Whatvis Concept or Summurize IYCF

IYCF CORE indicator 8

1. Early initiation of b/f

2. Exclusive B/F till 6 months

3. Continued b/f up to 1 yrs

4. Introduction to solid and semi liquid and soft drinks

5. Minimum meal frequency

6. Minimum dietary diversity

7. minimum acceptable diet

8. Consumption of iron rich diet or iron fortified foods

Optional IYCF indicators 7

1. Children ever breastfed

2. continued breastfeeding to 2 yrs

3. Age appropriate breastfeed

4. Predominant breastfeeding under 6 months

5. Duration of breastfeeding

6. Bottle feeding

7. Milk feeding frequency for non breastfeeding children

Consequences of malnutrition

Lower economic productivity

Less return on investment and education

Increase chronic diseases

Risk in adult life

Impaired physical development

Delayed and impaired mental and psychosocial development

Reduce immunity to infection diseases

How can do you know good community involvement in acute malnutrition mgt?

Cases coming early to treatment

Enhance complicated are rare

Strong and ongoing early identification of cases

Community will able to demand for time response

The defaulter and mortality will be low and cure rate will be high

5 dominant of CMAM

Enabling environment

Excess to service

Excess to supply

Competence for cmam

Quality of service

Forms of malnutrition

Under weight

Chronic malnutrition

Micronutrient deficiency

Acute malnutrition

Key elements of program quality

Integration of d/t components

Training staff on protocol

Supervision

Community mobilization and early diagnosis

4 tools of monitoring and evaluation

Individual ration card

Registration book

Referral slip

Records of home visit/PDM

ENA is a strategy or approach to expand the coverage of seven affordable and evidence-based actions to improve the nutrition of women and children, especially those under the age of two. The seven Essential Nutrition Actions are:

Exclusive breastfeeding for children 0-6 months

Adequate complementary feeding for children 6-24 months with continued breastfeeding for at least 24 months

Adequate nutritional care of the sick and severely malnourished child

Adequate nutrition for women

Prevention of vitamin A deficiency for women and children

Prevention of anemia for women and children

Prevention of iodine deficiency for all members of the household.

The ENA approach emphasizes contacts at critical stages in the lifecycle to deliver the above interventions so that growth and micronutrient status of children and women improve. These contact points are:

Pregnancy •

Delivery and early neonatal consultations •

Postnatal and family planning contacts •

Immunization contact •

Well child visits, including growth monitoring and promotion •

Sick child visits, especially during and just after illness

Give 5 examples of appropriate child care practice

Indoor space

Room arrangement

Space for piracy

Child related disability

Gross motor play

Why IYCF focuses on PLW and under two yrs old children in dollo addo refugee context?

They are vulnerable for malnutrition and illness

They are the weakest individual group who needs extra support

They need additional and balanced food because of the infant,s rapid growth and PLW weakness

B.c of household food insecurity

b/c lack of good care and breastfeeding causes malnutrition

IYCF is one of the best strategies to promote child health and god care practice

To promote the mental and psychological status

To reduce mortality and morbidity

Similarity and differences b/n national and refugee CMAM

Similarity

They use same products e.g. PPN PPS

Have same components

Systemic and specific treatment

Same Target group

Community mobilization

Active case finding

Referral System

Defaulter tracing mechanism

Difference

Anthropometric measurement e.g. muac ,WFH

Appointment date wkly and bi-wkly

Decentralized and centralized

More stakeholders and monitoring

Reporting period

Protocols

Major challenges and opportunities of IYCF

Challenges

Cultural beliefs

Mother work overload

Breastfeeding difficulties

Bottle feeding

Lack of knowledge and awareness

Lack of support from males

Illnesses e.g. oral thrush and diarrheal diseases

Opportunities

Integrated with CMAM components

BCC strategy and IEC materials

Primary Health care facility

ENA approach

ANC and PNC services

Trained traditional birth attendance

Mother to mother support approach

Father to father support approach

Individual counseling

Health education

Nutritional status of children less than 2 years and mothers should be promoted

at 6 essential points of contact with the community and the health care unit

include:

􀂃 Antenatal care

􀂃 Delivery

􀂃 postnatal care and Family planning

􀂃 Immunization

􀂃 Growth monitoring and well baby clinic

􀂃 Sick baby clinic

3 rules of home treatment of home visit

Extra food

Continue feeding

When to return

IYCF strategies

Exclusive breastfeeding

Complementary

Mother to mother support group

Health education

Individual counseling

FGDS

Father to father support group

Ten steps of successful breastfeeding

Have a written breastfeeding policy that routine communicated to all health care staff

Train health care staffs to this policy

Inform all pregnant women about benefit and mgt of breastfeeding

Help mothers initiative breasting as soon as possible after giving birth

Show mothers how to breastfeed and to maintain

Give new born infants no food or drink then breast milk unless medically indicated

Encourage mothers and babies to stay to gather at least 24 hrs

Encourage breastfeeding demand

No artificial and bottle feeding

Promote and support the establishment of breastfeeding support group

Primary failure of OTP

No wt gain 21 days for non edematous children

Failure to reduce edema in 14 days

Edema still persists in 21 days

Secondary failure

Failure appetite test

Wt loss at 5% of body wt at any visit

Wt loss 2 consecutive wks

Failure to gain more than 2.5g /ka/day

Primary failure of SC

Failure to gain appetite on day 4

Failure to start losing edema on day 4

Edema still persist on day 10

Failure to enter phase 2 in day 10

Secondary failure SC

Failure to gain more than 5g/kg/day 3 consecutive days

Nutrition: – is the sum total of the process by which living things

Receive and utilize the necessary materials for survival, growth and

Maintenance of worn out tissues.

Malnutrition: – is the condition that results from an imbalance

between dietary intake and requirements. It includes under nutrition,

which results from less food intake and hard physical work and over

nutrition results from excess food intake and less physical activities.

Diet: – is defined as food containing all the nutrients in a sufficient

amount and in proper ratio.

Roughage: – is defined as food fibres which enable the body to get

rid of waste products, which would otherwise become poisonous to

In general feeding is dependent on the controlling centres, appetite

and satiety in the brain. There are a variety of stimuli, nervous,

chemical and thermal, which may affect the centres and so alter

feeding behaviour.

Daily calorie requirements of individuals

􀂊 Infants 1 – 3 years need 1,000 cal/day

􀂊 Children 5 years need 1,500 cal/day

􀂊 Children 5 – 8 years need 1,800 cal/day

􀂊 Children 10 – 12 years need 2,000 cal/day

􀂊 For adolescents and adults calorie requirements depend on the

degree of physical activities

From 13 – 20 years of age

Office worker Heavy work

2, 800 cal/day 3,500 cal/day

Adults

2,300-cal/day 2,700 cal/da

Very heavy work up to 4,000 cal/day

For pregnant woman, the daily figure must be increased by 150

The energy requirements of individuals depend on

♦ Physical activities

♦ Body size and composition

♦ Age may affect requirements in two main ways

– During childhood, the infant needs more energy

because it is growing

– During old age, the energy need is less because aged

people are engaged with activities that requires less

climate

Food groups

♦ Milk, cheese, yoghurt

♦ Meat, poultry, fish and alternates

♦ Fruits and vegetables

♦ Bread and cereals

♦ Fats, sweets and alcohols

Staple foods

Staple foods are foods, which form the largest part of a nation’s diet.

They are of plant origin and are classified into three main groups

􀂊 The grain and cereals

􀂊 The roots and tubers

􀂊 The starchy fruits

Types of carbohydrates

Monosaccharides:

􀂃 Glucose

􀂃 Fructose

􀂃 Mannose

􀂃 Galactose

Disaccharides:

􀂃 Sucrose (a disaccharide present taste sugar)

􀂃 Lactose (a disaccharide present in milk)

􀂃 Maltose (a disaccharide present in starch)

Ten process of successful management of SC

Treatment and Prevention of hypothermia

Treatment and Treat and prevent hypoglycemia

Treatment and prevent dehydration by using resomal

Correct electrolytes imbalance by giving extra feed

Resume and treat infection by antibiotic

Correct micronutrient deficiencies by giving extra feeds and vitamins Like VitA and folic acid

Start cautious feeding to stabilize child,s condition usually 2 -7 days

Rebuild wasted through high protein/calory feeds like f100 RUTF

Provide stimulation play and loving care

Prepare parent to continue proper feeding and stimulate after discharge

Key intervention to break cycle of malnutrition

Preventing Low weight and height of the child

Preventing low HT and WT adolescent girl

Prevent low WT and HT of women

Family planning

To decrease energy expenditure

Male participation

BCC – interpersonal and group talks, mass media support group, visual and print materials

Stages of BCC

Pre contemplation (no knowledge)

Contemplation (awareness)

Intension (ready to act)

Trial (trying new behavior)

Maintenance new behavior (acted and maintened)

Breastfeeding practice matrix

-early initiation

-exclusive breastfeeding

-frequency

-on demand

-colostrums’

-sick child

Function of vitamins:

􀂃 To promote Growth

􀂃 To promote Reproduction

􀂃 To promote Health & vigor

􀂃 To promote Nervous activity

􀂃 To promote Normal appetite

􀂃 To promote Digestion

􀂃 To promote Utilization

􀂃 To promote Resistances to infection

Identifications of vitamin A deficiency at the

community level

Vitamin A deficiency Who cut – off level for

45

sign/symptoms identifying a public health

problem

Night blindness >1%

Bitot’s Spot(s) >0.5%

Conjuctival

Xerosis/ulceration/keratomalacia >0.01%

Corneal scar >0.05%

Source: WHO/UNICE, 1994

Prevention of vitamin A deficiency

􀂃 A diet containing plenty of vitamin A is the best.

􀂃 Breast-feed infants for at least one year. Do not discard the 1st

breast milk soon after delivery.

􀂃 At 6 months start to feed infants with dark green vegetables,

yellow and orange fruits and if possible, some finely chopped and

well cooked liver.

􀂃 Include some fats in the child’s diet

􀂃 Children with diarrhea, measles, respiratory and other serious

infections need extra vitamin A.

􀂃 Pregnant and lactating mothers should eat foods rich in vitamin A

every day.

􀂃 Tell families that night blindness is an early warning sign of

xerophthalmia (Vitamin A deficiency).

􀂃 Teach school children to look for night blindness

Strategies to control and eliminate vitamin A deficiency

􀂃 Universal supplementation of vitamin A

􀂃 Food fortification

􀂃 Food diversification

Six nutrients

Protein

Carbonhydrate

Fat

Vitamins

Water

Minerals

The major consequences of iodine deficiency

􀂃 Mental retardation

􀂃 Defects in the development of nervous system

􀂃 Goiter

􀂃 Physical sluggishness

􀂃 Reduced work capacity

􀂃 Impaired work performance

􀂃 Decreased average intelligence

􀂃 Loss of memory

􀂃 Inability to produce enough milk for offspring

􀂃 Lower birth weight

􀂃 Growth retardation

􀂃 Dwarfism

􀂃 Deaf-mutism

􀂃 Cretinism

􀂃 Reproductive failures (abortion, prematurity, stillbirth)

􀂃 Increased childhood morbidity and mortality

􀂃 Economic stagnation and

Children at risk

High risk factors which often have influences on a child's nutritional

States are the followings:

􀂃 Low birth weight

􀂃 Twins or multiple births

􀂃 Many children in the family

􀂃 Short intervals between births

􀂃 Poor growth in early life

􀂃 Early stopping of breast milk < 6 moths

􀂃 Introduction of complementary feeding either too early or too late

􀂃 Many episodes of infections

􀂃 Illiterate mothers,

􀂃 Resources scarcity,

Nutritional assessment

Survey

Surveillance

Screening

Harmful traditional practices with regard to nutrition

􀂃 During period of fasting important nutrients are not eaten, such as

milk, eggs, butter, meat, fish, meal pattern, etc.

􀂃 Pork is forbidden for religious and cultural reasons

􀂃 Lack of sun light (lack of Vitamin D) during infancy to protect the

child from the “evil eyes”

􀂃 Discrimination in feeding among family members, adults before

children, adult males over adult females

􀂃 Practicing heavy meals once, may be twice a day

􀂃 Giving butter to neonate to swallow, hoping to keep the intestine

smooth

􀂃 Delay to start complementary food

􀂃 Refusing to give the child meat for fear of infection

What is a SMART behaviour objective/result?

Behavioural results are best stated in terms of the intended behaviour change

or the maintenance of an existing desired behaviour. A behavioural result

usually has at least three features, which makes it a SMART result:

Clear identification of the participant group.

Detailed description of the promoted behaviour (appropriate and realistic); and

how many times the behaviour should take place.

_ The measurable result you hope to observe over a specific time period.

What is an indicator?

An indicator is information on a particular circumstance that is measurable in some

form. Indicators are approximations of complex processes, events and trends. They

can measure the tangible (e.g., service uptake), the intangible (e.g., community

empowerment), and the unanticipated (e.g., results that were not planned). An

indicator gives an idea of the magnitude and direction of change over time. But it

cannot tell us everything we might want to know.

Challenges in IYCF programming

As noted above, IYCF practices in south central Somalia are significantly sub-optimal. However, almost every mother has the ability to breastfeed exclusively if she is given the time and support to do so. Analysis on beliefs, attitudes and the social and policy environment have highlighted the following gaps:

At household level

– Lack of knowledge by mothers and other key decision makers on the importance of optimal IYCF and its various practices

– Maternal undernutrition means weakened mothers for delivery and for breastfeeding

– Widespread social and cultural beliefs that hinder optimal practices such as a belief that women do not have the ability to exclusively breastfed for the first six months; or that colostrum is harmful so initiation of breastfeeding should be delayed; or that a woman cannot breastfeed while pregnant

– Women not given the space, support, time or other resources to practice optimal IYCF

– Food insecurity in poor households affects resources and can hamper a woman’s ability to practice optimal behaviours

– Early or late introduction of appropriate complementary foods, as well as a lack of diversity in foods used to feed young children

– Poor water and sanitation facilities and practices, poor storage of complementary foods

At community level

– Poor support in communities for some desirable practices, especially exclusive breastfeeding (in terms of time, resources and confidence in the behaviors

– Poor access to qualified health services and skilled support for IYCF

– Low availability and usage of micronutrient dense food for the mother and for complementary feeding

– Availability, even in rural communities, of commodities which hinder optimal practices such as bottles and breastmilk substitutes

At national level

– Formal and informal employment situations are not conducive to practice optimal behaviours, often forcing mothers to be separated from infants and young children

– Health facilities and many NGOs do not have IYCF specific or IYCF sensitive policies

– No implementation of the Code for the Marketing of Breastmilk Substitutes means that formula and other products are readily available and are distributed in emergencies

IYCF Strategy and Action Plan Somalia 2013-2017

– Limited reach and scope of a centralized government means a significant lack of social services and a lack of other supportive policies and legislation

– Lack of supportive partnerships and networks, especially community

Limited supportive supervision of available service providers

– Food insecurity as a cause of livelihood insecurity and asset stripping contribute to high poverty which complicates the ability to practice optimal behaviours

Strategies for IYCF programming

As previously mentioned, the IYCF Strategy and Action Plan is modeled on a health systems strengthening approach and considers the pillars of:

– Leadership and Governance. Upstream work which consists of coordination, communication, and advocacy as well as ensuring that strategies, policies and legislation (when possible) is in place to support and promote optimal IYCF

– Capacity development. Increasing the skills and knowledge of service providers, decisions

IYCF Strategy and Action Plan Somalia 2013-2017

makers, and the community for the practice of optimal IYCF behaviours.

– Service Delivery. Ensuring that there is access to skilled support at community and facility level and that utilization of the services is enhanced.

– Health Information. Establishing and maintaining systems to collect and disseminate information on IYCF for monitoring and evaluation purposes.

Benefits of breastfeeding

For infants

it save lives

Contains balanced proportion and sufficient nutrients

Promotes adequate growth and Development

It is always clean

It contain antibodies

It is always ready and at the right temperature

Easy to digest

Protect against allergies

Contain enoughH2O

Helps jaw & teeth dev.t (suckling develops facial muscle)

Better psychomotor ,affective and social dev.t of infants

Protect from diseases

Colostrums Use as laxative

For the mother

BF is more than 98% effective for FP in the 1st 6 months

Putting baby to the Breast immediately, facilitate the expulsion of placenta ,b/c suckling stimulate uterine contraction

Reduce risk of bleeding after delivery

Breast milk production stimulated Immediate and frequent suckling prevent engorgements

Reduce the mother work over load

It is economical

Stimulates bond b/n mother and baby

Reduce risk of pre-menopausal breast and ovarian cancer

For family

No expense in buying formula

No medical expense

Few emotional difficulties associated with child sickness

Birth space

Time is saved

Reduce work load

For the community

Save hard currency(no import of formula food)

Health babies make a Healthy Nation

Decrease national expense in Treatments

Improves child survival, decrease morbidity and mortality

Protect the environments(fire wood)

Variations in the composition of breast milk

Colostrums is the breast milk that women produce in the first few days after delivery. It is thick and yellowish or clear in colour.

Mature milk is the breast milk that is produced after a few days. The quantity becomes larger, and the breasts feel full, hard and heavy. Some people call this the breast milk `coming in'.

Foremilk is the milk that is produced early in a feed.

Hind milk is the milk that is produced later in a feed.

Hind milk looks whiter than foremilk, because it contains more fat. This fat provides much of the energy of a breastfeed. This is an important reason not to take a baby off a breast too quickly. He should be allowed to continue until he has had all that he wants

PSYCHOLOGICAL BENEFITS OF BREASTFEEDING

Emotional bonding

close, loving relationship between mother and baby

mother more emotionally satisfied

baby cries less

mother behaves more affectionately

less likely to abandon or abuse baby

Development

children perform better on intelligence tests in later childhood

Proper attachments

Signs of proper attachment Good attachment is important to enable the infant to suckle effectively, to remove the milk efficiently, and stimulate an adequate supply.

Tease the infant’s lower lip with the nipple, in order for the infant to open wide his/her mouth.

The infant’s mouth covers a large part of the areola (there is more areola showing above rather than below the nipple).

Both lips are turned outwards.

The areola and the nipple will stretch and become longer in the infant’s mouth.

The infant’s chin touches the breast.

Poor attachment results in incomplete removal of milk, which can lead to sore nipples, inflammation of the breast, and mastitis.

Signs of efficient suckling

Slow and regular sucking at the following rhythm: two suctions and one swallowing.

The infant takes slow deep sucks, sometimes pausing.

Suckling is comfortable and pain-free.

The mother hears her baby swallowing.

The breast is softer after the feed

Demonstration of Different Breastfeeding Positions

1. Sitting position

Usual position of most mothers.

Make sure infant’s and mother’s stomachs are facing each other.

2. Side-Lying

This position is more comfortable for the mother after delivery and it helps her to rest while breastfeeding.

The mother and infant are both lying on their side and facing each other.

3. American Football

This position is best used: after a Caesarean section;

when the nipples are painful; or 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 his/her head is at breast level.

The mother supports the infant’s head and body with her hand and forearm.

Ask one or two participants to demonstrate this position with a doll and a breast model.

BF observations

Signs of possible difficulty

Shoulders tense, leans over baby

Baby's body away from mother's

Baby's neck twisted

Baby's chin not touching breast

Only shoulder or head supported

Signs that breastfeeding is going well

Mother relaxed and comfortable

Baby's body close, facing breast

Baby's head and body straight

Baby's chin touching breast

Baby's bottom supported

Proper attachments

Preparation and how to breastfeed (Proper positioning)

The mother must be comfortable.

Hold the infant in such a way as to have his/her face at the mother’s breast level (the infant should be able to look up at the mother’s face, not facing her chest or abdomen).

The infant’s stomach should be against the mother’s stomach.

The infant’s head, back, and buttocks should be in a straight line.

The infant needs to be close to the mother.

The infant is brought to the breast; the baby's whole body should be supported, not just the head and shoulders.

The mother should hold her breast with her fingers in a C shape, the thumb being above the areola and the other fingers below. Fingers should not be in scissor hold because this method tends to put pressure on the milk ducts and can take the nipple out of the infant’s mouth

Advantages of colostrums

Contains disease-protecting substances (antibodies) that defend against disease-causing organisms.

Serves as the baby’s first immunization.

Helps the baby’s intestine to mature.

Prevents allergies.

Reduces the severity of infections like measles and diarrhea.

Stimulates passage of the infant’s first stool (meconium) and cleans the stomach.

Advantages of early initiation of breastfeeding

Facilitates expulsion of the placenta. When the baby is put to the breast immediately after birth, the baby’s suckling stimulates uterine contractions.

Ensures sufficient breast milk production.

Minimizes maternal bleeding after delivery.

Prevents breast engorgement with immediate and frequent suckling

Optimal BF 0 to 6 months Key messages ( for Ethiopia)

Initiate breastfeeding within the first hour of birth even if before the placenta expelled

Give the 1st yellow milk

EBF, for 1st 6 months

BF your baby in demand at least 10 times day and night

Empty one breast firs before switch to other

Two extra meals for the mother

Increase frequency during child illnes

After each illness increase frequency of BF to fasten recovery and wt. gain

Take Vit.A with in 45 days

Sleep under Insecticide treated net

Expose your child to sun for 20 to 30min.daily

COLOSTRUM

B. Adequacy

Adequacy

FADUA

F – Frequency

A – Adequate

D – Energy dense (Oil to the porridge)

U – Utilization (Hygiene aspect during preparation)

A – Acceptable (Taste before giving to the child)

Feeding in exceptionally difficult circumstances

Emergency situations

Malnourished children

Low-birth-weight babies

Infants of HIV-infected mothers

Orphans

Possible signs that a baby is not getting enough breast milk

Baby not satisfied after breastfeeds

Baby cries often

Very frequent breastfeeds

Very long breastfeeds

Baby refuses to breastfeed

Baby has hard, dry, or green stools

Baby has infrequent small stools

No milk comes out when mother expresses

Breasts did not enlarge (during pregnancy)

Milk did not ‘come in’ (after delivery)

Counseling the mother on BF

Every mother needs four elements of

supportive care to ensure

Adequate Nutrition

Helpful maternity service

Appropriate health service

Continuing assistance and social support

Adequate nutrition – In addition to the daily energy requirement (2100KCal)

For lactating – 750KCal/day

For Pregnant – 550KCal/day

Key counseling Skills

Accept what a mother thinks and feels

Recognize and praise what a mother and baby are doing right

Give practical help

Give little and relevant information

Use simple language

Make one or two suggestions

In counseling follow

GALIDRA

G – Greet

A – Ask (W/t the baby doing, w/t problems)

L – Listen

D – Discuss (Encourage the mother)

R – Recommend (Summary of the session and if she has a Q. give her a chance)

A – Appointment

Management of flat and inverted nipples

Antenatal treatment is not helpful

Build the mother’s confidence

Help the mother to position her baby

If a baby cannot suckle effectively in the first week or two help his mother to feed with expressed milk

Causes of blocked duct and mastitis

Poor drainage of whole breast:

infrequent feeds

short feeds

Poor drainage of part of breast:

ineffective suckling

pressure from clothes

pressure from fingers during feeds

Treatment of blocked duct and mastitis

Most important – improve drainage of milk

Look for cause and correct

Suggest:

frequent feeds

gentle massage towards nipple

warm compresses

Start feed on unaffected side; vary position

Antibiotics, analgesics, rest

Estimated risk and timing of mother-to-child transmission of HIV in the absence of interventions

Timing of MTCT of HIV Transmission Rate

During pregnancy 5-10%

During labour and delivery 10-15%

During breastfeeding 5-20%

_______________________________________________________________________________________________________

Overall without breastfeeding 15-25%

Overall with breastfeeding to 6 months 20-35%

Overall with breastfeeding to 18–24 months 30-45%

Factors which affect mother-to-child transmission of HIV

Recent infection with HIV

Severity of disease

Sexually transmitted infections

Obstetric procedures

Duration of breastfeeding

Exclusive breastfeeding or mixed feeding

Condition of the breasts

Condition of the baby’s mouth

Policy of supporting breastfeeding

As a general principle, in all populations, irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted and supported.”

Infant feeding options from 0-6 months for HIV-positive women

5 KEY STEPS COMMUNITY

Community capacity assessment

Community sensitization

Active case finding

Ongoing sensitization

Follow up

Functional Consequences

Low immunity

Illness

Death

Mental impairment

Reduced productivity

Principles of CMAM

Maximum access and coverage

Timeliness

Appropriate medical and nutrition care

Care for as long as needed

Infections impairs the nutritional status through several routes

Reduced food intake

poor appetite

mother/carer may withhold food

Increased utilization by the body

energy and nutrients

Losses during diarrhoea

protein, zinc

potassium, magnesium

Immediate causes

Lack of food intake and disease create a vicious cycle in which disease and malnutrition exacerbate each other i.e. the Malnutrition-Infection Complex.

Infection Malnutrition

lack of food intake and disease must both be addressed to support recovery from malnutrition.

Underlying causes

Food: Limited access or availability of food

Health: Limited access to adequate health services and/or inadequate environmental health conditions

Care: Inadequate social and care environment in the household and local community

Basic causes

Strategies and policies of central or regional governments level, that affect the allocation of resources influence what happens at community level. Example of resources;

Human

Economic

Political and

Cultural

Geographical isolation and lack of access to markets due to poor infrastructure, displacement or conflict can have a huge negative impact on food security and health.

Causes in the child

Low birth weight

Frequent infections such as diarrhoea, respiratory infections,

malaria which lead to poor appetite, weight loss, poor

resistance to disease

Worms

Bottle feeding

HIV/ AIDS

Causes related to mother/ care giver

Mother is ill or malnourished

Mother has too much work to do in the home and in looking after children

She has to collect fuel and water daily

She has to work outside the house to help make money for the family

She is uneducated and follows incorrect practices such as withholding food when the child is sick

Mother is divorced or widowed

Causes at family level

Too many children to feed

No family planning therefore no child spacing so child isn’t breast fed long enough

Household income spent on cigarettes, alcohol.

Child is orphaned

Husband not supportive, uncaring, alcohol problems, unemployed, violent, illetricy and ignorance

Causes at community level

High unemployment

Unproductive land for farming, high population density compared to the land size

Poor farming practices

Remote area, poor transport and therefore poor access to markets

Money, by tradition overspent on weddings, dowries

Disasters (natural or manmade…)

Causes at province or national level

Conflicts

Famine

Floods or draught

National debt, lack of foreign exchange

Previous food aid which led to a dependence so that prices of locally grown crops dropped because there was no demand for them. Seed grain used up.

Corrupt, inefficient governments, extreme political systems that cause poverty.

Unjust trading laws which favour wealthy countries.

The malnutrition-infection cycle!

Types of Malnutrition

Malnutrition due to a lack of micronutrients :

Anaemia or Iron Deficiency

Vitamin A Deficiency

Iodine Deficiency

Lack of vitamin D – Rickets

Lack of Vitamin C- Scurvy

Lack of Niacin – Pellagra

Lack of Thiamin – Beri-Beri

Malnutrition due to a lack of energy and protein foods

Malnutrition due to micronutrients deficiencies

Anaemia or Iron Deficiency

Anaemia is nearly always present in severe malnutrition. Anaemia is usually caused by insufficient iron in the diet. Diseases such as bilharzia, malaria, hookworm, whipworm can make anaemia worse.

Signs and symptoms:

Pale skin, muscous membranes

Person is tired, not as active

More prone to infections

In severe anaemia: shortness of breath, rapid pulse, low blood pressure.

Vitamin A Deficiency

Vitamin A can lead to blindness and decreases the child’s ability to fight off infections such as diarrhoea, respiratory infections and measles.

This is the commonest cause of blindness in children. Affected eyes go through 3 stages:

night blindness

Photophobia

dryness of the cornea (whites of eyes) with bubbly ‘bitot’ spots, ulceration and bursting of the cornea.

Iodine Deficiency

The most obvious sign of Iodine deficiency is goitre ( a swollen thyroid gland).

Other symptoms include loss of energy, miscarriages,stillbirths.

Children born to iodine deficient mothers can have mental retardation (cretinism), deafness, muteness.

Where iodine cannot be found in the local foods, iodized salt can be added to the diet.

Marasmus Kwashiorkor (Bilateral Pitting Oedema)

Thin appearance

skin under upper arm loose

apathy

ribs and shoulder bones easily seen

skin of buttocks has baggy pants

no bilateral pitting Oedema

moon face

Dermatosis

apathy

loss of appetite

hair changes

Irritable (cries)

Consultation is an essential key of follow-up for severe malnourished patient:

To identify all medical problems and propose an adapted treatment;

To follow beneficiary condition;

To prevent medical complications;

To transfer beneficiary according his/her condition to adapted structure.

In OTP and SC, it is very important to take time to do consultation. Medical evaluation is essential and must be done carefully.

BCC is listening, understanding, and then

negotiating with individuals and

communities for long-term positive health

behaviors

HIV infection1: if replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS)

Reviews have shown that success on breastfeeding can be achieved by:

Implementing a complete package of interventions (comprehensive, relevant, evidence-based package, based on assessment of needs and situation)

Designing effective strategies and ensuring quality implementation (applying best practices, using appropriate strategies, providing appropriate training & supervision)

Working at all levels (national, health system, community, communication)

Achieving universal coverage (vision and planning for national scale and ensuring equity)

Ensuring continuity (sustained, ongoing implementation, fully institutionalized)

Interventions to improve complementary feeding of young children

A systematic review identified a number of effective interventions to improve complementary feeding practices [104]. The interventions of note include the following:

 Nutrition education improves caregiver practices through the following strategies [105,106]:

– Provision of information about local foods, industrially-processed complementary foods, and in-home fortification of foods to caregivers.

– Promotion of appropriate feeding behaviours (see Guiding Principles for Complementary Feeding of the Breastfed Child (PAHO/WHO 2003) (Resources Annex 1-2).

– Use of multiple channels to educate and counsel caregivers (from communication through mass media to individual counselling).

 Use of high-quality locally-available foods improves complementary feeding through:

– Combining locally available low-cost foods to create adequate complementary foods (for example by using linear-programming) [107].

– Employing traditional processes to improve the adequacy of plant-based complementary foods (i.e. germination, soaking, fermentation) or to increase energy density (e.g. adding amylase to foods) [108].

– Including animal source foods (ASF) to improve the quality of the diet [109].

– Promoting home gardening, animal husbandry, and poultry production to increase the availability of high-quality foods at the household level.

 Use of supplements (such as vitamin-mineral powders, and lipid-based nutrient supplements) improves nutrient quality of complementary foods [110,111].

 Use of fortified complementary foods improves complementary feeding through ensuring availability of quality complementary foods, locally or industrially processed, and promoting consumption [112].

16

 Use of a blended complementary food together with multi-micronutrient powders and counselling on complementary feeding practices improved growth more than provision of the food alone [113].

 Special support to food insecure populations improves diets of young children [114] through:

– Social schemes, economic models to ensure access to complementary foods.

– Distribution of micronutrients and other micronutrient-rich products.

– Distribution of fortified complementary foods to families in need1.

– Social protection schemes which link provision of counselling and education with in-kind supplements or vouchers for specific products. These schemes have been implemented in a number of Latin American countries, mostly with positive outcomes in terms of reducing rates of stunting [115], [116].

Core processes in development, planning and implementation of a comprehensive approach to improving IYCF

IYCF strategic planning and implementation

IYCF STRATEGY

Additional Opportunities for INTEGRATION

PLANNING, mobilization of resources

IMPLEMENATION and MONITORING; REVIEW and EVALUATION

ADVOCACY, COORDINATION, PARTNERSHIP

SITUATION ANALYSIS

POLICY

Figure 17: HSS platforms & IYCF

IYCF policy, legislation, strategy, annual plans, coordination mechanism, links with other sectors, norms & standards

Leadership, policy and governance

IYCF key interventions properly reflected in minimum package of services for health facilities & community health care

Development of standard minimum packages of services

Pre-service curricula, in-service training for all relevant HW & CW, job descriptions/tasks reflecting IYCF, work structures modified to include IYCF, mentoring & supportive supervision

Health management information systems

Food supplements, also HW/CW job aids & communication materials)

Supply management

IYCF services fully institutionalized in all maternities, PHC (MCH) & community health care; supervision includes IYCF & conducted regularly

Financing/budgets

IYCF key indicators and process benchmarks fully integrated in HMIS & linked to standard operating procedures & quality assurance mechanisms

Components and interventions for a comprehensive IYCF strategy

Legislation:

1.Development & enforcement of national legislation on the marketing of BMS.

2.Development & enforcement of national legislation on maternity protection.

IYCF interventions for skilled support by the health system:

3.Development/updating of IYCF integrated curriculum for health provider pre-service and in-service education.

4.Establishment of IYCF counselling and other support services in health facilities at relevant MCH contacts in primary health care services.

5.Capacity development on IYCF and maternal nutrition during pregnancy and lactation for health providers and lactation counsellors.

6.Institutionalization of the Ten Steps to Successful Breastfeeding in all maternities (BFHI).

IYCF interventions for community-based counselling and support:

7.Establishment of community based integrated IYCF counselling services at community level and capacity development of community workers.

8.Creation of mother support groups for IYCF in the community.

Communication:

9.Implementation of communication for behaviour and social change through multiple channels.

Additional complementary feeding components:

10.Improving the quality of complementary foods through locally available ingredients.

11.Measures to improve the availability and use of local foods through increasing agricultural production of high quality local foods (e.g. homestead production, animal husbandry, linking with agricultural extension).

12.Provision of nutrition supplements and foods for complementary feeding (MNPs, LNS, fortified complementary foods, etc.) in food-insecure populations and social & commercial marketing of nutrition supplements and foods for complementary feeding in general population.

13.Social protection schemes with nutrition component – complementary feeding. (e.g. in kind complementary foods, vouchers, cash transfers).

IYCF in difficult circumstances:

14.HIV and infant feeding.

15.IYCF in emergencies.

Six key steps are suggested for the design and development of a communication strategy and implementation plan:

1. Establishment of a national coordination mechanism for communication aspects of the national IYCF strategy.

2. Undertaking and analysing a communication situation assessment and formative research.

3. Development of a communication strategy and operational plan.

4. Design of messages and materials and selection of channels.

5. Implementation of the communication plan.

6. Monitoring interim communication outcomes and evaluating impact on behaviours.

Strategy component: Additional complementary feeding interventions/components

9. Improving the quality of complementary foods through locally available ingredients.

10. Measures to improve the availability and use of local foods through increasing agricultural production of high quality local foods (e.g. homestead production, animal husbandry, linking with agricultural extension).

11. Provision of nutrition supplements and foods for complementary feeding (MNPs, LNS, fortified complementary foods) in food-insecure populations and social & commercial marketing of nutrition supplements and foods for complementary feeding in general population, including stimulating quality local production.

12. Social protection schemes with nutrition component.

9. Improving the quality of complementary foods through locally available ingredients

The national IYCF strategies need to specifically address IYCF programming in emergencies for the following reasons:

 Breastfeeding is safe, free and a crucial life-saving intervention for vulnerable children whose risks of death increase markedly in emergencies.

 Emergency situations exacerbate risks for non-breastfed children and those who are on mixed feeding.

 Both exclusive breastfeeding up to 6 months and continued breastfeeding after 6 months are crucial in reducing the risk of diarrhoea and other illnesses in older children, which is heightened in emergencies.

 Donations of BMS undermine breastfeeding and cause illness and death.

 IYCF is central to reducing the high risk of undernutrition during emergencies.

 Safe, adequate, and appropriate complementary feeding, which significantly contributes to prevention of undernutrition and mortality in children after 6 months, is often jeopardized during emergencies and needs particular attention.

6 ―practical steps‖ for IYCF actions in emergencies which should be planned as a part of national IYCF strategy and emergency preparedness:

1. Endorse or develop policies.

2. Train staff.

3. Co-ordinate operations.

4. Assess and monitor.

5. Protect, promote and support optimal infant and young child feeding.

6. Minimize the risks of artificial feeding.

The major priority actions in emergencies are highlighted in the Chapter 3.5.2 of this programme guidance and include the following areas:

i. Emergency preparedness and planning.

ii. Protecting, restoring and supporting breastfeeding.

iii. Preventing and handling donations of BMS and powdered milks.

iv. Ensuring appropriate feeding for children with no possibility to be breastfed.

v. Ensuring availability and use of age appropriate complementary foods and supplements.

vi. Ensuring the integration of IYCF counselling with emergency programmes for management of SAM (1).

As in breastfeeding, there is no single universal 'best' package of complementary feeding interventions because of country and contextual variations. In all contexts – both food secure and food insecure situations – three core action areas are suggested. These include:

1. IYCF counselling and communication on optimal feeding and care practices

2. Optimal use of locally available foods

3. Strategies to improve availability and affordability of quality foods.

Notes on core interventions for all situations:

a)IYCF counselling related to complementary feeding addresses optimizing use of local foods according to the context and specific nutrient gaps (use Linear Programming), e.g. adding amylase, emphasizing use of animal source foods, micronutrient rich foods, developing and teaching improved recipes for complementary foods; problem-solving, feeding, care & hygiene practices. Communication for behaviour & social change is based on evidence of barriers to optimal complementary feeding and uses multiple channels

b)Strategies for increasing availability of quality foods: improving production, commercial and social marketing of high-quality local foods, homestead production, animal husbandry, links with agriculture extension.

c)Strategies for increasing affordability of high quality foods: vouchers/coupons, conditional cash transfers or other social safety nets, or through free distribution.

situation analysis requires three steps:

1. Food security situation

2. Complementary feeding practices

3. Assessment of availability and affordability of foods

Outcome Indicators

% of infants between 6-8 of age with complementary foods introduced

% of children still breastfeeding at 12-15 months

% of young children still breastfeeding between 20-23 months of age 

% of infants who had the minimum meal frequency

% of infants and young children 6-23 months of age who received a minimum acceptable diet

% of infants 6-23 months who received an MNP, LNS or fortified complementary food in target areas

Impact Indicators

% of stunted children under 5 years of age (HAZ < – 2),

% of underweight children under 5 years of age (WAZ < – 2),

% of wasted children under 5 years of age (WHZ < – 2)

Communication for Improved IYCF Practices:

Policy dialogue and advocacy to build support for IYCF & the communication strategy.

Formative research, including behavioural assessment with an analysis of benefits and barriers to change within the population, assessment of participant groups, identification of specific, feasible actions by different groups that achieve the desired outcomes and assessment of communication channels.

Development of targeted, concise messages to promote ―do-able‖ actions along with practical help.

Consistent messages and materials across all program communication channels & wider IYCF programme to address critical behaviours and attitudes.

Building counseling and communication skills for health and community workers & other communicators.

Multiple exposures of specific participant groups to messages through selection of appropriate channels (mass media, print, interpersonal, event, traditional, religious etc).

Monitoring of behavioural objectives for all participant groups & evaluation of impact. 

Do’s:

1.Use evidence from KAP studies and barrier analysis to design strategies (including messages).

2.Emphasize the risks of artificial or mixed feeding as well as benefits of breastfeeding.

3.Use multiple channels with emphasis on inter-personal communication and community-based approaches.

4.Ensure continuous communication at multiple levels.

Don’ts:

1.Use generic messages (e.g. “breast is best” or “breastfeed exclusively for 6 months” or “breastfed baby = healthy baby”) with no discussion of WHY and no context.

2.Focus only on the benefits of BF with no mention of risks of sub-optimal feeding practices.

3.Rely heavily on information, education, communication (e.g., posters, slogans, mass media).

4.Expect a campaign approach to be sufficient on its own (e.g., World Breastfeeding Week).

Key communication skills

1.Establishes rapport or friendly relations with community members, sometimes called “smooth interpersonal relations”:

Starts with greetings and by engaging members in a respectful, relaxed conversation on a common topic of interest.

Fosters friendly environment through praise, smiles/facial expression, posture, other non-verbal gestures.

Inspires confidence and trust by showing that he/she understands and respects local customs, traditions and norms, and speaks the local language.

Avoids judgmental tones.

2.Listens actively and attentively:

Encourages all members to express ideas, problems and issues.

Maintains appropriate eye contact with all members.

Shows empathy with members by indicating interest in understanding their views.

3.Involves and inspires members in friendly debate and dialogue to express opinions, discuss problems/issues, make decisions and agree on collective actions:

Manages group discussion, problem solving and conflict resolution.

Asks open-ended questions to check for understanding

Uses local examples, anecdotes, humour (as appropriate), and engages members to share own stories to illustrate/explain subject or issue and to reflect on their feeling and actions (touches their hearts and not just their minds)

Invites feedback, ideas, comments and suggestions

Assists in examining consequences of each option discussed

If not from community, trains and involves local mobilizers/animators to facilitate

4.Explains subject matter and answers questions clearly, credibly and with confidence

Encourages both girls and boys, women and men, marginalized and disabled to participate and avail of opportunity to benefit

Summarizes points of discussion and actions

Box 23: Essential behaviours for exclusive breastfeeding

A mother practices optimal breastfeeding during the first six months when she:

1.Initiates breastfeeding within one hour of birth.

2.Feeds the colostrum to the baby.

3.Positions and attaches the infant correctly at the breast.

4.Breastfeeds on demand.

5.Breastfeeds frequently during the day.

6.Breastfeeds during the night.

7.Offers second breast after infant empties the first.

8.Gives only breastmilk; gives no water or teas or any other liquids or foods.

9.Continues breastfeeding when she is sick.

10.Increases breastfeeding frequency during and after infant‘s illness, including diarrhea.

11.Seeks help from a trained health worker or counselor if she has problems with breastfeeding.

12.Eats sufficient nutritious foods herself and takes supplements as recommended by the health provider

Box 24: Essential Behaviours for complementary feeding

A mother practices optimal complementary feeding during the period 6-23m of the infant‘s life when she:

1.Starts feeding additional foods to the child at the age of 6 months.

2.Starts with soft or mushy foods at first that are age appropriate and are not too thin or thick, and gradually shifts to foods of a solid consistency if the child is ready.

3.Continues breastfeeding up to two years of age or beyond.

4.Offers solid or semi-solid foods 2-3 times per days when child is between 6-8 months of age, and 3-4 times per day after that, and offers nutritious snacks 1 or 2 times per day, as desired.

5.Offers a variety of foods, from all the food groups (grains, roots and tubers, legumes and nuts, animal source foods and fruits and vegetables) and increases in variety and quantity as the child grows.

6.Practices good hygiene in preparation and storage of complementary foods (including washing hands before and using clean water and utensils).

7.Continues breastfeeding and feeding complementary foods during illness.

8.Gives the child iron-rich foods such as animal source foods or iron supplements if iron-rich foods are less available.

9.Uses feeding times for interacting with the child, to teach and stimulate social development as well as

encourage the child to eat.

The priority messages that are selected should be:

 Clear, practical and understandable: promoting or prompting small, doable actions

 Appealing, memorable and able to hold the attention of intended participants

 Credible /believable

 Acceptable and appropriate to the local culture and language

 Relevant to intended participants‘ prevailing circumstances

 Addressing the barriers, norms and beliefs in the community

Table 4: Examples of indicators for IYCF communication strategy

Inputs

 # of district communication plans finalized

 # of health workers and CHWs/lay counsellors trained on communication skills

 # of communication materials produced

 # of communication materials distributed

 # of communication equipment items distributed

 # of radio spots/programmes broadcast

 # of supervisory visits to communicators (health providers, community workers, communication groups, mother support groups etc.) conducted

 # of radio spots/programmes broadcast

 # religious leaders sensitized

Outputs

 % of districts implementing communication strategy & allocating resources to it

 % of planned communication sessions at health facility or in community conducted

 % trained CHWs/lay counsellors who are providing counselling and conducting communication sessions

 % of target mother support groups functioning

 % of districts which received and have distributed communication materials on IYCF

 % of planned advocacy sessions with directors of health/religious leaders/media etc. held

 % of population who heard a radio spot or programme on IYCF

 % of religious congregations where IYCF included in prayers/sermons etc.

 % of population reached with different types of communication activities: health system, community, radio, etc.

Outcomes

 % health workers and CHWs/lay counsellors who use at least 4 communication skills (as per Box 23)

 % of pregnant and lactating women who know that colostrum should be given to a newborn

 % of mothers and caregivers who can explain the benefits of early initiation and exclusive breastfeeding

 % of women who know that breastmilk contains sufficient water

 % of mothers who can correctly name at least 6 of the 12 optimal breastfeeding practices (as per Box 19)

 % of lactating women who do not give water or other fluids/foods to infants

 % of elder women who tell new mothers that babies don‘t need water

 % of lactating women who breastfeed on demand including during the night

 % of mothers who can correctly state the age of introduction of complementary foods

 % of formally employed mothers who are breastfeeding

 % of mothers who can correctly name at least 5 of the 9 optimal complementary practices (as per Box 20)

 % of mothers and caregivers who can explain how often a child 6-23m needs to be fed

 % of mothers and caregivers who can list the important food groups that a child >6months needs to be fed

 % of mothers who can state which foods are in each of the food groups

 % of mothers who said they ate additional food while pregnant and lactating

Impact

 % of newborns who started breastfeeding within first hour

 % infants <6m exclusively breastfeeding

 % infants still breastfeeding at 12-15 months

 % of children 6-23m who receive a minimum acceptable diet

 % of mothers who fed their children 6-23m of age with the recommended frequency

 % of mothers who fed their children 6-23m of age with the recommended variety of foods

Contact points for counseling and support on HIV and infant feeding:

After an HIV-positive test result, but before delivery, in order to inform about the infant feeding recommendations (one or more sessions);

Soon after birth (e.g., before discharge from hospital) to support the mother on feeding her child;

Within the first week after delivery to help the mother successfully establish the feeding of her child;

During routine postnatal care and at every well-child/immunization or sick-child attendance (as is the practice for women who are not HIV-positive and their children);

Additional sessions may be required during special high-risk time periods, such as when the mother has breast problems, before she goes back to work and at 11 and 12 months to assess and decide if breastfeeding can be phased out;

However, it is recognized that not all women come for counseling when they are pregnant or at regular intervals after birth.

Priority actions

The Operational Guidance on Infant and Young Child Feeding in Emergencies (see Resources Annex 1-11) contains 6 ―practical steps‖ for implementation of IYCF actions in emergencies:

1. Endorse or develop policies.

2. Train staff.

3. Co-ordinate operations.

4. Assess and monitor.

5. Protect, promote and support optimal infant and young child feeding.

6. Minimize the risks of artificial feeding.

Some myths on breastfeeding in emergencies to take into consideration during design of counselling and communication messages:

"STRESS MAKES MILK DRY UP"

While extreme stress or fear may cause milk to momentarily stop flowing, this response, like many other physiological responses to anxiety is usually temporary. There is growing evidence that breastfeeding produces hormones that reduce tension, calm the mother and the baby and create a loving bond.

"BABIES WITH DIARRHEA NEED WATER OR TEA"

As breastmilk is almost 90% water, exclusively breastfeeding babies with diarrhoea do not usually need additional liquids such as glucose water or tea. Water is often contaminated in emergency situations. In the case of severe diarrhoea oral rehydration therapy (administered by cup) may be required.

"ONCE BREASTFEEDING HAS STOPPED, IT CANNOT BE RESUMED"

With an adequate relactation technique and support, it is possible to help mothers and their babies to restart breastfeeding after they have switched to BMS. This is sometimes vital in an emergency

“MOTHERS WHO DON’T HAVE ENOUGH TO EAT CAN’T BREASTFEED”

Only the most severely malnourished mothers will have reduced breastmilk production and quality. Mothers should be encouraged to breastfeed frequently so they will see that production of breastmilk improves. Supplementary feeding for pregnant and lactating mothers is also essential.