Behavior Change Communication on Infant and …...Behavior change communication on infant and young...

nourish. nurture. grow.

TRAINEE HANDBOOK THREE

Ha Noi, July 2011

Behavior Change Communication on Infant and Young Child Feeding

in the Community (Franchise Model)

Behavior change communication on infant and young child feeding in the community (franchise model) .i

Acknowledgement

ACKNOWLEDGEMENT

Alive & Thrive (A&T) acknowledges the special cooperation of the National Institute of Nutrition (NIN)in reviewing and giving helpful feedback on the three training manuals on Infant and Young Child Feeding (IYCF) for health-facility and community-based health workers.

We would like to express our sincere gratitude to the following experts in Infant and Young Child Nutrition (IYCN), training and behavior change communication (BCC), without whose support, the development of these training manuals would not have been possible:

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

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

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

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

We would also like to express our appreciation to health workers and Viet Nam Women’s Union members from fourteen provinces for participating in our training to become the provincial trainers forA&T and for contributing useful comments that enabled the finalization of these manuals.

We extend our gratitude to A&T team members in Viet Nam who worked closely with the consultantteam to review and provide comments on these training manuals. The special support of the A&T monitoring and evaluation team in developing the pre and post-tests and effectively evaluating thetrainings of trainers has been critical in finalization of these manuals.

We thank Maryanne Stone-Jimenez, Technical Consultant, for her comments on the technical contentand layout of the training manuals.

We would also like to thank the World Health Organization (WHO), the United Nations Children’s Fund(UNICEF), the Pan American Health Organization (PAHO), and other organizations whose training materials and references made our task of putting this manual together a great deal easier.

Finally, we would like to express our sincere gratitude to the Department of Maternal and Child Health,MoH Viet Nam for their support and guidance in the development of these training manuals.

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

Behavior change communication on infant and young child feeding in the community (franchise model)ii.

INTRODUCTION

Addressing child malnutrition, particularly stunting among children under two years old, is a high priority for the Government of Viet Nam. In recent years, Viet Nam has made substantial efforts to reduce the malnutrition rate among children under five years old from 38.7% in 1999 to 31.9% in 2009(NIN). However, underweight, and in particular, stunting among children under two years old, remainshigh in Viet Nam in comparison to countries with the same economic status in the region. An extremelylow rate of exclusive breastfeeding (EBF) for the first six months, and poor complementary feeding(CF) practices are the main reasons for the high stunting rate among children under two years old inViet Nam.

To support the government in the reduction of the high malnutrition rate among children under fiveyears old, Save the Children (SC), through a partnership with the Academy for Educational Develop-ment (AED), GMMB, the International Food Policy and Research Institute (IFPRI) and the Universityof California, Davis is implementing the A&T project in Viet Nam over a period of five years (2009-2013). The project goal is to reduce malnutrition and death caused by sub-optimal IYCF practices byimproving the rate of EBF and CF practices for children aged 0-24 months.

In order to achieve this, A&T will support health facilities in fifteen provinces to establish IYCF counseling services in rural and urban areas using a social franchise model. In addition, IYCF supportgroups will be established in mountainous areas. A package of training manuals has been developedfor health facility managers and staff and community-based workers, including nutrition collaborators,village health workers and the Viet Nam Women’s Union members on IYCF and counseling skills. Theparticipants who are trained will be able to provide IYCF counseling services in health facilities and inthe community. The package includes a set of four manuals and four trainee handbooks as follows:

Introduction

MANUALNO. TOPIC TRAINER

MANUALSTRAINEE

HANDBOOKS

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

2. Counseling on IYCF at Health Facility ü ü

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

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

Behavior change communication on infant and young child feeding in the community (franchise model) .iii

Introduction

* This fourth manual is designed for use only in project area where residents have difficulty accessinghealth facility and where IYCF Support Groups are already established.

This book you are reading is Trainee Handbook Three which will be used by community-based workers,including village health workers, nutrition collaborators and village Viet Nam Women’s Union members,who participated in A&T training. This book will be used as a reference during the implementation ofBCC on IYCF in the community.

We would appreciate any comments and suggestion users have about this trainee handbook. Kindly directcomments, suggestions, and questions to Mrs. Tran Thi Kiem - A&T Office – E4B Trung Tu DiplomaticCompound, 6 Dang Van Ngu, Dong Da, Ha Noi or via email: [email protected]

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

Thank you.

Behavior change communication on infant and young child feeding in the community (franchise model)iv.

NOTE FOR TRAINERS

The purpose of the training manual

Trainee Handbook Three is meant to enhance the IYCF capacity of community-based workers withinprovinces where the IYCF social-franchise models will be implemented. This handbook is designedfor use by community-based workers, including IYCF community-based workers, supervisors, projectofficers, and the Viet Nam Women’s Union members.

This handbook can be used as a reference in BCC on IYCF in the community. It has four main parts:

1. Part 1: Overview of IYCF, the A&T project, and the Franchise Model.

2. Part 2: BCC in the community on IYCF. This section provides community-based workers with essential skills to organize BCC sessions at households and enables them to generate demandfor services provided at the “Mat troi be tho” franchise.

3. Part 3 and 4: Technical content on IYCF. This section provides community-based workers withfundamental knowledge on IYCF including breastfeeding (BF) and complementary feeding (CF).

Note for trainers

Behavior change communication on infant and young child feeding in the community (franchise model) .v

Contents

CONTENTS

ACKNOWLEDGEMENTS......................................................................................................................i

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

NOTE FOR TRAINERS .......................................................................................................................iv

ACRONYMS ........................................................................................................................................vi

IYCF DEFINITIONS.............................................................................................................................vii

2.5-DAY TRAINING SCHEDULE .......................................................................................................viii

PART ONE: INTRODUCTION ON IYCF ..............................................................................................1

Session 1: Introduction of IYCF in Viet Nam and the Window of Opportunity ..............................3

Session 2: Introduction of Alive & Thrive and the Franchise Model ..............................................8

Session 3: Following up Mothers as Target Groups of the Franchise “Mat Troi Be Tho” ............11

PART TWO: BEHAVIOR CHANGE COMMUNICATION ...................................................................21

Session 4: Behavior Change Communication.............................................................................23

Session 5: Good Communication Skills – Interpersonal Communication on IYCF in Community...................................................................................................29

PART THREE: IYCF CONTENT ........................................................................................................33

Session 6: Health and Nutrition Care for Pregnant Women and Lactating Mothers ...................35

Session 7: Monitoring the Growth of Children.............................................................................39

Session 8: Breastmilk and the Importance of Breastfeeding ......................................................48

Session 9: The Child’s Demand and Nutrients Provided by Breastmilk......................................50

Session 10: Breastmilk Production .............................................................................................53

Session 11: Positioning and Attachment .....................................................................................57

PART FOUR: COMPLEMENTARY FEEDING ...................................................................................63

Session 13: Importance of Complementary Feeding ..................................................................65

Session 14: How to Prepare Complementary Food to Meet the Child’s Needs..........................68

Session 15: Preparing a Hygienic Meal ......................................................................................73

Session 16: Food Demonstration................................................................................................75

Sample Recipes ......................................................................................................76

Session 17: Child Feeding during Illness (Sickness) and after Recovery...................................82

Behavior change communication on infant and young child feeding in the community (franchise model)vi.

ACRONYMS

A&T Alive & Thrive

AED Academy for Educational Development

AV Audio-visual

BCC Behavior Change Communication

BF Breastfeeding

BMI Body Mass Index

CBW(s) Community - Based Worker(s)

CF Complementary Feeding

CHC(s) Commune Health Center(s)

EBF Exclusive Breastfeeding

IFPRI International Food Policy Research Institute

IYCF Infant and Young Child Feeding

MoH Ministry of Health

NIN National Institute of Nutrition

SC Save the Children

SL Slide

WHO World Health Organization

Acronyms

Behavior change communication on infant and young child feeding in the community (franchise model) .vii

IYCF definitions

IYCF DEFINITIONS

Breastfeeding (BF) Indicators

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

2. EBF under 6 months: The proportion of infants who are fed exclusively with breastmilk for thefirst six months (180 days). That means an infant receives only breastmilk and no other liquids orsolids, not even water, with the exception of drops or syrups consisting of vitamins, minerals supplements or medicine according to health-worker instructions.

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

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

CF Indicators

5. Introduction of complementary foods: The proportion of infants 6-8 months of age who receivesolid, semi-solid, or soft food.

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

7. Consumption of iron-rich or iron-fortified foods: The proportion of children 6-23 months of agewho receive iron-rich food or iron-fortified food that is specially designed for infants and young children, or that is fortified in the home.

Types of Malnutrition

8. Underweight: refers to humans who are considered to be under a healthy weight. The definitionis usually made with reference to the body mass index (BMI). (Weight-for-age Z score <-2).

9. Stunting: is a reduced growth rate in human development. It is a primary manifestation of malnu-trition in early childhood, including malnutrition during fetal development brought on by the malnourished mother. (Height-for-age Z score <-2).

10. Wasting: refers to the process by which a debilitating disease causes muscle and fat tissue to"waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is believed thatepisodes of wasting have a short duration, in contrast to stunting, which is regarded as chronicmalnutrition. (Weight-for-height Z score <-2).

11. Overweight: refers to the process when accumulated muscle and fat tissue causes the bodyweight to be over the standard of the same age and gender. Overweight is identified when weight-for-age Z score >2.

Behavior change communication on infant and young child feeding in the community (franchise model)viii.

2.5- Day training schedule2.

5-D

AY T

RA

ININ

G S

CH

EDU

LE

DAY

1D

AY 2

DAY

3 (1

/2 D

AY)

Pre-

test

(20

min

)R

evie

wR

evie

w

Intro

duct

ion

– Ic

e-br

eake

r – T

rain

ing

obje

ctiv

es (4

0 m

in)

Sess

ion

8:(4

0 m

in)B

reas

tmilk

and

impo

rtanc

e of

BF

Sess

ion

17:(

40 m

in)C

hild

feed

ing

durin

g illn

ess

and

afte

r rec

over

y

Sess

ion

1:(3

0 m

in)

Intro

duct

ion

of IY

CF

in V

iet N

am a

nd th

e W

indo

w o

f Opp

ortu

nity

Sess

ion

9:(3

0 m

in)T

he c

hild

’s

nutri

tion

need

s an

d nu

trien

ts p

rovi

ded

by b

reas

tmilk

Sess

ion

18:I

n-cl

assr

oom

pra

ctic

e (7

5 m

in)C

ouns

elin

gon

CF

– G

ener

ate

dem

and

Que

stio

n an

d an

swer

Sess

ion

2:(4

5 m

in)

Intro

duct

ion

of A

live

&Thr

ive

proj

ect a

nd th

e fra

nchi

se m

odel

Sess

ion

10:(

35 m

in)

Brea

stm

ilk p

rodu

ctio

n

Tea

brea

k (1

5 m

in)

Sess

ion

3:In

-cla

ssro

om p

ract

ice

(80

min

)R

ole

& re

spon

sibi

lity

of

Com

mun

ity-B

ased

Wor

kers

(CBW

s)

Villa

ge m

appi

ng to

follo

w-u

p an

d m

onito

r mot

hers

Sess

ion

11:(

50 m

in)P

ositi

onin

g an

d at

tach

men

tTr

aini

ng s

umm

ary

(30

min

)

Sess

ion

12:I

n –

clas

sroo

m p

ract

ice

(75

min

)In

terp

erso

nal-c

omm

unic

atio

n sk

ills o

n IY

CF

for m

othe

rsC

ondu

ct a

ctiv

ities

at v

illage

s af

ter t

rain

ing

(30

min

)

Post

-test

and

Tra

inin

g ev

alua

tion

(30

min

)

Lunc

h br

eak

(11:

30 –

13:

30)

Sess

ion

4:(3

0 m

in)B

CC

Se

ssio

n 13

:(30

min

)Im

porta

nce

of C

F

Sess

ion

5:(3

5 m

in)I

nter

pers

onal

-com

mun

icat

ion

skills

Sess

ion

14:(

40 m

in)H

ow to

pre

pare

com

plem

enta

ryfo

od t

o m

eet t

he c

hild

’s n

eeds

Sess

ion

6:(3

5 m

in)H

ealth

and

nut

ritio

n ca

re fo

r pre

gnan

t wom

en

and

lact

atin

g m

othe

rsSe

ssio

n 15

:(30

min

)Pre

parin

g a

hygi

enic

mea

l

Tea

brea

k(1

5 m

in)

Sess

ion

7:(4

0 m

in) M

onito

ring

the

grow

th o

f chi

ldre

nSe

ssio

n 16

: (90

min

) Foo

d de

mon

stra

tion

Dai

ly s

umm

ariz

atio

n &

eva

luat

ion

Behavior change communication on infant and young child feeding in the community (franchise model) .1

Part One

INTRODUCTION ON IYCF


Session 1: Introduction of IYCF in Viet Nam and the window of opportunity

SESSION 1: INTRODUCTION OF IYCF IN VIET NAM AND THE WINDOW OF OPPORTUNITY

1. Current situation of IYCF in Viet Nam and Window of Opportunity

IYCF plays a key role in child health and survival, similar to building the strong foundation for a house.Children targeted in IYCF programs are those under five years of age.

Currently in Viet Nam there are more than 7 million children under 5, of whom:

• 1 in 5 children is underweight.

• 1 in 3 children is stunted.

This is despite the fact that Viet Nam is a food-secure country, ranks as the second largest rice-exporterin the world, and enjoys a high literacy rate of 90%.

2. Vulnerable period

00 - 3 0 - 6 6 - 9

10

20

30

40

50

9 - 12 12 - 15 15 - 18 18 - 21 21 - 24

StuntingUnderweight

The vulnerable period is 6 to 20 months

Source: NIN surveillance : 10 A&T provinces (2009)

STUNTING: VULNERABLE PERIOD

○ The green column represents the rate of stunting, and the dark blue column represents therate of underweight.

○ From 0-6 months, the malnutrition prevalence in children remains low (about 10%) but increases sharply from 6 months to 24 months – more than doubles (almost 25 %).

○ There a sharp increase in the rate of malnutrition in the period of 6-24 months because this isthe time when the child starts CF; CF practices are the fundamental factors influencing the

Behavior change communication on infant and young child feeding in the community (franchise model)4.

nutritional status of the child. Therefore, this is a vulnerable period for children and also the“Window of Opportunity” – the most effective time for nutrition interventions.

○ Once a child is over 2 years old, it is very difficult to reverse the stunting that has already setin. Therefore in the first two years we need to focus on improving BF and CF practices to pre-vent children from being malnourished and stunted.

Impact of “Windows of Opportunity” to the child’s development


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

Severe Moderate Mild Well-nourished

94.589.585.3

81.2

158.0162.5

167.3

170.9

Average growth from 3-18: years 77cm

Heightat 18 y

Heightat 3 y

○ Research shows that a child’s height at three years is highly related to his/her height as anadult – by adding about 77-80 cm to a child’s height at age three you can predict their heightas adults to a great extent. Therefore someone who is severely stunted as a child will be ashort adult while someone who is well nourished as a child will be a tall adult.

○ Hence, in order to ensure all children will become tall and healthy adults in the future, we needto focus on improving IYCF practices to prevent stunting from a very early age. This interventionneeds to be implemented by appropriate activities at different ages: from the seventh monthof pregnancy until the child is 24 months old.



3. Windows of Opportunity – the most effective time for IYCF interventions

Preconception through pregnancy

0-6 mo: Exclusive Breastfeeding

6-24 mo: Complementary feeding and continued BF

WINDOWS OF OPPORTUNITY

○ In pregnancy, a mother needs to be cared for and receive good nutrition. In the last trimesterof pregnancy, a mother needs to be provided with knowledge about BF.

○ When the child is 0-6 months, a mother needs support to ensure that the child is breastfed im-mediately after birth, and exclusively for the first 6 months.

○ When the child is 6 -24 months, a mother needs to know how to give age-appropriate CF andcontinue BF until the child is 24 months.

• Conclusion: 0-24 months is a very important period in the development of a child, hence we callthis period the “Window of Opportunity” for interventions to be implemented the most effectively.

According to A&T formative research on the IYCF situation in ten A&T provinces of Viet Nam in2009, the main issues on IYCF are as follows:

• BF issues:

○ More than 90% of mothersreceive ANC care but little or no counseling on BF.

○ 80-90% of women have a skilled attendant at birth but no/few have support at delivery for initiation of BF.


○ No PNC visits (except for complications).

○ Only 55% of infants are breastfed within the first hour after delivery.

○ Only 10% of infants are exclusively breastfed for the first 6 months.

• Barriers to BF:

○ Perception of insufficient milk quality and quantity.

○ Separation of mother and child after delivery.

○ Perception that water is needed to clean baby’s mouth, quench thirst.

○ Availability of formula.

○ Mothers have to go to work.

○ Lack of appropriate information and support.

• CF issues:

○ CF is given as early as 2-3 months.

○ Consistency and quality are issues.

○ Diets are highly iron-deficient.

4. Optimal IYCF practices (WHO recommendations)

15 optimal IYCF practices include:

• Ideal BF practices

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

2. No infants are given prelacteals before BF*.

3. All infants are fed colostrum*.

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

5. All infants are exclusively breastfed until 6 months of age* (180 days).

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

7. No children are fed with bottles and pacifiers.

• Ideal CF practices

8. All young children are fed semi-solid complementary food beginning at 6 months of age (180 days)*.

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




10. All young children meet their recommended daily energy requirements*.

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

12. All children are given a variety of food (with four food groups or more).

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

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

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

* Source: ProPAN

Young children: 6-23 months old.

Note: WHO age calculation:

○ 0- month-old baby: children from the time of delivery to 29 days of age.

○ 1- month-old baby: children from 30 to 59 days of age.

○ 5- month-old baby: children of 5 months to 5 months plus 29 days of age.

○ Children under 6 months: children under 180 days of age.

○ EBF in the first 6 months means in the first 179 days of age and initiate CF at 6 months of age meansat 180 days of age.

MESSAGE TO REMEMBER

• 0-24 months is a very important period in the development of a child, hence we call thisperiod the “Window of Opportunity” for interventions to be implemented the most effectively.

• Main content of 15 optimal IYCF practices:

○ BF:

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

- All infants are exclusively breastfed for the first six months.

○ CF:

- All infants are fed complementary food beginning at 6 months of age (180 days).

- All infants and young children meet their recommended daily energy requirements andfood diversity (with four food groups or more).

SESSION 2: INTRODUCTION OF A&T AND THE FRANCHISE MODEL

1. Introduction to A&T

1.1. A&T in Viet Nam

• 5-year initiative (2009-2013).

• Bangladesh, Ethiopia, & Viet Nam.

• Preventing child deaths by improving BF and appropriate CF practices.

• Funded by Bill & Melinda Gates Foundation through the Academy for Educational Devel-opment and Save the Children.

1.2. A&T – Vietnamese partners

• MoH – Department of Maternal and Child Health.

• NIN.

• Provincial Department of Health.

• Viet Nam Women’s Union.

• UN Agencies.

• NGOs.

1.3. Project period: February 2009 – December 2013

1.4. Program areas

• North: Ha Noi, Hai Phong, Thai Nguyen, Thanh Hoa.

• Centre: Da Nang, Quang Tri, Quang Ngai, Quang Nam, Quang Binh.

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

1.5. Program objectives

• Double EBF rates for the first 6 months by the end of the project.

• Improve CF for children (6-24 months of age) in both quality and quantity by the end ofthe project.

• Reduce stunting for children under 2 years old by 2% per year.

2. IYCF franchise model:

A&T has cooperated with the NIN to build a standardized IYCF franchise model at health facilities inall project areas with the name “Mat troi be tho” (Childhood Sun). At each facility, a separate room will

Session 2: Introduction of Alive & Thrive and the franchise model


be selected to set up a “Mat troi be tho” franchise. This room will be similar in all provinces in not onlyappearance and decoration but also in the standardized IYCF service packages provided.

2.1. Brand name of “Mat troi be tho” franchise



FRANCHISE DESIGN

• Professional• Trustworthy• High -quality• Functional• Welcoming• Child -friendly


A&T FRANCHISE BRAND

The logo set is composed of three elements:

• The logo: The beaming sun both symbolizes a blooming sunflower as well as a smiling child ingood care. The sun represents life while the two leaves stand for nurturing hands. The overallmeaning is caring for a healthy, happy child and for the future generation.

• The clinic name: The clinic name “Mat Troi Be Tho” is synonymous with the above meaning and emphasizes “child” as the prime target of the clinic. The clinic name is short and easy to rememberand understand. It is highly indicative of the nature of the project as well as its target.

• The project slogan: “Nutrition today, health tomorrow” - The slogan emphasizes the importanceof appropriate nutrition for babies to create a foundation for their future development and for thefuture of Viet Nam.

Value of the brand name:

• Professional.

• Trustworthy.

• High-quality.

• Functional.

• Welcoming.

• Child-friendly.

2.2. IYCF service package at “Mặt trời bé thơ” franchise

In order to reduce the stunting rate, we need to provide nutrion care for the child from the gestation pe-riod. Thus, target clients of the franchise are mothers from the last trimester of pregnancy until the childis 24 months old, as well as their families. During these 27 months, the counseling content is dividedinto five service packages in accordance with knowledge and information needs on five developmentperiods of a child as follows:

2.3. The significance of five service packages

1. EBF Promotion: is to provide timely and appropriate information on EBF for mothers beforedelivery and in the third trimester of pregnancy.

2. EBF Support: is to interactively support mothers with the initiation of BF after delivery at healthfacilities with the purpose of helping mothers to initiate BF within one hour after birth, withproper positioning and attachment at the first feed.

3. EBF Management: is to follow-up and support a mother to maintain EBF – which is carried outfrom 1-2 weeks postpartum till the baby is six months of age.

4. CF Education: is to provide basic information needed for mothers to give appropriate CF at 5-6 months of age.

5. CF Management: is to follow-up and support mothers from 6-24 months postpartum to ensure appropriate CF in both quality and quantity.



1. EBF Promotion

3rd

Trimester Pregnancy

3 Contacts- 2 individual

- 1 Group

2. EBF Support

Delivery

1 Contact- At delivery

& during stay at health facility

3. EBF Management

0-6 months

4 Contacts- 2 individual

- 2 group

4. CF Education

5-6 months

1 Contact- individual

5. CF Management

6-24 months

6 ContactsCombination of individual

& group

15 contacts over 27 months (minimum = 9 contacts)

8 contacts 7 contacts

FRANCHISE SERVICE PACKAGE


REMEMBER: The main targets of the franchise “Mặt trời bé thơ” are

• Pregnant women from the third trimester of pregnancy until the child is 24 months of age.

• Fathers of children under two years and other family members.

Session 3: Follawing up mothers as target groups of the franchise “Mat troi be tho”


SESSION 3: FOLLOWING-UP MOTHERS AS TARGETGROUPS OF FRANCHISE “MAT TROI BE THO”

1. Roles and responsibilities of community-based workers in the franchise “Mat troibe tho”

Living in the community, close to the villagers, understanding them as well as being a person who monitors and manages the population of the community, a community–based worker (CBW) can helpthe villagers to know about the “Mat troi be tho” franchise and to understand the importance of IYCFso that they want to go to the franchise for IYCF counseling services.

The main roles and responsibilities of CBWs at the “Mat troi be tho” franchise are described in moredetail below:



At H

ealth

Fac

ility

- F

ranc

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Mat

troi

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tho

Fran

chis

e Pa

ckag

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BF

Prom

otio

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BF

Supp

ort

3. B

F M

anag

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t4.

CF

Educ

atio

n5.

CF

Man

agem

ent

Targ

et A

udie

nce

6-9

mon

ths

Preg

nanc

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eliv

ery

0-6

mon

ths

5-6

mon

ths

6-24

mon

ths

# C

onta

cts

31

41

6

Crit

ical

Poi

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6-7

mon

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f pr

egna

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At le

ast 2

wee

ks

befo

re d

eliv

ery

1-7

days

pos

t de

liver

y (a

t hea

lthfa

cilit

y or

hom

e)

2nd

wee

k po

st d

eliv

ery

1-2

mon

ths

2-3

mon

ths

4-5

mon

ths

5-6

mon

ths

6-7

mon

ths;

8-9

mon

ths

10-1

1 m

onth

s; 1

2-14

mon

ths

15-1

8 m

onth

s; 1

8-24

mon

ths

IN T

HE C

OM

MUN

ITY

- De

man

d ge

nera

tion

by th

e CB

Ws

(hea

lth w

orke

rs, n

utrit

ion

colla

bora

tors

and

vill

age

mem

ber o

f the

Vie

t Nam

Wom

en’s

Uni

on);

Dem

and

Gen

era-

tion

by C

BW

s(O

ne h

ome

visi

tpe

r tw

o w

eeks

from

the

third

trim

este

r of

preg

nanc

y to

six

mon

ths

of a

gean

d in

tegr

ated

com

mun

ica-

tions

)

•Pr

epar

e a

map

of t

he v

illag

e an

d m

ark

out p

regn

ant w

omen

and

mot

hers

of c

hild

ren

0-24

mon

ths:

○Pr

egna

nt w

oman

:Giv

e in

vita

tion

card

s to

go

to th

e C

HC

– “M

at tr

oi b

e th

o”fra

nchi

se; r

emin

d th

e m

othe

r of m

onth

ly p

regn

ancy

chec

kups

and

cou

nsel

ing

and

diss

emin

ate

on in

itiat

ing

BF im

med

iate

ly a

fter b

irth

durin

g ho

me

visi

ts.

○M

othe

r with

a 0

-6 m

onth

old

chi

ld:M

ake

hom

e vi

sits

at d

iffer

ent t

imes

with

the

follo

win

g pu

rpos

es:

Supp

ort d

urin

g de

liver

y if

the

mot

her d

eliv

ers

at h

ome

and

chec

k on

the

mot

her a

nd b

aby

at h

ome.

Dur

ing

the

first

wee

k af

ter

deliv

ery

hel

p th

e m

othe

r to

brea

stfe

ed p

rope

rly (p

ositi

onin

g an

d at

tach

men

t); in

tegr

ate

into

the

CBW

’s re

gula

r tas

k to

pro

vide

enco

urag

emen

t for

the

mot

her t

o pr

actic

e EB

F.Fo

llow

up

and

rem

ind

the

mot

her t

o go

to th

e “M

at tr

oi b

e th

o”fra

nchi

se fo

r ind

ivid

ual a

nd g

roup

cou

nsel

ing.

Whe

n th

e ch

ild is

5-6

mon

ths

of a

ge, e

ncou

rage

the

mot

her t

o go

for C

F pr

omot

ion.

○

Mot

her w

ith a

6-2

4 m

onth

old

chi

ld:M

ake

hom

e vi

sits

to:

Mot

ivat

e th

e m

othe

r to

go to

the

“Mat

troi

be

tho”

franc

hise

for C

F co

unse

ling

and

food

dem

onst

ratio

ns.

Iden

tify

CF

prob

lem

s; c

heck

if th

e m

othe

r pre

pare

s “b

ot”,

“cha

o”pr

oper

ly a

nd h

ygie

nica

lly;

prov

ide

enco

urag

emen

t and

sup

port

the

mot

her t

o ov

erco

me

barri

ers

to p

ract

ice

appr

opria

te C

F.

Che

ck if

the

mot

her s

till b

reas

tfeed

s an

d pr

ovid

e m

otiv

atio

n to

con

tinue

to B

F up

to 2

4 m

onth

s of

age

. •

Cou

nsel

hus

band

s /fa

ther

s/g

rand

mot

hers

to e

nsur

e su

ppor

t for

mot

hers

.•

Mot

ivat

e hu

sban

ds/fa

ther

s /g

rand

mot

hers

to g

o to

the

“Mat

troi

be

tho”

fran

chis

e.•

Iden

tify

posi

tive

devi

ants

and

sen

d fo

r Bab

y C

ompe

titio

ns (a

t com

mun

es);

enco

urag

e m

othe

rs a

nd fa

mily

to p

artic

ipat

ein

com

mun

icat

ion

activ

ities

and

com

petit

ions

at t

heir

com

mun

es.

•D

istr

ibut

e co

mm

unic

atio

n m

ater

ials

on

IYC

F an

d pr

omot

iona

l mat

eria

ls.



2. Making a village map

In order to monitor and manage mothers easily as target groups of the “Mặt Trời Bé Thơ” franchise,each village needs a village map so that the CBWs will know when to visit the mother and encourageand motivate the mother to go to the franchise at appropriate times.

How to make a village map to follow up mothers

The village health worker will make a draft map on a large piece of paper step by step as learned inthe class (first, draw important places along the main road of your village, the Bodhi tree, village gate,schools, CHC, etc. From those main places, go into more detail such as small alleys, hamlets, trees,and houses until the painting is complete with village roads, alleys, trees, and houses of pregnantwomen and mothers with children under 24 months).

These responsibilities can be integrated into routine activities of community-based workers inthe village:

Responsibility of CBWs is to make home visit at appropriate times in order to:

1. Help the mothers to practice EBF for the first six months.

2. Help the mothers and families to practice appropriate CF.

3. Motivate mothers to go to the “Mat troi be tho” franchise as appropriate.

SERVICE PACKAGE CBW’S TASK COMBINED PROGRAM

BF PromotionMotivate mothers to go for pregnancy checkups

Provide BF knowledgeMaternal and Child Care ANC

BF Support Make home visit one week postpartum Maternal and Child Care

BF management Remind and support mother to EBF Vaccination program, Routine childweighing

CF management Monitor, support mother to practice appropri-ate complementary feeding and continue BFuntil the child is 24 months

Routine child weighing, NationalNutrition Program

Other communication channels at communes:Village and commune loudspeaker system

Commune meetings (WU, Farmer Association, etc), Well Baby Competition

Distribute communication materials

Use the draft map in the meeting with members of WU and the head of the village to identify the exactnumber and position of target households.

Keep a small corner of the paper to draw a monitoring table as follows:

○ A pregnant woman is a pistil (a small circle).

○ A mother in 1 week postpartum has a petal (one more circle as a petal).

○ A mother from 1 week-6 months postpartum has two petals.

○ A mother with a child aged 6-12 months has three petals.

○ A mother with a child aged 12-24 months is a full flower.



TARGET GROUP MONTH

1 2 3 4 5 6 7 8 9 10 11 12

6 -9 month pregnant women

Mothers have 1 week child

Mothers having child < 6 month

Mothers have child 6-12 month

Mothers have child 12-24 month

Total

• After agreeing on the number and location of houses with pregnant women and mothers with achild under 24 months, revise and finish the map.

• The map needs to be updated monthly and hangs in the village for all mothers to see during theproject period.

• Note the following cases:

○ A household with two children under 24 months (of different mothers).

○ A mother with a young child under 24 months gets pregnant again.



The following table summarizes the responsibilities of CBWs and appropriate times for giving supportto mothers.

ROLE OF COMMUNITY-BASED WORKERS AND APPROPRIATE TIMING FOR GIVING SUPPORT TO MOTHERS

Timing Follow up and support mother at certain timing

6 7th month of pregnancy (2 weeks before delivery at the latest)

• Give invitation cards, remind the mother to go for pregnancy checkups to receive BF counseling

1 week postpartum • Make home visit to encourage and support the mother to breastfeed exclusively and maintain breast milk supply

Mother having a child aged 0-6 months

• Follow-up, encourage & support the mother to breastfeed exclusively.• Identify difficulties for timely support• Remind the mother to go to “Mat troi be tho” franchise to receive all

counseling sessions • Provide CF knowledge

Mother having a child aged 6-24 months (Ensure 1-2 times/month)

• Monitor the child’s growth• Follow-up with the mother on CF practices• Encourage and support the mother to continue to BF• Identify difficulties for timely support • Remind the mother to go to “Mat troi be tho” franchise to receive all

counseling sessions


Form

Y1

- Lis

t of w

omen

7-9

mon

ths

preg

nant

and

mot

hers

who

hav

e ch

ildre

n un

der 2

yea

rsSession 3: Follawing up mothers as target groups of the franchise “Mat troi be tho”


89

1011

121

23

45

67

89

1011

121

23

45

67

89

1011

12

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

NoM

othe

r's n

ame

Mot

her

's

age

Chi

ld d

ate

of

birt

h1s

t Inv

itatio

n ca

rd re

ceiv

ed

date

Writ

e do

wn

child

's a

ge b

y m

onth

. Use

this

form

to c

ompl

ete

YB fo

rm.

Year

201

1Ye

ar 2

012

Year

201

3



INSTRUCTION FOR Y1 FORM

Name List of pregnant women 7-9 months and mothers with children under 2 years

Symbol Y1

PurposeTo keep track of mothers from the 7th month of pregnancy until the child is 24months

Provide information to the YB form

Level/Location Hamlets/villages

Implimentor Demand generators (CBW)

Data source List of pregnant women from CHCs or CBWs which they manage themselves

Time/frequency Update monthly or whenever a new mother/pregnant woman comes to the center

Management/ Archives Form Y1 is filled and kept by CBW.

Steps to fill out theform

Fill all information one the cover page: CBW name, village, commune, districtand province name

• Collumn (2) The mother’s fullname. Can add the names of their husbands or parents in parenthese to distinguish. For example : Nguyen Thi Thanh (Hoa). Note: Write in order of the mother who has the oldest child to pregnant women

• Collumn (3) Mother’s date of birth (if known)

• Collumn (4) the child's date of birth:

○ Write the expected date of birth for the pregnant women update it with actualdate of birth of the child upon delivered

○ In case of premature death or neonatal motality, write down the status atbirth and cross out the rest of the form

• Collumn (5) Date received the first invitation card: The date CBW gives thefirst invitation card to the mother and introduce the Franchise - MTBT.

• Collumns (6,7,8): 1 column stands for 1 month: CBW write down the child'sage by month.

Note:

○ If the child is more than 24 months old then cross out the rest of the calendar

○ If the mother moves to another region or the child has died then note thisand cross out the rest of the calendar.

Validation/ supervision,support

A) Supervisor (frequency)

1. Franchise management (quarterly)

2. Supervisors from upper level (randomly)

B) Testing method: Number of mothers matchs the information in A3 and PEMCbooks

C) Checklist

1. Fill out name of CBW, village, general information

2. Write down the child's age by month

Form

YB

– M

onth

ly C

BW

repo

rtSession 3: Follawing up mothers as target groups of the franchise “Mat troi be tho”


Commun

e:..................................................................

Villag

e:........................................................................

CBW

's n

ame:

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

......

...

Province

:...

....

....

....

....

....

....

....

....

....

...

District:

....

....

....

....

....

....

.....

......

......

.....

.

June

Dec

embe

rJu

neD

ecem

ber

June

Dec

embe

r

1P

regn

ant w

omen

7-9

mon

ths

2M

othe

rs g

ivin

g bi

rth

3M

othe

rs w

ith c

hild

ren

0 - 4

mo

29 d

4M

othe

rs w

ith c

hild

ren

5 - 5

mo

29 d

5M

othe

rs w

ith c

hild

ren

6 - 1

1 m

o 29

d

6M

othe

rs w

ith c

hild

ren

12 -

23 m

o 9

d

7M

othe

rs w

ith c

hild

ren ≥

24 m

onth

s

8N

o. o

f inv

itatio

n ca

rds

give

n

* Not

e: T

his

form

will

fille

d by

CBW

and

giv

en to

Com

mun

e P

roje

ct s

taff

in t

he m

onth

ly m

eetin

g tw

ice

a ye

ar in

Jun

e an

d D

ecem

ber

Num

ber o

f pre

gnan

t wom

en a

nd m

othe

rs w

ith c

hild

ren

unde

r 2 y

ears

in v

illag

e

No

Mot

her/p

regn

ant w

omen

sta

tistic

s 20

11

(1)

(2)

(3)

2012

2013



Name Number of pregnant women and mothers with children under 2 years in village

Symbol YB

PurposeSummary of the mothers being followed

Provide information for PYB form, only use when no A3 or PEMC books

Level/Location Village/hamlet

Implimentor Demand generator/Commune based worker (CBW)

Data source A3 and PEMC books, or Y1

Time/frequency In June and December

Management/ Archives Form YB will be completed by CBW and reported to Franchise staff

Steps to fill out theform

Fill each column using data from A3 and PEMC books, or using Y1 if other twounavailable in June or December

• Pregnant women 7-9 months

• Mothers giving birth

• Mothers with children 0 - 4 mo 29 d




• Mothers with children ≥ 24 months

• No. of invitation cards given

Validation/ supervision,support

A) Supervisor (frequency)

1. Franchise management (monthly)

2. Supervisors from upper level (randomly)

B) Testing method:

1. Number of subject matchs with A3 and PEMC books, or Y1

INSTRUCTION FOR YB FORM


Part Two

BEHAVIOR CHANGE COMMUNICATION

SESSION 4: BCC

1. Concept of health behavior :

Healthy behaviors are daily practices or actions that are positive to health.

Healthy behaviors are affected by ecological, environmental, social, economic, culture, and politicalelements.

Behaviors consist of following sections: knowledge, attitude, beliefs, and practice.

Session 4: Behavior change communication


BEHAVIOR = KNOWLEDGE + ATTITUDE + BELIEFS + PRACTICE

Examples of healthy behaviors on IYCF:

• Behaviors that are good for health:

○ Eat and drink sufficiently during pregnancy.

○ Consume iron tablets as instructed by health staff.

○ Breastfeed the baby colostrum.

○ EBF in the first six months.

○ Give the babies appropriate CF.

○ Give the babies vitamin A drink.

○ Monitor the babies’ weight.

○ Strengthen BF when the baby is ill (sick).

○ Wash hands with soap before feeding or BF babies.

○ Etc.

• Behaviors that are harmful to health (risk behaviors):

○ Discard colostrum.

○ Give the baby liquorices right after birth.

○ Give the baby complementary food before baby has completed six months of age.

○ Give the baby limited food when s/he has diarrhea.

• Behaviors that are neither good nor harmful to health:

○ A baby wearing a silver bracelet.

○ Putting a red point on the baby’s forehead when taking the baby out.

The aim of any BCC activities is not just to improve knowledge but to ensure that the knowledge becomes actions, i.e., behavior changes and is maintained. If at least 70-80% people in the communitystart practicing the behavior so that it becomes a norm or standard practice in the community, then wecan consider BCC successful.

For example, if in the community 80% of mothers breastfeed their child within an hour after delivery,80% of mothers EBF in the first six months…. then these practices have become the community normsand we can say that the EBF program is successful.

4. The steps of individual behavior change

Human behavior is changeable and changes in a quick or slow manner depending on various reasons.Human behavior itself is complicated. Therefore, it is difficult and complicated to change it. However,in order to change harmful behavior into positive behavior and then practice and maintain this positivebehavior, the persons targeted by need to experience a process. This process can be summarized infive steps as outlined below:

• Step 1: Pre-awareness.

• Step 2: Awareness.

• Step 3: Intention.

• Step 4: Trials – assessment.

• Step 5: Maintenance/relapse.

2. What is BCC?

• BCC is composed of communication activities that are planned to create sustainable behavior ofindividuals and the community.

• BCC is conducted based on the understanding of practices among the community. BCC involvessharing appropriate information to help an individual and then the community to develop new skillsor beliefs, and then encouraging them to overcome difficulties to practice and maintain new behaviors.

• BCC on IYCF aims to change/create a new community norm on IYCF.

3. The process of behavior change in community



COMMUNITY NORM

ACTION

KNOWLEDGE


STEPS OF BEHAVIOR-CHANGE PROCESS AND INTERVENTIONS BY COMMUNITY-BASED WORKERS



3. Provide basic information

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

1. Identify knowledge, belief and practice

9. Provide/support resources needed

8. Support to address barriers

7. Discuss implementation and analyze barriers /motivators

6. Encourage and motivate

5. Give examples of positive deviants

4. Provide knowledge and skills

Pre - awareness

Awareness

Intention

Trials - Assessment

Maintenance Relapse

11. Follow up, support, and encourage maintenance

10. Discuss experience and make a decision

Community-based workers’ interventions

FURTHER READING: MS. LAN’S STORY AS AN EXAMPLE

Step 1- Pre-awareness: Ms. Lan does not know that 88% of breastmilk is water so sheoften gives her baby water, especially when it is hot. In this case, the community-basedworker should tell her that there is a lot of water in breastmilk (88%), and therefore, thebaby will not get thirsty.

Step 2 - Awareness: Ms. Lan knows that breastmilk has enough water but she still givesher baby some spoons of water after each breastfeed to clean the baby’s mouth. The com-munity-based worker needs to ask the mother why she does this and provide her with information. “Breastmilk contains a lot of anti-bodies so the baby does not need to cleanhis/her mouth and the infant does not have teeth so the mother should not be afraid thatsediment will harm the baby’s teeth, etc.

Step 3 - Intention (prepare for change): Ms. Lan knows that the baby does not need todrink water for any reason and also wants to change her behavior but her husband andmother-in-law do not agree and always force her to “clean the baby’s mouth” after eachbreastfeed and to give water to the baby when it is hot, etc. A community-based workerhas to clearly ask and encourage Ms. Lan as well as meet her family to explain and encourage them to support Ms. Lan to practice behavior that is good for the baby.

Step 4 - Trials - Assessment: With the support from her family, Ms. Lan has tried not togive her baby water after each breastfeed and breastfeeds her baby more when it is hot,etc. The whole family sees that there is no problem and the baby grows well.

Step 5 - Maintenance/Relapse: Normally, any difficulty arising during the practice of newbehavior will lead to a “relapse”. For example, after a few days of not giving water to herbaby, one of Ms Lan’s relatives visits her and says that she should give the child fruit juiceto supplement vitamins. Ms Lan wonders if she should follow this advice. The community-based worker must always follow-up (in the service package of BF management) and identify difficulties in time and talk to Ms. Lan and her family so that they understand thatbreastmilk contains sufficient nutrients, including vitamins. On the other hand, the baby’sstomach is very small so if s/he drinks fruit juice, s/he will suckle less. This both affectsmother’s milk secretion and is dangerous for the baby because s/he can easily get diarrhea.

From Ms. Lan’s story, we can see that in BCC, for timely support in maintaining new behavior, the community-based workers need to know the steps that the mother is currentlydoing, to identify the mother’s “motivators” and “barriers” as well as to be able to negotiatechange with the mother.



5. BCC interventions at different levels

BCC on IYCF takes place on four different levels: at home, in a community, at health facilities (healthcenters), and at the policy level. At each level, we need to use different interventions in order to changeIYCF behavior throughout the community.



BCC INTERVENTIONS AT DIFFERENT LEVELS

Home

Community

Negotiate individualbehavior change

Change communitynorms & problem solve

Training &capacity building

AdvocacyPolicy

Healthcenter/PVO


5.1. Policy: by advocacy

Policy here can be understood as Law, Decree, Regulation, etc. (e.g.: Law of Traffic Safety - wearinghelmet, Decree 21 regarding breastmilk substitutes). A good policy will create a favorable environmentfor behavior change.

5.2. At health facility: by training and capacity building

Health workers help mothers/caregivers to practice new behavior in a comprehensive manner. Healthworkers are viewed by the community as reliable sources of information. Therefore, health-serviceproviders must be knowledgeable and skilled and have a positive attitude to provide good services.Therefore, health providers at both the community and health facility must be trained and retrained.

5.3. In the community: by changing community norms and problem-solving

Good policies and good health services do not ensure successful behavior change at the communitylevel. For any behavior to become a community norm, it must be accepted, adopted, and maintainedby the community till it gradually becomes a community norm. To do so, it is necessary to change oldcommunity practices and to create new practices.

E.g:

○ When BF, mothers often give water to their child => feed the child breastmilk only.

○ Mothers introduce CF early => introduce CF when the child reaches 6 months of age.

In order to change a community norm, many activities are required: mass media, interpersonal com-munication via clubs, organizations, group discussions, etc.

5.4. At home: Approach is negotiating to change individual behavior.

Each family and each individual must practice new behaviors and new practices well so that the wholecommunity will practice and maintain that behavior and so that a new community norm can be formed.Thus, BCC at the household level is the critical level of the whole program because even with a favor-able environment and good support policies, if each individual doesn’t change his or her behavior anddoesn’t use the service then the program will fail.



FURTHER READING

Example: EBF for the first six months

• Policy: Need to advocate leaders to make a policy that allows mothers to have sixmonths maternity leave after delivery so that they can breastfeed their babies.

• At health facility: Health workers need to be trained to improve knowledge on IYCFand counseling to support eachmother with the initiation of BF within an hour afterdelivery at the health facility.

• In community: Disseminate through the mass media information on the benefitsof BF, especially EBF for the first six months, and communicate directly via commu-nity channels: mothers’ clubs, women’s meetings, group discussions, etc.

• At home: Convince mothers to breastfeed the child with colostrum in case of deliv-ery at home, EBF for the first six months, do not give water to the child, do not givecomplementary food early, etc.

MESSAGES TO REMEMBER

• Healthy behaviors are daily practices or actions that are positive to health.

• BCC is the process of propagating and advocating to change harmful behavior intopositive behavior.

• Successful BCC requires interventions at all four levels with a consistent message atthe household level, the community level, the health-facility level, and the policy level.

• A BCC program is successful when the new behavior becomes a norm that is accepted by the majority of the community.

SESSION 5: INTERPERSONAL-COMMUNICATION SKILLS

1. Some communication skills

In interpersonal communication on IYCF, the skills of listening and learning, observing, providing information, and generating demand are important skills that are often used. Therefore, in this section,these skills, as well as how to use counseling cards to support interpersonal communication more effectively, will be the focus.

1.1. Listening and learning

• Listen carefully to get information about mothers’ IYCF practices

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

○ Looking into their eyes, nodding your head, smiling to show agreement, and using such simpleadditional words as “well”, “yes”, “really”, etc.

○ Not arguing or interrupting mothers unnecessarily.

○ Not doing personal work while mothers say.

○ Minimizing impacts that can cause distraction (television, telephone, other noise, etc.).

• Ask questions on unclear points or repeat key points that mothers just shared in similar butshorter words to see if you understand correctly. If you understand incorrectly, mothers can adjustit. For example, you can say, “It seems that you say...”, “In other words,...”.

• Using non-verbal communication effectively:

○ Use appropriate gestures, eye-contact, smiles, facial expressions, postures (sitting, standing,walking, etc.).

○ Remove barriers between communicators and target groups.

○ Look into mothers’ eyes intimately.

○ Sit at the same height as the target groups. Keep an appropriate distance between communi-cators and target groups.

○ Do not be in a hurry.

○ Do not grunt, mumble, sign or yawn, etc.

• Avoid judging words such as: not correct, wrong, not good, bad, etc. If you use these words withtarget groups, it will make them feel guilty or that there is something wrong, and then they will beafraid to tell you all the things you need.

• Use open-ended questions: Basically, there are three types of questions:

Session 5: Interpersonal - Communication Skills


Closed-ended questions

○ Closed-ended questions are those that limit answers to words such as “yes” or “no”, “right” or“wrong”, “already” or “not yet”, etc.

○ For example: Question: “Do you go for pregnancy check-ups?

Mothers will answer: “Yes” or “No”.

○ Answers are often short and less informative and so you need to ask further questions. Duringthe communication process, close questions should be minimized.

Open-ended questions

○ Open-ended questions are those that require target groups to think and provide more information.

○ Open-ended questions often begin or end in words such as: Why? When? How? How many?What? Where? Open-ended questions should be used during the communication process toget more information.

Example: Which difficulties do you encounter while BF your baby?

Oriented (leading) questions

○ Leading questions are those in which the communicator leads target groups to give answersthat the communicator expects. Avoid using these types of questions during a communicationsession.

○ Example: “You think that breastmilk is very important to babies, don’t you?”

During the listening process, in order to fully understand the target’s issues, CBW should make inter-active questions to identify the target’s problems clearly. Thus the skill of making questions is also important.

How to ask questions: In order to identify the target’s feelings, emotions, context, & behaviors (to understand what they know, trust, and do)

• Ask one question at a time.

• Ask short and clear questions.

• Ask relevant questions, i.e., questions must be relevant to communication topics. Do not ask aboutother irrelevant issues.

• Use open-ended questions to help target groups share their feelings, context, and behavior (to understand what they know, trust, and do). Use open-ended questions as much as possible. Some-times, close-ended questions may be needed to confirm what the mother has said.

• Avoid leading questions. Do not put words into the mother’s mouth – e.g., “You exclusively breast-feed your baby?” Instead, ask, “How do you feed your baby?”



1.2. Observation skill

How to observe effectively

• Observe all aspects carefully: facial expression, gestures, responses, behaviors of target groupsor other people, context in which they live, baby’s status, etc.

• Choose an appropriate position for observation and moving.

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

• Observe objectively; do not judge subjectively.

Don’ts during observation:

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

• Scrutinize with unsympathetic and insensitive eyes.

• Use disrespectful and impolite non-verbal languages.

1.3. Providing information and generating demand

Provide information

• Create a friendly and reliable atmosphere when communicating.

• Accept what mothers think and feel – avoid being judgmental.

• Provide specific and relevant information.

• Use simple words that are easy to understand.

• Encourage mothers to ask question and clarify doubts.

Generate demand

• Identify what will motivate clients to go to the “Mặt trời bé thơ” franchise.

• Identify challenges that prevent clients from going to the “Mặt trời bé thơ” franchise.

• Use motivators to encourage clients to go to the “Mặt trời bé thơ” franchise.

• Discuss solutions to help clients overcome challenges.

• Repeat visits to motivate clients to use franchise services.

2. Communication materials

At village level:

• Invitation cards

• Loudspeaker scripts



At commune level:

• Mother-and-child booklet

• Leaflets

In which:

○ Invitation cards: Each CBW is responsible for identifying pregnant women and mothers whoare eligible for franchise services. As pregnant women and mothers are identified, community-based workers are required to give them invitation cards and motivate them to go to the franchise “Mặt trời bé thơ”

○ Loudspeaker scripts: every 2-3 months, CBWs will be given a CD with messages to be playedon the village loudspeakers.

○ Mother-and-child booklet: During the first visit to the “Mặt trời bé thơ” franchise, pregnantwomen/mothers will be registered and given a mother-child book. CBWs must ensure that thepregnant women/mothers keep these books safely and use them.

○ Leaflets: During visits to the “Mặt trời bé thơ” franchise, pregnant women/mothers, fathers, andcaregivers will be given leaflets on a variety of topics. Once they return to the village, they mayconsult CBWs on the content of these leaflets.




Part Three

IYCF CONTENT

SESSION 6: HEALTH AND NUTRITION CARE FOR PREGNANT WOMEN AND LACTATING MOTHERS

1. The importance of health and nutrition care for pregnant women

• Approximately one out of five women in Viet Nam is malnourished. Therefore it is very importantto focus on appropriate nutrition care during pregnancy in order to:

○ Enable the pregnant woman to be healthy and her fetus to grow well.

○ Enable mothers to be healthy at delivery.

○ Enable mothers to be healthy to breastfeed their children.

• Manage ANC well to detect early any abnormal signs in the mother or the fetus in order to maketimely interventions and avoid innate defects.

Note: Health and nutrition care is very important for pregnant women because it helps the fetus togrow well and increases the energy storage for the mother in order for her to breastfeed properly, whichcontributes to reducing the stunting prevalence in children.

Session 6: Health and nutrition care for pregnant women and lactating mothers


FURTHER READING

• In the first trimester, the internal organs of the fetus develop, so it is very importantto supplement micro-nutrients.

• In the second trimester, the fetus develops in length and the mother’s undernutritionin this period is likely to cause intrauterine stunting.

• In the last trimester, the fetus develops mainly in weight and a mother’s poor weightgain in this period often leads to a low-birth-weight baby.

2. Health and nutrition care for pregnant women

2.1. Nutrition care for pregnant mother

What women eat and drink during pregnancy is one of the decisive factors for the development of afetus. The mother needs to eat for herself and her baby. Therefore, she needs to eat well, drink well,and sleep well, with an appropriate work schedule.

The mother’s weight gain during pregnancy:

During pregnancy, it is necessary for the mother to gain 10 kg to 12 kg (of which, 3 kg occurs into thefirst trimester, 4-5 kg in the second trimester, and 5-6 kg in the third trimester). Gaining weight well will

help the mother to accumulate fat as a reserve for milk production after delivery and prevent malnutritionfor the fetus.



FURTHER READING

Diet for a pregnant woman• Energy demand

Eat more in order to gain weight: The demand for energy of a pregnant mother in thelast two trimesters is higher than that of a normal woman. Therefore, a pregnant motherneeds to eat one to two extra bowls of rice and other appropriate food every day so thatshe takes in an extra 360 calories per day (especially, in the last trimester).

• Protein and lipid demand

Protein and lipid are essential for forming and building the baby’s internal organs, espe-cially in the first trimester.

○ Animal protein is abundant in seafood such as shrimp, crab, fish, snail, etc. Inaddition, meat, eggs, and milk provide vitamin D that supports better absorptionof calcium. The protein demand of a pregnant woman in the last trimester is 70gper day.

○ Protein such as: soya, green bean, and other kinds of pea, sesame, peanut.These foods are cheaper than meat but contain a higher amount of protein andalso contain fat that helps to increase food energy and to absorb fat-soluble vi-tamins better (vitamin A,D, and E).

• Vitamins, minerals and micro-nutrients

Food that provides vitamins, minerals, and fiber including green vegetables and fruit.

○ Common vegetables in our country, such as rau muong, rau ngot, rau cai xoong,rau den, etc., contain a lot of vitamin C, carotene (beta-Carotene), B12, B2, iron,and folic acid.

○ Ripe fruit such as banana, papaya, orange, and mangoare very necessary formothers. Mothers should eat ripe fruit daily if possible.

○ Food that is rich in iron/ folic acid:

- Iron is essential for blood production. Therefore, to avoid iron-deficiencyanemia, in addition to consuming iron tablets, mothers should eat iron-richfoods, such as red-colored lean meat (beef), especially, liver and internalorgans, fish, dark-green leaves, all kinds of bean and peas, etc.

- To absorb iron better, mothers should also eat vitamin C-rich food such asfruit, yoghurt, and so on.

- Avoid drinking tea or coffee; they reduce iron absorption.

2.2. Health care for pregnant women

• Antenatal care: periodic pregnancy check-ups every three months, consumption of iron/ acid folictablet, tetanus vaccination, weight monitoring.

○ A pregnant mother should have at least three pregnancy check-ups (one per trimester) in orderto monitor the development of the fetus:

- First time: in the first trimester in order to be certain that the mother is pregnant and to receive counseling on diet and methods to relax .

- Second time: in the second trimester in order to check whether the fetus is developing normally and to receive appropriate health and nutrition care.

- Third time: in the last trimester in order to check whether the fetus continues to develop nor-mally, to examine for the likelihood of a breech delivery, and to estimate the time of delivery.

○ Tetanus vaccination: To protect the baby from tetanus, the pregnant mother needs to have twotetanus injections:

- The first injection is in the fourth or sixth month.

- The second injection should be one month after the first injection and at least a month before delivery.



- Folic acid is essential for the development of the fetus’s brain. Food that isrich in folic acid includes lettuce, spinach, cabbage, green bean, cauliflower,peanut, etc.

○ Calcium-rich food: Calcium is necessary for the growth of the fetus’s andmother’s bones and teeth.

- Calcium-rich foods such as shrimp, crab, milk, dairy products, and cerealsare essential for fetus development in the last trimester when the fetus’sheight increases.

○ Zinc-rich food:

- Lack of Zinc can cause sterility, miscarriage, premature delivery, and post-mature delivery, neonatal death, and unusual delivery. The best sources ofzinc-rich food are meat, fish, and seafood.

○ Lodine-rich food:

- Lack of Iodine during pregnancy can cause a natural miscarriage, still birth,or premature delivery. The newborn can suffer permanent brain damage orhave congenital defects such as a paralytic arm or leg or a lisp, or be deafand dumb or cross-eyed. Mothers should use iodized salt and spices withIodine and consume seafood (fish, shellfish, seaweed).

• Do not use stimulants such as alcohol, coffee, cigarettes, thick tea, etc.

○ Utilization of iron/folic acid: To prevent iron-deficiency anemia and spinal- cord congenital defects for infants.

○ Weight monitoring: Health staff need to monitor the mother’s weight during pregnancy check-ups at health facilities in order to know whether herweight gains are reasonable. In addition,the mother will be counseled by health staff about her diet if necessary.

• Nutrition counseling

• Counsel on BF and breast care: To ensure that lactiferous duct is unblocked after delivery.

○ Gently clean the breasts when having a bath daily.

○ Do not continuously flip drops of milk that have stagnated; just clean and gently flip.

○ If the nipple is inverted, it should only be pulled out when the fetus is full-term (from 38 weeksof pregnancy). Pulling the nipple out too early may cause the uterus to contract, which will influence the growth of the fetus.

3. Nutrition care for a lactating mother

• Eat enough and eat diverse foods; do not follow a restrictive diet.

• A lactating mother needs to eat 2-3 extra bowls of rice/day.

• Drink a lot of water, about 1.5 to 2 liters of water daily.

• Consume vitamin A tablets –1 dose within one week after delivery.

• Continue to consume iron tablets during the first months postpartum.

• Mother needs to rest properly and stay near the baby to ensure BF.

• Do not consume wine, beer, thick tea, or coffee. No smoking.

• Do not use medicine without health worker’s instructions.




For pregnant women:• Eat well (1-2 extra bowls/day) – Drink well – Sleep well

• Weight monitoring: the mother needs to gain 10-12 kg during the pregnancy period

• Use iron and folic-acid tablets everyday during pregnancy

• Tetanus vaccination

For lactating mothers• Eat well (2-3 extra bowls/day) – Drink well – Sleep well

• Keep rooming-in to ensure EBF

• Use 1 dose of vitamin A after delivery

• Continue to use iron tablets until the end of the 1st month

Session 7: Monitoring the growth of children


SESSION 7: MONITORING THE GROWTH OF CHILDREN

1. Definitions to remember:

• Underweight: The term underweight refers to humans who are considered to be under a healthyweight. The definition is usually made with reference to the body mass index (BMI). (Weight-for-age Z score <-2).

• Stunting: is a reduced growth rate in human development. It is a primary manifestation of malnu-trition in early childhood, including malnutrition during fetal development brought on by the malnourished mother. (Height-for-age Z score <-2)

• Wasting: refers to the process by which a debilitating disease causes muscle and fat tissue to"waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is believed thatwasting often occurs after a short duration of lacking food such as during floods, war, etc. (Weight-for-height Z score <-2)

• Overweight: refers to the process when accumulated muscle and fat tissue causes the bodyweight to be over the standard of the same age and gender. Overweight is identified when weight-for-age Z score >2.

2. The importance of monitoring the growth of young children

• Monitor the child‘s growth by measuring the child‘s height and weight. This helps to assess thechild‘s nutritional status.

• Early detection of abnormal signs (nutritional status) of the child makes appropriate treatment possible.

• The mother herself can monitor her child‘s nutritional status so as to identify malnutrition or obesityand therefore to seek advice in time. Nutritional assessment by weight, height, and MUAC.

3. Nutritional asessment by weight, height, and MUACRecap weighing measurement:



Introduce tools to measure the child’s height (length and height)

Note:

• When height measuring is impossible, measure him lying and subtract 0.7 cm from the result.

• When a baby is 24 months old, he can either stand or lie down for measuring, but it should be notedthat if you measure his height, compare it to the classification for height measuring, if you measurehis length, then compare it to the classification for length measuring.

• When the child is 24 months old or over, measure his height.

MEASURING PERSON

Using right handto pull the footboardagainst thechild’s feet

Left hand tohold the child’sknees

SUPPORTERUsing two handsto hold thechild’s head

The child lies straight along the board

Movablefootboard

Reading results

Movableheadboard

Foldingdirection



Child Mid-Upper Arm Circumference Measurment

Note:

When to weigh the child:

• From the time of delivery till the baby is two years old, weigh the child regularly on a monthlybasis.

• For children 2-5 years old: once every six months. Malnourished children should be weighedmonthly.

• Use the same type of scale; the best way is to use the scale that is specialized for children.

• When weighing, let the child wear only thin clothes.

• Normally:

○ The child’s weight will triple 12 months from birth, then increase by 2 kg per year.

○ A six-year-old child will weigh about 20 kg.

When to measure the child’s height:

• At delivery.

• Measure once every six months.

• Measure length for children under 2 years and measure height for children over 2 years.

• In cases when the child is over 2 years but cannot stand, we measure his/her height and thensubtract 0.7 cm from the result.

• Normally:

○ A baby is about 50 cm in length at delivery, 65 cm in length at six months, 75 cm at oneyear, 85 cm at 2 years and 95 cm at 3 years.

○ The child’s height will increase by 5 cm per year.

○ At the age of eight, the child is 120 cm in height.

4. Counsel mothers on how to assess the child’s nutritional status based on thegrowth chart

• When:

1) Integrate into home visits, especially for households with malnourished children;

2) In child weighing – if problems are detected in the growth chart.

• How: based on the trend line linking the results of monthly measurement markings on thegrowth chart, the CBW will identify mothers’ and caregivers’ child-feeding patterns and thencounsel as suggested in the following table:





THE CURVE YELLOW (OVERWEIGHT)

BLUE (SAFETY AREA)

RED (DANGEROUS,

MALNOURISHED)

Goes up

The child is overweight andcontinues to gain moreweight, deteriorating nutri-tional status: there is a prob-lem with the child’s diet;recommend that the mothergoes to the “Mat troi be tho”franchise for the best coun-seling.

The child is growing well:Compliment the mother andencourage her to maintain thediet.

The nutritional status is improved, but the child is malnourished: Continue mon-itoring closely, support moth-ers to increase nutrition forthe child.

Goes horizontally

The child is overweight,though s/he is not putting onmore weight but his/her nutri-tional status hasn’t improvedmuch: recommend that themother brings the child to ahealth facility to check and receive appropriate support

The child doesn’t gain weightbut has not been in a danger-ous situation: Ask about thechild’s diet and illness to givean appropriate recommenda-tion

The child’s nutritional status isnot improved; s/he is still malnourished: encourage themother to bring the child to ahealth facility to check and receive appropriate support

Goes down

The child is overweight but islosing weight and his/her nutritional status is being improved: Advise the motherto maintain the current diet,but she needs to be careful.Once the curve goes into theblue area, the mother shouldvisit the “Mat troi be tho” fran-chise for counseling.

The child is losing weight buthas not been in a dangeroussituation: Ask about thechild’s diet, or any illness, andencourage mother to bringthe child to a health facility tocheck and receive appropri-ate support

The child is malnourished andlosing weight: bring the childto a health facility immedi-ately for a checkup, and to receive appropriate support


• The child’s nutritional status can be identified by: weight, height, and MUAC.

• Use a growth chart to monitor child growth in order to identify any early malnutritionrisk of the child and to counsel mothers in time.

• From the time of delivery until the baby is 2 years, s/he needs to be weighed regularly.

• Then continue weighing once every six months. For malnourished children, monthlymeasurement is required.

Session 8: Breast milk and the importance of BF


SESSION 8: BREASTMILK AND THE IMPORTANCE OF BF

1. Different types of breastmilk

• Colostrum: is available in mother’s breast from 14-16 weeks of pregnancy and is produced in thefirst few days after delivery.

• Transitional milk: is available 3-7 days after delivery, when colostrum is changing into maturemilk.

• Mature milk: is available 7-10 days after delivery, when transitional milk completely changes intomature milk and exists until the child is weaned. Mature milk is made up of 2 parts:

○ Foremilk is what is secreted first when the child is breastfed. It is greenish and produced inlarge amounts and provides plenty of protein, lactose, water, and other nutrients.

○ Hindmilk is secreted later in a breastfeed. It is white milk, contains more fat than foremilk, andprovides the energy to help the child grow well.

Note: Each type of breastmilk has a special benefit and different secreting times. Thus CBWs need tounderstand the content and characteristic of each type of milk to give appropriate counseling to mothersand the community. Particularly, always remind mothers that hindmilk contains more fat and is energy-rich so it is important to empty one breast before switching to the other to enable baby to get the hindmilk.

2. Colostrum and the benefit of colostrum

Colostrum is the special breastmilk that is produced immediately after birth and for the first few daysafter delivery. Colostrum is thick and yellowish or clear in color. Colostrum, particularly colostrum withinone hour after birth, has many benefits for the baby such as:

• Providing the infant with antibodies and helping to protect against allergies and infections(colostrum acts as the child’s first vaccine).

• Helping clear meconium and preventing jaundice for infants.

• Helping the baby’s intestine to mature after deliver and preventing allergies.

• Being rich in vitamin A, which helps to reduce the severity of infection.

Currently in many health facilities that do deliveries, health workers practice skin-to-skin contact immediately after birth. This is beneficial for the baby and the mother because skin-to-skin contact:

• Keeps the baby warm, stabilizes body temperature and breathing rate; as a natural reflex, the babywill find the mother’s breast to suckle colostrum right after birth, which helps mother;

• Stimulates uterus contraction, reducing risk of postpartum bleeding;

• Stimulates milk secretion and the “let down” reflex.

Session 8: Breast milk and the importance of BF


3. EBF

EBF means that an infant is given no additional solids or liquids in addition to breastmilk, not evenwater, with the exception of vitamins, minerals, supplements or medicine (according to health worker’sinstruction).

Note: 88% of breastmilk is water; thus in the first six months, the baby only needs breastmilk with noadditional water even when it is hot.

The child’s stomach is very small and is able to contain a certain amount of food/drink. Therefore, ifs/he is given water, it will replace the space for breastmilk, giving the child empty calories as well asincreasing the risk of infection.

4. Benefits of BF

To children:

• Protects against infections.

• Provides a superior source of the nutrients needed to help the child grow quickly and fight againstdiseases: vitamin A, protein, liquid, sugar, vitamin C, and iron, etc.

• Stimulates optimum development of the brain.

• Easy to digest.

• Clean, always ready, and of appropriate temperature.

To mother and family:

• Immediate BF stimulates uterus contraction, reduces risk of bleeding, helps expel placenta.

• Reduces risk of breast, ovarian, and cervical cancer.

• EBF delays a new pregnancy.

• Promotes bonding between mother and child.

• Promote post-partum weight loss.

• Reduce expenses, e.g., buying formula milk is expensive.


• Initiate breastfeeding immediately or as soon as possible, at least within one hourafter birth.

• Exclusive breastfeeding for the first 6 months with no additional solid and/or liquidfood, not even water.

• Empty one breast before switching to the other to ensure the baby gets the hindmilkthat helps the baby to grow well.

Session 9: The Child’s nutritional need and nutrients provided by breastmilk


SESSION 9: THE CHILD’S NUTRITIONAL NEEDS AND NUTRIENTS PROVIDED BY BREASTMILK

1. Size of a baby’s stomach and a newborn’s need for nutrients in 1-2 days after birth

As we know, mothers usually worry that their babies are hungry because they don’t have enoughbreastmilk. In fact, the baby’s stomach after birth is very small as can be seen in the following picture:

Simply speaking, on the first day the baby’sstomach is as big as a small grape (equal to1-2 teaspoons), on the third day it is as bigas a lemon, and around the 10th day it isabout the size of a big egg.

Meanwhile, colostrum is available in themother’s breasts from the 14-16th week ofpregnancy so immediately after birth themother’s breasts already contain enoughcolostrum to breastfeed the baby. Thus, although the breast is not full, there isenough milk to breastfeed the baby.

In the first 1-2 days, the infant only needs avery small amount of breastmilk, from a fewdrops to 1-2 teaspoons in each feed. Assuch, the baby will breastfeed more frequently, which helps to stimulate the “letdown” reflex. This ensures that colostrum is sufficient to meet the baby’s demand in the first 1-2 days.In terms of quality, colostrum is thick and rich in energy, vitamin A, and antibodies.

However: On the first day after delivery, since the breast is not full yet and the baby doesn’t know howto suckle, the mother needs to help the baby to latch on correctly and breastfeed frequently to stimulatebreastmilk production (help breastmilk to come in early).

REMEMBER

In the first 1-2 days after birth, colostrum is absolutely able to meet the baby’s demand,both in terms of quantity and quality, provided that the mother initiates BF as soon aspossible after delivery and breastfeeds frequently.

SIZE OF A NEWBORN BABY’S STOMACH

5 - 7 ml = a grape

1 - 2 days 3 - 4 days 10 days

22 - 27 ml = a lemon

60 - 80 = an egg




• Each column in the chart represents the energy required per day by age from 0-23 months.

• The black area is energy supplied from breastmilk.

• The white area is the energy gap that needs to be provided for.

• The energy gap only appears when the child is 6 months old. Thus, breastmilk is the most suitablefood source for a baby,and is also free of charge. So we need to make the best use of this preciousfood source.

• The mother should only give complementary food when breastmilk is no longer able to meet all ofthe child’s energy demands.

2. Need for nutrients of 0-6 month old children and the amount supplied from breastmilk

WHO research has shown that breastmilk is absolutely sufficient to meet the child’s demand so thereis no need to provide the child with any solid/liquid food, not even water. It can be seen clearly in thefollowing chart:

BREAST MILK ALWAYS SATISFIES BABY’S DEMAND FOR NUTRIENTS WITHIN THE FIRST 6 MONTHS

1000

800

600

400

200

0

Ener

gy (k

cal/d

ay)

0-2 m 3-5 m 6-8 m 9-11 m 12-23 mAge (months)

Energy Gap

Energy from breast milk

Energy required by age and the amount supplied from breast milk

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


3. Some BF principles

• Help the baby to position and attach correctly for the first breastfeed.

• Breastfeed the baby immediately after delivery (within one hour).

• Breastfeed the baby on demand, both during the day and night.

• Breastfeed exclusively for the first six months.

• At each breastfeed, empty one breast before switching to the other.

• Do not give the baby a bottle-feed or pacifier.

• If the baby is sick, continue BF with more feeds and longer feeds.

• Breastfeed the baby before giving him other food.

• Continue BF until the baby is 24 months old.



REMEMBER

• In the first 6 months, the baby only needs breastmilk with no additional solid/liquidfood, not even water.

• The baby needs to be given complementary food starting from the 6th months ofage (180 days). However, the baby still needs to be breastfed until 24 months.

Session 10: Breastmilk production


The breast is composed of two parts:

1. Cells and ducts where milk is secreted.

2. Supporting tissue and fat that gives the breast its shape. The amount of cells and ducts arethe same for all women but that of supporting tissues and fat varies, which makes the mostdifference between large and small breasts.

Therefore, milk production does not depend on breast size.

SESSION 10: BREASTMILK PRODUCTION

1. Anatomy of the breast

The mother’s breast, which produces milk for the baby, is composed of milk glands, ducts, nipple, andareola.

ANATOMY OF THE BREAST

Supportingtissue and fat

Alveoli

Montgomery’s glands

Areola

Nipple

Larger ducts

Ducts

Milk-secreling cells Prolactin makesthem secrete milk{

Muscle cells Oxytocin makesthem contract{

REMEMBER

Breastmilk production does not depend on breast size (big or small). All women canmake plenty of milk. If the mother knows how to breastfeed properly, she always hasenough breastmilk for her baby, even when she has twins or triplets.

2. How breastmilk is produced and secreted.

In a woman’s body, there are two types of hormones:

• One hormone stimulates milk secretion (prolactin): Prolactin is secreted after a feed. The mother’sbreast is not full of breastmilk anymore so this is to “inform” her body to secrete breastmilk to “fill”the breasts. If the breast is full, prolactin is not secreted. (E.g.: it is the same as a pool with an automatic valve. If the pool is full of water, the valve closes so that water does not flow into thepool. If the water level is down, the valve opens so that water flows into the pool, etc.)

More prolactin is secreted at night.

This explains why BF at night makes the mother produce more milk. Breastmilk will be producedas the baby suckles, even when the baby is 2-3 years old, etc. and when the mother wants to stopBF; she only needs to stay separated from the baby for 1-2 days.

• Another hormone stimulates the “let down” reflex (Oxytocin): Oxytocin is secreted before or duringa feed. It helps the muscle cells around the aveoli contract, which makes the milk flow out. The secretion of oxytocin is dependent on the mother’s psychology. If the mother is worried or upset orthere is a lack of trust, etc., it is difficult to produce oxytocin; then the mother will find it difficult toproduce breastmilk.



REMEMBER

In order to sustain the breastmilk supply for the healthy development of the baby, themother needs to be encouraged and supported to breastfeed the baby on demand, bothduring the day and at night. She should also be relaxed.

3. Factors influencing milk production

Mother’s psychology is related to the oxytocin secretion, affecting milk secretion. Thus, the followingpsychological factors may cause a mother’s “milk loss”:

• Worry, perception of insufficient milk.

• Tiredness.

• Anger.

• No rooming-in.

• Full breasts for too long.

• Ulitity of stimulants, cigarettes, and alcohol.



4. Expressing and storing breastmilk

One of the main reasons milk secretion is reduced is because mothers often have left-over milk in thebreast or the breast is full for too long without BF the child (mother goes to work…).

Some situations when a mother needs to express breastmilk for her baby:

• When the mother goes out or goes to work and leaves breastmilk for a baby To feed a low-birth-weight baby who cannot breastfeed.

• To feed a sick baby, who cannot suckle enough.

• Mother or child is sick, and doctor doesn’t allow BF.

• Breast is so full that the child cannot attach.

Note: The family needs to support the mother to breastfeed the child directly as this is the best option.In cases when community-based workers recognize that a mother needs to express breastmilk, theCBWs should motivate them to go to CHC for counseling on expressing breastmilk.

FURTHER READING

• In breastmilk there is a substance that reduces and inhibits milk production. If thebreast is full, this substance reduces milk secretion which helps the breast not to betoo full. Thus, if the child suckles or the milk is expressed, this inhibitor will also betaken out and more milk is produced.

• If the child stops suckling on one breast, then this breast also stops producing milk.If the child suckles more on one breast then that breast will produce more milk andget bigger

• In order for the breast to continue producing milk, we need to let the child suckle orexpress milk until it is empty. If the child cannot suckle on one or both breasts, weneed to express milk to stimulate milk secretion.

How to store breastmilk:



Storage place Temperature Duration Notes

At room temperature 19-26°C 4 hours (ideal), up to 6-8 hours

(acceptable)

- Use glass or hard-sided plastic containers with well-fitted tops.

- Containers should not be filled to thetop – leave an inch of space to allowthe milk to expand as it freezes.

- Put only 60 to 120 ml (two to fourounces) of milk in the container (theamount your baby is likely to eat in a single feed) to avoid waste.

- Place breastmilk container in a bowlof hot water or run hot water over thebreastmilk container to warm storedbreastmilk.

- Do not bring temperature of milk toboiling point and do not use a microwave oven to heat human milk.

In a refrigerator <4°C 3 days (ideal), up to 8 days (acceptable)

In a freezer -18 to -20°C 6 months (ideal), up to 12 months

(acceptable)


• Breastmilk production does not depend on the size of breasts (big or small).

• If the mother knows how to breastfeed properly, she always has enough breastmilkfor her baby, even when she has twins.

• A mother should not let the breast be full for too long because this inhibits milk secretion and may cause “milk loss”.

Session 11: Positioning and attachment


Note: Whether the mother is sitting or lying down, it is important that both the mother and the baby arerelaxed and comfortable, and that the baby is not twisted. This helps the baby to suckle longer and getthe hindmilk.

Correct positions:

SESSION 11: POSITIONING AND ATTACHMENT

Positioning

Whether mother is sitting or lying down when holding the baby, it is important to ensure four key pointsof positioning a baby at the breast:

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

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

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

• The baby’s whole body is supported.



POSITIONING

Attachment




1 - good; 2 - poor

1212

Good and poor attachment

What differences do you see? What differences do you see?

Attachment (outside appearance)


GOOD AND POOR ATTACHMENT(FROM INSIDE AND OUTSIDE)

Compare figure 1 and figure 2 inside and outside appearance:

○ Figure 1: Good attachment: the baby takes a mouthful of the breast; the baby’s chin approaches the areola; his/her tongue touches the areola (larger ducts) so the baby pressesout more milk; avoid creating gaps so that the baby does not suck the air.

○ Figure 2: Poor attachment: the baby only sucks the nipple, creating gaps between the baby’smouth and the mother’s breast and does not press the areola. Therefore, the baby sucks theair, which makes him/her artificially full. After a feed, if the mother does not carry the baby,slightly pat the baby on the back so that the baby can burp; the baby can easily vomit breastmilk.

REMEMBER: FOR SIGNS OF GOOD ATTACHMENT

• More areola seen above baby’s upper lip.

• Baby’s mouth wide open.

• Lower lip turned outwards.

• Baby’s chin approaching the mother’s breast.



How to attach a baby at the breast

Position baby’s nose level to the nipples. Use afinger or nipple to lightly touch the baby’s lipsso that the baby opens his mouth.

Wait until the baby’s mouth is wide open, thenbring the nipple right onto his mouth.

Ensure that the baby takes a mouthful of breast,nearly covering all of the areola.

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

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

breast

When the baby is full, hold him tightly in yourarms.

When finished, BF will bring a satisfactory feel-ing to both mother and baby.

Conclusion: Good attachment is the first step to ensuring successful BF as well as the best way toprevent common BF difficulties - such as poor suckling, not getting enough milk, not getting hindmilk -which results in poor weight gain, etc. for the baby and nipple fissure, plugged ducts, etc. for the mother.

Consequence of poor attachment and solution:

• Nipple fissure.

• Engorgement – plugged ducts.

• Mastitis (abscess).

• Baby is not breastfed sufficiently, cries.

• Baby is breastfed more frequently and for longer.

• Reduce milk secretion.



DIFFICULTY SOLUTION PREVENTION

Not enough milk

Breastfeed more frequently. Encourage themother to believe that the more the baby isbreastfed, the more milk is produced. Eatfood that is good for milk production

Initiate BF as soon as possible after deliv-ery. Encourage the mother and build herconfidence. Breastfeed on demand, bothduring the day and night. Empty one breastbefore switching to the other.

Nipple fissure

Help the baby to attach to the breast. Do notapply anything to the breast, only put somemilk drops on the nipple and areola andlightly message. Motivate the mother to goto the franchise.

Help the baby to attach well to the breastright at the first breastfeed.

Engorgement –plugged ducts

Breastfeed more frequently, both during theday and night. Express breastmilk and feedthe older child if possible.

Breastfeed the child immediately after birthbefore the mother develops engorgement.Breastfeed both during the day and night.

Mastitis (abscess)

When hard swelling, warmth, and fever isdetected, take the mother to the franchise“Mặt trời bé thơ”.

Do not let engorgement last too long.Breastfeed the child on demand, both during the day and night

Note: For all the difficulties, motivate the mother to continue BF more frequently or express breastmilkand feed the child with a cup. Do not bottle-feed the child because this can lead to “nipple confusion”and breast refusal (because suckling from the bottle with teat is easier as milk flows easily out of thebottle and the baby doesn’t need to suck as hard as s/he does from mother’s breast).



FURTHER READING

Breast refusal: identify reasons that cause the baby to refuse suckling and help mothersto overcome difficulties:

• The baby is sick: treat the disease; if the baby is not able to suck, the mother needsto be supported in expressing milk and feeding the baby by cup and spoon.

• The baby is hurt:

○ Trauma post-delivery: help the mother to hold her baby in ways that are not painfulto the baby.

○ Thrush: treat with honey or Gentian violet

○ Teething: encourage the mother to breastfeed patiently.

○ Blocked nose: instruct the mother on how to clean the baby’s nose and suggestto the mother that she should breastfeed her baby for shorter durations but morefrequently than usual.

• BF technique: explain to the mother reasons for difficulties during a breastfeed. In-struct the mother how to breastfeed properly.

• If the breasts are too full of milk: expressing milk will help soften the breast andmake it easier for the baby to attach.

• Changes that make the baby unhappy: such as the mother using soap, perfume,or strange food. Advise the mother to stop if possible.

• Helping the mother to breastfeed again: always stay close to the baby, give thebaby the breast whenever s/he is willing to suckle, help the baby attach in right way.

• Advise the mother to be patient in helping the child to breastfeed again, do not bot-tle-feed him.

Steps for good BF

• Step 1: Mother sits or lies down in a comfortable, relaxing position with her back lean-ing against the bed or wall or sitting on a chair. A pillow or folded blanket is put onmother’s thigh to support the baby.

• Step 2: Hold the baby and prepare for BF:

○ Baby’s head, body, and bottom in line.

○ Baby’s abdomen approaching the mother’s.

○ Baby facing the mother’s breast, nose against the nipple.

○ For infants, not only the baby’s head and shoulder but also his bottom should besupported

• Step 3: Mother brings her nipple into the baby’s mouth by:

○ Putting her four fingers below the breast with her first finger supporting the breast,her thumb above and fingers away from her nipple.

○ Taking the baby’s head near the breast, touching her nipple with baby’s lips, andwaiting until baby’s mouth is wide open, then quickly bringing his mouth onto thebreast.

○ Baby’s bottom lip below the nipple, his chin touching the breast. More areola seenabove.

○ Feeling no nipple pain when the baby is attached well at the breast, feeling a warmmilk flow coming out, stiff right after baby’s sucks; slow, deep sucks, round cheeks,baby’s temporal muscle moving, baby releases the breast after finished, does not cry.




Part Four

COMPLEMENTARY FEEDING

SESSION 13: IMPORTANCE OF CF

1. What is CF

Complementary feeding means giving soft, semi-solid, and solid food in addition to breastmilk.

Common complementary food:

• Main meals: semi-solid soup, porridge, rice, ‘bot’, etc. that is prepared appropriate by age.

• Snacks: biscuit, fruit, yoghurt, egg, etc.

In other words: When the child is 6 months old or older, breastmilk cannot meet all of the child’senergy demands. Thus, in addition to BF, the child needs complementary food to fill this energy gap.We call this “CF”.

2. Why CF is needed

WHO research has shown clearly why we need to give the child complementary food and when theoptimal age is to start CF.

Session 13: Importance of CF


WHY DO WE HAVE TO CONTINUE BF WHILE GIVING THE CHILD CF?

1000

800

600

400

200

0

Ener

gy (k

cal/d

ay)

0-2 m 3-5 m 6-8 m 9-11 m 12-23 mAge (months)

Energy Gap

Energy from breast milk

Energy required by age and the amount supplied from breast milk



• In this chart, each column represents the total amount of energy needed by age. The dark area indicates the amount of energy provided by breastmilk and the white area indicates the energy gap.

• From six months (180 days) onwards, there emerges a gap (white area) and this gap increases asthe baby grows older.

• Therefore, for most babies, six months of age is the best time to start CF – no earlier, no later.

3. Appropriate CF (Amount and Frequency of CF)

When a child starts to eat complementary food, the child’s digestive system needs time to get accustomed to the food and the child needs to learn how to eat; thus the family should accustom thechild gradually to increased amounts of food, from liquid to solid food. Start with 2-3 small spoonfulsof the food twice a day. The adjustment period usually lasts for a few days (it should not be longer thanone week).

The child’s diet needs to be increased by age according to NIN’s recommendations below:

• Giving complementary food too early or too late is not good for the child as:

○ Too early: Makes the baby breastfeed less, wasting the precious nutrients and antibodies supply, reducing milk secretion, and increasing the risk of diarrhea because the child’s digestivesystem is still weak

○ Too late: Breastmilk cannot provide sufficient energy for the healthy development of the child,thus increasing the risk of malnutrition.

• From six months onward, breastmilk will not provide enough energy for the child, so the motherneeds to give her baby CF. Thus, for the majority of children, 6 months is the optimal age to startCF (not earlier, not later).



REMEMBER

• The optimal age to start complementary feeding is when the child is 6 months old(180 days).

• While giving the child complementary food, continue to breastfeed him/her up to 2years or longer to help the child to grow well.

AGE NUMBER OF MEAL/ DAY AMOUNT OF FOOD AT EACH MEAL

6-8months 2-3 main meals + 1-2 snack + frequent BF

Begin with 2-3 spoonfuls (when baby starts CF)

increasing gradually to 1/2 of a 250 ml-sized bowl

9-11months 3-4 main meals + 1-2 snack + BF 1/2 of a 250 ml-sized bowl

12-23months 3-4 meals + 1-2 snacks + BF 3/4 to one 250 ml-sized bowl

Note: If the child is breastfed, there is no need to give other milk/formula, only breastmilk and complemen-tary food. If the child is no longer breastfed, additionally give: 1-2 cups of milk/day and 1-2 extra meals/day.

4. The principles of CF

• Start to give complementary food at 6 months (180 days) while continuing to breastfeed until 24months.

• Feed the child liquid food, then solid food, moving gradually from a small to large amount; startwith 1-2 spoonfuls of liquid “bot” on the first day.

• Number of meals increases gradually by age.

• Take advantage of the local food sources.

• Feed diverse foods. Each feed must contain at least four food groups.

• Make the food energy-dense by adding oil or fat.

• Give the child snacks such as fruit, yoghurt, etc.

• Ensure clean utensils and clean hands when preparing the food and feeding the child.

• Feed the child more during and after an illness. Give the child more meals a day. Give more wateror fruit juice, especially when the child has a high fever or diarrhea.

• Do not add MSG to the child‘s food.

• Do not give the child sweets or soft drinks before a meal.



CHILD’S NUTRITION NEEDS = BREASTMILK + COMPLEMENTARY FOOD

• Start CF from 6 months (180 days)

• Ensure the appropriate number of CF meals per day.

• Ensure the right quantity of complementary food per meal.

• Give the child diverse foods, especially iron-rich food.

• Continue BF until the child is 24 months of age.

• Sufficient quantity: ensure you provide enough energy (kcal) that the child needs, increasingquantity according to the child’s age.

• Sufficient quality: ensure the diversity of foods to provide enough energy, vitamins, and minerals. Each meal needs to have at least four food groups, including:

1. Starch, glucose: Starch contained in rice, corn, wheat flour; some kinds of roots as: cassava, sweet potato, potato; fruit containing starch as: plantain, jackfruit.

2. Protein: Animal-source protein contained in meat, fish, egg, milk, and shrimp. Plant-sourceprotein contained in beans and peas.

3. Lipid: Lipid exists in oil, fat, butter, and some kinds of oil-seed such as sesame and ground-nuts.

4. Vitamins, minerals, and fiber: These exist in all kinds of vegetables and fruit (papaya,mango, orange, banana, etc.).

• Suitable to stomach’s size: For example, a 6-8 month child has stomach size of 200 ml, equalto 2/3 of a small bowl. If the amount of food is more than 200ml, the child will vomit, burp, become scared of eating, and eventually lose appetite.

SESSION 14: HOW TO PREPARE COMPLEMENTARY FOODTO MEET THE CHILD’S NEEDS

1. What is a complementary feed that meets the child’s needs?

The complementary feed needs to meet 3 criteria:

Session 14: How to prepare complementary food to meet the child’s needs


Complementary foods that meets the child’s needs

Size of 8 month old baby’s stomach = 200ml

Need to ensure 3 criteria

1. Sufficient quantity

2. Sufficient quality

3. Suitable to the baby stomach’s size


2. Common problems when preparing complementary food for children and solutions



COMMON PROBLEMS NOTES

SOLUTIONS(SEE SAMPLE MENU IN SESSION 16)

Food that is too thickor too thin foodmakes it difficult forthe child to swallow orthe child has to eattoo much

Prepare complemen-tary food with the rightconsistency

• Toast cereal grains before grinding them into flour.

• Mash/chop food into a thick puree and feed this to thechild instead of the liquid part of the soup.

• Replace part of the water with milk/coconut milk.

• Add peanut or sesame flour.

• Add bean flour with the staple flour.

Not enough energy/ nutrients

Give the child diversefoods, including all fourfood groups

• Add meat, fish, shrimp, etc. and especially iron-richfood such as liver.

No oil Add oil/fat into thechild’s “bot” • Add oil, margarine, or fat appropriate by age.

Does not follow theprocess

Prepare the comple-mentary food in an appropriate way

Process of making “bot”:• Step 1: soak “bot” in water

• Step 2: boil meat/fish/shrimp, etc.

• Step 3: add the soaked “bot” and stir until it is clear incolor

• Step 4: add ground vegetables and cook until boilingpoint

• Step 5: add oil, sauce/salt

No snacks Give the child fruit,eggs, yoghurt, etc • 1 - 2 snacks/day

Above are some solutions to overcome common difficulties when preparing a complementary feed tomeet the child’s energy demands and some recipes appropriate for the child’s age. However, preparingan appropriate complementary meal alone is not enough. We also need to make sure that the childeats to satiety to meets the child’s nutritional needs and help the child to grow well.

Counselors need to advise the mother to practice “active feeding” to help the child to eat well, and toprevent force-feeding that makes the child afraid of eating and not want to eat at all. Below are somenotes for feeding:

Food

• Pay attention to the child’s taste while preparing food.

• Combine different foods to encourage the child to eat.

• Give finger foods so that the child can feed him/herself.

FURTHER READING

QUALITY AND DIVERSITY IN COMPLEMENTARY FEEDS

1. Food groups that are necessary for complementary feeds

How to feed

• Feed the child slowly, with patience.

• Wait until the child finishes the food and then continue.

• Minimize the distraction of the child.

• Give encouragement and support when the child wants to feed him/herself.

• Stay with the child during the meal and be attentive.

• Create a happy atmosphere during mealtime.



2. Protein group is a food group that is rich in protein

• Animal-source food that contain high nutritious value are those such as: egg,milk, meat, fish, shrimp, crab, eel, pupa, organs such as liver. If various kinds of meat(pig, pork, poultry, etc.) are available for the child to eat, it is not necessary that thechild eats only lean meat; the caregiver needs to use both fat and lean meat.

• Vegetable-source food: All kinds of beans, peas: black beans, green beans, soya.Among these, soya contains the highest content of protein and lipid. This is a kind offood that, when combined with cereals, will become nutrient-richfood like animal-source food -- but cheaper.



Animal-source foods are very good for the child, and help thechild grow active, healthy, and strong

Peas, beans, legumes, ground-nuts, and kinds of cereal thatare good food for a child

• Food group that is rich in energy:

○ Includes: oil, butter, fat, and sugar. Oil and fat supplement energy for a child’sfeed. They make food tender and easier to swallow. Besides animal-fat, the caregiver should feed the child groundnut oil, sesame oil, or soya oil. Because theabsorption rate of essential fatty acids is not higher than fat, these can be absorbed easily. Feeding the child fat and oil not only increases the energy of theportion, but also helps the child to absorb vitamins that dissolve in oil such as vitamin A,E,D, andK.

• Food group that is rich in vitamins, minerals, and fiber:

○ Vegetables and ripe fruit are sources that supplement various vitamins and minerals. They are great foods for children.

○ All kinds of vegetables that have dark-green leaves such as rau ngot, rau muong,rau den, mong toi. And rau cai, which contain lots of vitamin C and micronutrientssuch as beta-carotene and iron and help the child avoid dry eyes and anemia. Allkinds of ripe fruit: papaya, mango, banana, orange, tangerine, sapodilla plum, etc.which contains lots of micronutrients – this is not to be diminished by cooking.



Fat and oil

Dark-green leaves, fruits, and the kinds of yellow-colored rootsthat prevent dry eye and infections

butter

coconut

Pumpkin

Carrot

Potato

Mango

Vegetables

Papaya

SESSION 15: PREPARING A HYGIENIC MEAL

Why hygienic and food safety is needed

• When CF is started, the child receives less immunity from breastmilk than before.

• When starting complementary food, therefore, the child‘s digestive system has to adapt to the newfood. The immune system of a child has not developed completely so s/he may easily contract dis-eases in their digestive system.

• Complementary food and utensils can be easily contaminated with germs.

In order to prepare a clean and hygienic meal, we need to ensure:

○ Clean hands.

○ Clean utensils.

○ Safe food and water.

○ Safe storage.

Session 15: Preparing a hygienic meal


1. Clean hands

Wash hands with soap and water

• Before handling food and regularly when preparing a meal.

• After using the toilet, cleaning a baby’s bottom, or holdingpets/animals.

• Wash your hands and the child’s hands before feeding.

2. Clean utensils

• Keep knives, chopping boards, containers, and the kitchenclean.

• Wash all the surfaces and utensils for cooking and all foodcontainers before and after using them.

• Use clean utensils and covered containers for the baby.

• Separate raw meat, poultry, and seafood from other foods.

• Use separate containers and chopping boards for cookedfood and raw food.

• Use covered containers to store food.

3. Safe food and water

• Water

○ Use clean or filtered water

○ Give the baby boiled water

• Food

○ Use fresh food

○ Do not use expired/old food

○ Wash and clean the raw food before cooking

○ Cook food well

○ Eat immediately after cooking

○ Stored food needs to be re-heated

4. Safe storage

• Keep the food in a covered container

• Keep food in dry, clean places

• Preserve dry food carefully

• Use cooked food within one hour

Session 15: Preparing a hygienic meal


FURTHER READING

10 principles of hygienic and safe food1. Purchase clean food, from safe and clean sources.

2. Wash hands with soap before preparing the meal and eating.

3. Use clean water when cooking and washing dishes, chopsticks, and utensils for children.

4. Use a separate chopping board for raw food and cooked food.

5. Food has to be cooked well-done.

6. Eat the food immediately after preparing it.

7. Keep the food in a covered container if you do not have time to eat it.

8. Keep the food in the refrigerator or somewhere without insects.

9. Reheat the cooked food carefully before eating

10. Use clean water for eating and drinking

SESSION 16: FOOD DEMONSTRATION(Only when mothers ask the CBW to demonstrate and only with adequate logistics)

Food-demonstration instruction

Preparation:

• Essential cooking utensils: gas cooker, three pots, bowls, chopsticks, plates, spoons (5 ml), knife,cutting board, clean towel, fresh water, etc.

• Food: enough to prepare three different types of complementary food (processed, cleaned).

• Cooking process.

• Age-appropriate CF recipes.

• Get food and utensils ready.

Food demonstration

Doing and saying what you are doing:

• How to measure water, “bot” exactly.

• What is the right order of food.

• Ensure hygiene and food safety while preparing food and store dry food (“bot”) after use.

Explain some common issue when preparing the food:

• Ensure that the food meets nutrition needs by age.

• How to check the consistency of food?

• How to reduce the consistency of “bot”/”chao”?

• How to increase the density of food?

• What to note while preparing food for sick children?

When the food is ready: ask everyone to taste and give comments.

Session 16: Food demonstration


Mix rice and soy bean following this ratio: 900g rice flour + 50g sticky rice + 50g soy or green beanflour to grind into flour for a child.

• Sample recipes for children:

SAMPLE RECIPES

Notes:

• These menus are recommended by A&T project. Mothers can replace the ingredients with theavailable home or local foods because with the amount recommended in the recipe, nutrients con-tained in different types of food in the same food group will not change significantly.

• 1 full teaspoon is equivalent to 5g of food or 5ml of water

• 0.5 teaspoon is equivalent to 3g of food

• We can replace similar vegetables/tubers; e.g. sauropus with morning-glory, spinach, etc., carrotwith pumpkin, etc.

• Rice and soy bean should be mixed by the ratio 5:1 (i.e. 1kg rice + 200g soy bean) in order to beground into flour for a child.

Food preparation practice

• Compositions of some common snacks

Sample recipes


6-8 MONTH 9-11 MONTH

Energy(kcal)

Protein(g)

Bio AIron (mg)

VitaminA (mcg)

Energy(kcal)

Protein(g)

Bio AIron (mg)

VitaminA (mcg)

Sweet potato 20g (1/10 tuber) 23.2 0.24 0.018 0 23.2 0.24 0,018 0

Egg yolk 10g (1/2 big egg yolk) 32.7 1.36 0.07 96 32.7 1.36 0.07 96

Yoghurt 50g (1/2 box) 30.5 1.65 0.0075 12.5 30.5 1.65 0.0075 12.5

Banana 30g (1/2 banana) 28.5 0.96 0.0045 0.9 28.5 0.96 0.0045 0.9

CHILDREN AGED 6-8 MONTHS (2 MEALS)


CHILDREN AGED 12-23 MONTHS ( 3 MEALS)

Rice flour + green bean: 2 teaspoons (16 g)Minced meat/fish/shrimp: 2 teaspoons (16g) Sesame oil: 1 teaspoon (2 g)Ground vegetable: 2 teaspoons (16 g)Sauce: ½ teaspoon (2g)Water: ¾ small bowl (150ml)

Rice flour + green bean: 2 teaspoons (16 g)Minced meat/fish/shrimp: 2 teaspoons (16g) Sesame oil: 1 teaspoon (2 g)Ground vegetable: 2 teaspoons (16 g)Sauce: ½ teaspoon (2g)Water: ¾ small bowl (150ml)

¾ bowl of solid soup equivalent to 5teaspoons of rice (33 g) Chopped meat/fish/shrimp: 3-4 teaspoons (24 -32 g) Sesame oil: 2 teaspoons (4 g)Chopped vegetable: 3 -4 teaspoons (16 g)Sauce: 1 teaspoons (4g)Water: 1/2 small bowl (100ml)

Sample recipes

Menu 1: eel semi-solid soup/porridge

Sample recipes





Rice flour + green bean: 2 teaspoons (16 g)

Eel boiled, meat removed &minced: 2 teaspoons (16 g)

Sesame oil: 1 teaspoon (2 g)

Ground sauropus: 2 teaspoons (16 g)

Sauce: ½ teaspoon (2g)

Water: ¾ small bowl (150ml)


Eel boiled, meat removed &minced: 2 teaspoons (16 g)


Ground sauropus: 2 teaspoons (16 g)


Water: 3/4 small bowl (150ml)

¾ bowl of solid soup equivalent to 5teaspoons of rice (33 g)

Eel boiled, meat removed, &chopped: 3 - 4 teaspoons (24 - 32 g)

Sesame oil: 2 teaspoons (4g)

Chopped sauropus: 3-4 teaspoons (16 g)

Sauce: 1 teaspoon (4g)

Water: 1/2 small bowl (100 ml)

• We can replace similar vegetables/tubers; e.g. sauropus with morning-glory, spinach, etc., carrotwith pumpkin, etc. (1 teaspoon full of tubers = 0.5 teaspoon of green vegetables).

Menu 2: Beef semi-solid soup/porridge





Minced beef:2 teaspoons (16 g)


Ground spinach: 2 teaspoons (16 g)



Rice flour + green bean:2 teaspoons (16 g)

Minced beef:2 teaspoons (16 g)


Ground spinach: 2 teaspoons (16 g)



¾ bowl of solid soup equivalent to5 teaspoons of rice (33 g)

Minced beef:3- 4 teaspoons (24 -32 g)


Chopped spinach: 3-4 teaspoons (16 g)






Menu 4: Fish semi-solid soup/porridge

Menu 3: Shrimp semi-solid soup/porridge

Sample recipes






Shrimp boiled, meat removed& minced: 2 teaspoons (3 g)


Ground morning-glory:2 teaspoons (16 g)




Shrimp boiled, meat removed& minced: 2 teaspoons (3 g)


Ground morning-glory:2 teaspoons (16 g)




Shrimp boiled, meat removed &chopped: 3- 4 teaspoons (24g -32 g)


Chopped morning-glory: 3-4 teaspoons (16 g)







Fish (Tilapia, etc.) cleaned,boiled, meat removed &minced: 2 teaspoons (16 g)


Ground spinach:2 teaspoons (16 g)




Fish (Tilapia, etc.) cleaned,boiled, meat removed &minced: 2 teaspoons (16 g)


Ground spinach:2 teaspoons (16 g)




Fish (Tilapia, etc.) cleaned, boiled,meat removed & chopped: 3-4 tea-spoons (24 -32 g)


Chopped spinach:3-4 teaspoons (16 g)



Sample recipes




Menu 6 : Egg semi-solid soup/porridge

Menu 5 : Chicken semi-solid soup/porridge





Egg yolk: 1 small egg yolk ( 12-16 g)


Ground green pumpkin:2 teaspoons (16 g)




Egg yolk: 1 small egg yolk (12g -16g)


Ground green pumpkin:2 teaspoons(16 g)




Egg yolk: 2 small egg yolks (24 -32 g)


Chopped green pumpkin:3-4 teaspoons (16 g)







Well-ground minced chickenmeat: 2 teaspoons (16 g)


Ground steamed carrot:1 teaspoons (16 g)




Well-ground minced chickenmeat: 2 teaspoons (16 g)


Ground steamed carrot: 2 teaspoons (16 g)




Well-ground minced chicken meat:3- 4 teaspoons (24g - 32 g)


Chopped steamed carrot: 2-3 teaspoons (16 g)



Sample recipes




Menu 8 : Pork semi-solid soup/porridge

Menu 7 : Liver semi-solid soup/porridge





Minced chicken liver: 2 teaspoons (16 g)


Ground green pumpkin: 2 teaspoons (16 g)




Minced chicken liver: 2 teaspoons (16g)


Ground green pumpkin: 2 teaspoons (16 g)




Chopped chicken liver:3 -4 teaspoons (24 -32g)


Chopped green pumpkin: 3-4 teaspoons (16 g)







Minced pork:2 teaspoons (16 g)


Ground amaranth: 2 teaspoons (16 g)




Minced pork:2 teaspoons (16 g)


Ground amaranth:2 teaspoons (16 g)




Chopped pork:3-4 teaspoons (24 -32 g)


Chopped amaranth:3-4 teaspoons (16 g)



Sample recipes



Menu 9 : Peanut semi-solid soup/porridge





Minced tofu:1 teaspoons (8 g)

Ground peanut:1 teaspoon (8 g)


Ground steamed pumpkind:1 teaspoon (16 g)




Minced tofu:1 teaspoons (8g)

Ground peanut:1 teaspoon (8 g)


Ground steamed pumpkind:1 teaspoon (16 g)




Minced tofu:2 teaspoons (16g)

Ground peanut:1 đến 2 teaspoons (8 -16 g)


Chopped steamed pumpkind: 2-3 teaspoons (16 g)



SESSION 17: CHILD FEEDING DURING ILLNESS (SICKNESS) AND AFTER RECOVERY

1. The importance of child feeding during illness

• When sick, the child often doesn’t want to eat and easily loses weight, thus prone to becomingsick again. Thus, good nutrition care will help the child to recover sooner and stay well.

• When ill, the child needs more energy and nutrients to fight against the infection.

• Prevent malnutrition.

2. Feeding the child during illness (sickness) and recovery

2.1. Feeding sick (ill) child

A sick child tends to cry, does not eat, eats less food, or vomits; therefore when feeding the child, weshould follow these suggestions:

• Feed the child many times, little by little.

• Increase BF in order for the child to get more water, nutrients, and protection factors against infec-tion. Breastfeed more frequently, little by little.

• Feed food that the child likes, feed diverse foods

• Give the child nutrient-rich complementary food; the food could be more consistent or tender thanusual if he/she likes. Tender food will be easier for the child to eat, particularly for a child who hasa sore throat or mouth inflammation or who vomits along with a cough.

• Hold the child in a position comfortable for the child in order for him/her to feel at ease while eating.

• Be extra patient, feed with extra love, and spend more time, encouraging and supporting the child.The caregiver should be a person whom the child likes.

Session 17: Child feeding during illness (sickness) and after recovery


FEEDING A SICK CHILD

• Encourage the child to drink and to eat – with lots of patience

• Feed the child many meals, little by little

• Breastfeed the child more frequently

• Feed food that the child likes

• Feed diverse and nutrient-rich foods

Emphasize: Continue to breastfeed frequently during and after illness

Encourage children to drink and eat during illness and provideextra food after illness to help them recover quickly.

Feeding the child having some common diseases



FEEDING DIARRHEA RESPIRATORY INFECTION FEVER

BF Breastfeed more than usualand longer

Breastfeed more than usualand longer

Breastfeed more than usualand longer

Eating

Feed the children manysmall meals.

Provide one extra meal fortwo weeks or till the childgains weight again.

Avoid feeding sugary foodsuch as soft drink, roots, andhigh-fiber cereal seeds because these can make diarrhea worse.



When feeding, the childshould be sitting in a straightposition in order to eat easier

Eat more fresh fruit



Eat more fresh fruit

Drinking

Give the child ORS after BFif he/she is in the EBF period.

If the child is not exclusivelybreastfeeding, give him/herone or many kinds of fluid:ORS, fruit juice, rice-water,porridge-water, clean water.Do not give the child softdrinks

Drink more water, fresh fruitjuices and more fresh fruit ifthe child has a fever.

Drink more water, fresh fruitjuices and more fresh fruitbecause the child has fever.

2.2. Child feeding during recovery

• Normally, when recovering, the child wants to eat more; therefore, the caregiver should increasethe amount of food. This is a good period to complement nutrients for him/her so as to limit loss ofweight, and help the child gain back the weight he or she had before illness.

3. Danger signs in children and treatment

When the child shows one of those danger signs, we need to take him/her to a health facility immediately

• Baby cannot breastfeed

• Baby has diarrhea and is thirsty

• Baby cannot drink or has difficulty in drinking

• Baby vomits a lot

• Baby’s stool is mixed with blood

• Baby has a fever (high temperature, higher than 380C)

• Baby has convulsions

• Baby sleeps soundly, hard to wake up

• Baby has abnormal signals (fast breathing, breathing difficulty, sunken rib-cage)

• Complement extra nutrients for the child. Give the child 1-2 extra meals per day until s/he gainsweight again and reaches normal growth level. This will be for at least 2 weeks.



CHILD FEEDING DURING RECOVERY

• Give extra breastfeeds

• Feed extra meals

• Give extra amounts of food

• Use extra nutrient-rich food

• Feed with extra patience and love

KEY MESSAGE TO REMEMBER

• Sick child: breastfeed more frequently; feed the child many small meals; give more water andgive ORS if required

• Recovering child: Continue breastfeeding and complementary feeding with one extrameal/day until the child gains weight again.

• Take the child to a health facility immediately when danger signs are detected.

TRAINEE HANDBOOK THREEBehavior Change Communication on Infant and Young Child Feeding in the Community (Franchise Model)Ha Noi, July 2011

Alive & Thrive Vietnam203 - 204, E4BTrung Tu Diplomatic CompoundNo 6 Dang Van Ngu, Ha Noi

Tel: +84-4-3573 9066Fax: +84-4-3573 9063www.aliveandthrive.org

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