilk, she can still be able to X
adequately breastfeed her baby.
4. A mother can prevent sore and cracked nipples by correctly positioning and attaching X
her baby at the breast.
5. Watery food is a better food for a 6-month old baby than soft porridge. X
6. The mother or caregiver needs to play with the baby to encourage the baby to eat all X
the food given.
7. Animal products, beans and legumes are the foods that help a child grow. X
8. Young children should be breastfed for at least 1 year. X
9. Mothers need support from the family or the community in order to feed their children. X
10. When a young child over 6 months has diarrhea, the mother needs to decrease the X
frequency of breastfeeding, frequency of other liquids, and the frequency of foods to
give child’s stomach a rest,
11. A pregnant woman needs to eat more than a woman who is lactating. X
12. Red meat, liver, and green leafy vegetables contain iron. X
13. A malnourished mother is likely to give birth to a low birth weight child. X
14. Breastfeeding benefits only the baby. X
15. It is important to sleep under an ITN to prevent anemia in women and children. X
16. Pregnancy and lactation are the only points in the lifecycle of females where nutrition X
should be improved.
17. It is important to focus on pregnant and lactating women and children under two year X
of age to improve nutrition outcomes.
18. When a mother is HIV-positive, she cannot breastfeed. X
19. Integration of nutrition into other sectors means reaching mothers, their babies and X
20. In traditional complementary foods, iron is almost always deficient. X

Document #60: ENA&EHA: Course Evaluation
Dear Participant,
Thank you for your valuable time for contributing and participating in this training. Please take a few
minutes to reflect on the training and provide your feedback which will be used to improve future
trainings.
Place a √ in the box that reflects your feelings about the following:
GOOD AVERAGE UNSATISFACTORY REMARKS
The Training
objectives were met
The training methods

used were mostly
The reading
materials used were
mostly
The Field Practice

session was mostly
Your capacity to
carry out an identical
training (for TOT) is
Time allocation for

discussions was
Facilitation of the
workshop was
mostly
1. Which sessions/topics did you find most useful?
2. Which sessions/topics did you find less useful?
3. What are your suggestions to improve the training?

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Essential Nutrition Actions

and Essential Hygiene Actions

Reference Manual: Health Workers and Nutrition Managers | I

II | Essential Nutrition Actions and Essential Hygiene Actions

Reference Manual: Health Workers and Nutrition Managers | III

Reference Manual: Health Workers and Nutrition Managers | V

Reference Manual: Health Workers and Nutrition Managers | 1

2 | Essential Nutrition Actions and Essential Hygiene Actions

Nutritional Care of Sick and Malnourished Children

Prevention and Control of Anemia

Prevention and Control of Vitamin a Deficiency

Reference Manual: Health Workers and Nutrition Managers | 3

4 | Essential Nutrition Actions and Essential Hygiene Actions

 Adolescent and women health

Food Security and Livelihoods

 Addressing seasonal food insecurity

 Early warning and resilience

 Social protection and safety nets

 Conditional and unconditional cash transfers

 Dietary quality and diversity

Water, Sanitation and Hygiene (WASH) interventions

 Promotion of hygiene behaviors and practices

 Hygienic and sanitary environment

 Drinking water – quality, distance and source

 Improved sanitation facilities

 Reduction and elimination of open defecation

Early Childhood Development (ECD) and Positive Caregiving

Reference Manual: Health Workers and Nutrition Managers | 5

Implementing the ENA Framework Entails Three Interconnected

6 | Essential Nutrition Actions and Essential Hygiene Actions

Reference Manual: Health Workers and Nutrition Managers | 7

WHO References (2013)

ENA Training Materials (2015)

Technical Capacity Assessment tools (JSI, 2013)

Quality Assessment of Nutrition Services-A How-To Guide (HKI. jnielsen@hki.org)

Supportive Supervision Tools

Care Group Guidance for Community

Formative Research Tools

8 | Essential Nutrition Actions and Essential Hygiene Actions

Reference Manual: Health Workers and Nutrition Managers | 9

10 | Essential Nutrition Actions and Essential Hygiene Actions

o women’s nutrition (adolescents, and during pregnancy and lactation)

 Perform the following skills:

o negotiate with mothers/fathers/caregivers to encourage them to try one improved practice

Reference Manual: Health Workers and Nutrition Managers | 11

# PRE ASSESSMENT YES NO

2. Vitamin A supplementation is necessary only for children under 1 year.

8. Young children should be breastfed for at least 1 year.

14. Breastfeeding benefits only the baby.

18. When a mother is HIV-positive, she cannot breastfeed.

12 | Essential Nutrition Actions and Essential Hygiene Actions

20. In traditional complementary foods, iron is almost always deficient.

Reference Manual: Health Workers and Nutrition Managers | 13

WHO WHEN/WHERE/CONTACT NUTRITION AND HYGIENE PRACTICES

Adolescent  Schools  Adolescent nutrition

Woman  Discussion groups  Woman’s nutrition

Pregnant  Antenatal and  One extra meal per day

Newborn Delivery  Place baby skin-to-skin with mother