IYCF

Participant Handbook
Maternal and Young Child Nutrition for

Medical and Allied Professionals
Training Module
January 2013
ii
Acknowledgments
ACKNOWLEDGMENTS
This Participant Handbook is part of the Maternal and Young Child Nutrition Training Module for
Medical and Allied Health Professionals, developed under collaboration between the United
Nations Childrens Fund (UNICEF) Philippines, the Philippine Department of Health (DOH) and
the Nutrition Center of the Philippines. The project aims to review, update and harmonize the
countrys training on maternal nutrition and infant and young child feeding (IYCF) so that
appropriate maternal and young child nutrition (MYCN) practices are uniformly understood by all
stakeholders and counseled to the community. Comprehensive MYCN Training Modules were
developed under this collaboration aimed at three audiences: medical and allied health
professionals, formal health workers and CHWs. The Maternal and Young Child Nutrition
Training Module for Medical and Allied Health Professionals includes the Trainers Training
Module, Training Curriculum, Facilitators Guide, Participants Handbook, and PowerPoint visual
aid for use by the trainer.
The Maternal and Young Child Nutrition Training Module for Medical and Allied Health
Professionals is based on WHO/UNICEF IYCF guidance documents and other relevant policies
on IYCF. The components of this training module were based largely on the World Health
Organizations (WHO) Infant and Young Child Feeding Model Chapter for textbooks for medical
students and allied health professionals. Additional information was taken from the Manual on
Infant feeding with emphasis on breastfeeding, jointly published by the Nutrition Center of the
Philippines (NCP) and the Association of Philippine Medical Colleges (APMC). Updates on the
feeding recommendations for infants of HIV-infected mothers were based on the Guidelines on
HIV and infant feeding 2010 published by the WHO in collaboration with UNAIDS, UNFPA and
UNICEF.
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Maternal and Young Child Nutrition for Medical and Allied Professionals
Training Module: Participants Handbook
Table of Contents
iii
TABLE OF CONTENTS
Acknowledgements
ii
Acronyms
iv
Introduction
3-Day Training Schedule
Session 1: Introductions, Expectations, Objectives
Session 2: Mothers Health and Nutrition During Pregnancy and Lactation
Session 3: Importance of Infant and Young Child Feeding and

Recommended Practices
20
Session 4: The Physiological Basis of Breastfeeding
29
Session 5: Complementary Feeding
41
Session 6: Management and Support of Infant Feeding in Maternity

Facilities
66
Session 7: Continuing Support for Infant and Young Child Feeding
72
Session 8: Appropriate Feeding for Exceptionally Difficult Circumstances

Session 8A: Low Birth Weight
Session 8B: Relactation
Session 8C: Infant and Young Child Feeding in Emergencies
Session 8D: Infants of HIV-positive mothers
Session 8E: Feeding Non-Breastfed children 6-23 months of age
Session 8F: Severe Malnutrition
91
99
110
122
135
139
Session 9: Management of Breast Conditions and Other Breastfeeding

Difficulties
144
Session 10: Policy, Health System, Community Actions (With Emphasis

on the Role of Health Workers)
154
Appendices
165
Glossary of Terms
172
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iv
Acronyms
ACRONYMS
ANC
ARA
ARVs
APMC
AO
BHFI
BMS
CHW
CMAM
DOH
EBF
EBM
ENA
EO
FIL
FNRI
FSH
HIV
IMCI
IUGR
IYCF
KMC
LAM
LBW
LH
MDG
MNCHN
MTCT
MUAC
MYCN
NDHS
NGO
NSO
ORS
RA
RUTF
SFP
SGA
UNFPA
UNICEF
WHO
Antenatal Care
Arachidonic acid
Anti-retroviral drugs
Association of Philippine Medical Colleges
Administrative Order
Baby-friendly Hospital Initiative
Breast milk substitute
Community health worker
Community management of acute malnutrition
Department of Health
Exclusive breastfeeding
Expressed breastmilk
Essential nutrition actions
Executive Order
Feedback inhibitor of lactation
Food and Nutrition Research Institute
Follicle stimulating hormone
Human immunodeficiency virus
Integrated management of childhood illness
Intrauterine growth retardation
Infant and young child feeding
Kangaroo mother care
Lactation amenorrhea method
Low birth weight
Luteinizing hormone
Millennium Development Goals
Maternal, Neonatal and Child Health and Nutrition
Mother-to-child transmission of HIV
Middle upper-arm circumference
Maternal and young child nutrition
National Demographic and Health Survey
Non-governmental organization
National Statistics Office
Oral Rehydration Salts
Republic Act
Ready-to-use therapeutic food
Supplementary Feeding Program
Small for gestational age
United Nations Population Fund
United Nations Childrens Fund
World Health Organization
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Introduction
INTRODUCTION
Importance of this course
Proper infant and young child feeding plays a crucial role in preventing malnutrition. The WHO
and UNICEF developed The Global Strategy for Infant and Young Child Feeding with global
public health recommendation for infants to be exclusively breastfed for the first six months of
life to help them reach optimal growth, development and health followed by a recommendation
for the timely introduction of nutritionally adequate, safe and appropriate complementary food at
six months while maintaining on-demand breastfeeding until 2 years of age or beyond.
{WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding} However, the rate
of exclusive breastfeeding during the first four months of life is no more than 35% worldwide.
{WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding} In the Philippines,
breastfeeding indices are relatively poor. The 2008 Philippines National Demographic and
Health Survey (NDHS) data showed that only one third (1/3) of Filipino children under six
months are exclusively breastfed, with the median duration of exclusive breastfeeding at only
three weeks. {National Statistics Office [Philippines] and ICF Macro, 2009, Philippines National
Demographic and Health Survey 2008} Data from the National Nutrition Survey 2008 indicates
that 35.9% of infants 0-5 months old are being exclusively breastfed. {Food and Nutrition
Research Institute-Department of Science and Technology, 2010, Philippine Nutrition Facts and
Figures 2008} The more recent 2011 Updating of the Nutritional Status of Filipinos data showed
that exclusive breastfeeding rate, based on the current feeding practice, is 48.9% among 0-5
month old infants. {Food and Nutrition Research Institute-Department of Science and
Technology, 2012, Nutritional Status of Filipinos 2011}. Water and complementary food is also
given very early. The NDHS 2008 data indicates that as early as 0-1 month old, 17.6% of
infants are given plain water only in addition to breastfeeding and 1% are already given
complementary food. {National Statistics Office [Philippines] and ICF Macro, 2009, Philippines
National Demographic and Health Survey 2008}. By 2-3 months of age, about 4.9% are already
given complementary foods and by 4-5 months of age, 23.3% are already receiving
complementary foods.
Optimal infant and young child feeding practices play an important role in child survival, growth
and development {UNICEF, 2011, Programming Guide: Infant and Young Child Feeding}.
Studies have shown that infants under 6 months of age who are not breastfed have a seven-fold
increased risk of mortality from diarrhea and a five-fold increased risk of mortality from
pneumonia {Robert E Black et al., 2003, Lancet, 361, 222634}. Furthermore, infants of the
same age who are non-exclusively breastfed have a more than two-fold increased risk of death
from diarrhea or mortality. Exclusive breastfeeding during the first 6 months of life and
continued breastfeeding from 6 to 11 months was ranked first among 15 interventions to prevent
under-five mortality while complementary feeding ranked third {Gareth Jones et al., 2003,
Lancet, 362, 65-71}.
To improve this situation, mothers and other family members and caregivers need support to
initiate and sustain appropriate IYCF practices. Professional, lay and peer support as well as
community-based breastfeeding promotion and support are among the interventions shown to
be effective in improving breastfeeding practices {UNICEF, 2011, Programming Guide: Infant
and Young Child Feeding}. Nutrition education has also been shown to improve caregiver
practices on complementary feeding. A high coverage of breastfeeding promotion and support
could prevent about 9% of child deaths under 36 months of age while the promotion of
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Introduction
complementary feeding and other supportive strategies prevents 1.5% more of child deaths
{Bhutta et al., 2008, Lancet, 371, 41740}.
Health professionals play a critical role in providing that support, by providing timely and
appropriate information to influence decisions about feeding practices. At present, IYCF is often
not well addressed in the basic training of doctors, nurses, and other allied health professionals.
Health professionals who lack adequate knowledge and skills may provide the wrong
information, such as recommending breast milk substitutes as a convenient solution to feeding
difficulties.
The Revised Implementing Rules and Regulations of the Milk Code clarifies that it is the
primary responsibility of health workers to promote, protect and support breastfeeding and
appropriate infant and young child feeding. It further states that part of this responsibility is to
continuously update their knowledge and skills on breastfeeding, without assistance, support or
logistics from milk companies.
Chapter IV of the Expanded Breastfeeding Act (RA 10028) of 2009 emphasized the need for the
continuing education, re-education and training on lactation management for health workers and
institutions. In addition, it stipulates the integration in relevant subjects in elementary, high
school and college levels of the importance, benefits, methods and techniques of breastfeeding.
It is vital for health professionals to have basic knowledge and skills to give appropriate advice,
to help solve feeding difficulties and to know when and where to refer mothers who experience
more complex feeding problems.
This manual provides the basic knowledge on maternal nutrition and infant and young child
feeding needed by health students and professionals. It also summarizes basic skills that every
health professional should master, such as positioning and attachment for breastfeeding, and
counseling skills.
Course Objectives
After completing the course, the participants will be equipped with the knowledge, skills and
tools to support mothers, fathers and other caregivers to optimally feed their infants and young
children.
The Course and the Handbook
The training course is divided into 10 sessions, which take approximately 21 hours not including
meals or the opening and closing ceremonies, given over a 3-day training.
The Participant Handbook is your main guide to the course, and you should keep it with you at
all times, except during practical sessions. In the following pages, you will find a summary of the
main information from each session, including descriptions of how to do each of the skills that
you will learn. You do not need to take detailed notes during the sessions, though you may find
it helpful to make notes of points of particular interest, for example from discussions. Keep your
Handbook after the course, and use it as a source of reference as you put what you have learnt
into practice.
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Schedule
TRAINING SCHEDULE COMMUNITY INFANT AND YOUNG CHILD FEEDING (IYCF) COUNSELING PACKAGE
TIME
08:15
08:30
08:30
10:30
DAY 1
Session 1: 60 minutes
Introductions, pre- assessment, group
norms, expectations and objectives
A mothers health and nutrition during
pregnancy and lactation
10:30
10:45
10:45
12:45
DAY 2
DAY 3
DAILY REVIEW
Session 8 contd. :

Management and support of infant
feeding in maternity facilities
8D: Infants of HIV-positive mothers 75 minutes

8E: Feeding Non-breastfed children 623 months of age - 30 minutes
8F: Severe Malnutrition - 15 minutes
TEA BREAK
Importance of infant and young child
feeding and recommended practices
The physiological basis of
breastfeeding
Session 8 contd. :
Continuing support for IYCF
8F: Severe Malnutrition - 15 minutes

Management of breast conditions and
other breastfeeding difficulties
Policy, health system and community
actions (with emphasis on the role of
health workers)
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12:45
13:45
13:45
15:45
LUNCH
Session 4 contd: 15 minutes

Complementary feeding
Session 8: Appropriate feeding in

exceptionally difficult circumstances

Policy, health system and community
actions (with emphasis on the role of
health workers)
8A: Low Birth Weight- 60 minutes

8B: Relactation- 30 minutes

Evaluation
15:45
16:00
16:00
17:00
Schedule
TEA BREAK
Session 8 contd:
8C: IYCF in Emergencies- 60
minutes
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Session 1: Introductions, expectations and objectives
SESSION 1
INTRODUCTIONS, EXPECTATIONS AND OBJECTIVES
Objectives
After completing this session, participants will be able to:
1. Begin to name fellow participants, facilitators and resource persons.
2. Discuss participants expectations, compare with the objectives of the training and
clarify the priorities/focus of the course.
3. Identify strengths and weaknesses of participants IYCF knowledge.
Specific Objectives of Training of Peer Counselors and Community Volunteers

The primary objective of training medical and allied health professionals is to equip them with
the knowledge and skills to support mothers, fathers and other caregivers to optimally feed their
infants and young children. The content focuses on maternal nutrition during pregnancy and
lactation, breastfeeding, complementary feeding, the Mother-Baby Friendly Hospital Initiative
and continuing community-based support, infant feeding in exceptionally difficult circumstances,
management of breast conditions and breastfeeding difficulties, and the roles of the health
worker in policy, health system and community actions. [An optional session on Human Milk
Banking may be included in the course later on, pending the finalization of guidelines by the
DOH-NCDPC.]
Upon completion of this course, the Participants will be able to:
1. Describe recommended maternal nutrition during pregnancy and lactation.
2. Describe importance of Infant and Young Child Feeding and recommended practices.
3. Describe recommended feeding practices through the first two years of life.
4. Explain the physiologic basis of breastfeeding.
5. Discuss the importance of complementary feeding.
6. Explain the important considerations in complementary feeding.
7. Summarize the main points of the Mother-Baby Friendly Hospital Initiative.
8. Identify methods for providing continuing support for infant and young child feeding after
discharge from the hospital or health facility.
9. Describe appropriate feeding practices in exceptionally difficult circumstances- low-birthweight babies, relactation, emergencies, infants of HIV-positive mothers, feeding nonbreastfed children 6-23 months of age and severe malnutrition.
10. Identify maternal or infant conditions that may affect breastfeeding and the correct
management for each condition.
11. Identify national policies related to MYCN.
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Session 1: Introductions, expectations and objectives
Notes
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SESSION 2
MOTHERS HEALTH AND NUTRITION DURING PREGNANCY AND
LACTATION
Objectives
1. Discuss the nutritional status of pregnant and lactating women in the Philippines.
2. Describe recommended maternal nutrition during pregnancy and lactation.
3. Explain the effects of mothers illness, intake of medication and drugs to breastfeeding.
4. Discuss family planning for a breastfeeding woman.
a. Discuss the importance of family planning and adequate birth spacing
b. Explain the relationship between breastfeeding and lactation amenorrhea method
(LAM)
c. Describe other family planning methods suitable for the breastfeeding woman.
Introduction
In this session, you will learn about the status of maternal nutrition in the country as well as their
health and nutritional needs. Women have high nutritional needs. Maternal nutrition plays a
pivotal role since it determines the nutritional status of her infant at birth and months and years
after that.
Nutritional status of pregnant and lactating women
The graph shows the nutritional status of Filipino pregnant women from 1998 to 2011. It is seen
that it decreased slightly by 1.3 percent points from 2008 to 2011 but not significantly.
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The graph shows the nutritional status of Filipino lactating women. From 2008 to 2011, there is
a decrease in the proportion of underweight lactating mothers but the decrease is not
significant. On the other hand, there is an increase in the proportion of overweight lactating
mothers.
The graph shows the anemia prevalence among pregnant and lactating women from 1993 to
2011. In 1993, 43.6% of pregnant women suffered from anemia. This decreased minimally to
42.5% in 2008. Anemia remains a severe public health problem among pregnant women.
For lactating women, anemia prevalence in 1993 was 43%, decreasing to 31.4% in 2008.
Among lactating women, anemia remains a moderate public health problem.
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The graph shows the prevalence of Vitamin A deficiency among pregnant and lactating women.
From 1993 to 2008, the prevalence of Vitamin A deficiency among pregnant women decreased
from 16.4% to 8.3%. For the group of lactating women, the prevalence of Vitamin A deficiency
decreased from 16.4% in 1993 to 6% in 1998, and remained at this level (6.4% in 2008). For
both pregnant and lactating women, Vitamin A deficiency remains a mild public health problem.
Recommended maternal nutrition during pregnancy and lactation

The provision of correct information and responsive counseling for maternal nutrition is included
in the integrated Maternal, Neonatal and Child Health and Nutrition (MNCHN) services indicated
in DOH AO No. 2008-0029.
Good nutrition for a woman is key for child survival and growth. The pregnant or lactating
mothers body needs extra food than her usual daily intake because they need to provide
energy and nutrition for the growing baby. During pregnancy, mothers need to eat one extra
small meal or snack between main meals. During lactation, mothers need to eat two extra
small meals or snacks between main meals. As for the adolescent mothers, they need more
food, extra care and more rest than an adult mother because she has to take care of her own
growing body and that of her growing baby.
Practicing Good Nutrition
No special food is required to produce breast milk.

Mothers need to eat a variety of locally available nutritious food each day, such as fresh
fruits and vegetables, grains such as rice or corn, peas and beans, milk, meat, fish and
eggs.
Mothers should drink plenty of water.
Avoid taking tea or coffee with meals and limit the amount of coffee during pregnancy.
Taking tea or coffee with meals can interfere with the bodys use of the foods.
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10
During pregnancy and breastfeeding, special nutrients will help the baby grow well and be
healthy.
Based on the Manual of Operations on Micronutrient Supplementation supported by
DOH AO No. 2010-0010 Revised Policy on Micronutrient Supplementation, mothers
should take iron and folic acid tablets once a day during pregnancy and once a week
after birth until the mother gets pregnant again to prevent anemia.
Take vitamin A supplements immediately after birth or within 1 month after delivery to
ensure that the baby receives the vitamin A in breast milk.
Through RA No. 8172 ASIN Law and RA 8976 Philippine Food Fortification Act of
2000, salt is required to be fortified with iodine and staple foods such as rice with iron,
wheat flour with iron and vitamin A, and cooking oil and sugar with vitamin A.
Other food manufacturers are also encouraged to fortify processed food products with
micronutrients through voluntary food fortification.
Mothers should be encouraged to consume fortified food products to help ensure that
mothers receive adequate amounts of micronutrients.
Always use iodized salt to prevent goiter in the mother; and learning disabilities,
delayed development, and poor physical growth in the baby.
Protecting Health
There are other important practices that should be advised to the mothers to protect their health.
Attend antenatal care at least 4 times during pregnancy starting as early as possible.
Rest more during the last 3 months of pregnancy and the first months after delivery.
After delivery, attend postpartum care or visit; the first visit should be within the first
week, preferably 2-3 days and the second visit within 4-6 weeks (DOH, 2003).
Take de-worming tablets to help prevent anemia.
To prevent malaria, sleep under an insecticide-treated mosquito net and take antimalarial tablets as prescribed.
Mothers should know their HIV status. If HIV-infected, consult a health care provider
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11
Effects of mothers illness, intake of medications and drugs to breastfeeding

Mothers Illness
If a mother has an illness or other condition, it is important to consider what effect it
might have on breastfeeding. She may need extra support to enable her to breastfeed,
for example if she has a disability, or is mentally ill. If a mother is very ill and unable to
breastfeed, options for feeding her infant or child until she can resume will need to be
considered.
If a mother has tuberculosis, she and her infant should be treated together according to
national guidelines, and breastfeeding should continue.
If a mother has hepatitis (A, B, or C) breastfeeding can continue normally as the risk of
transmission by breastfeeding is very low.
A mother who is HIV-positive should exclusively breastfeed her infant for the first 6
months of life, introducing appropriate complementary foods thereafter, and continue
breastfeeding for the first 12 months of life.
Some medications taken by a mother may pass into her milk. There are very few
medicines for which breastfeeding is absolutely contra-indicated. However there are
some medicines that can cause side effects in the baby they may warrant the use of a
safer alternative or avoidance of breastfeeding temporarily.
Box 2.1 HOW DRUGS ARE CLASSIFIED FOR BREASTFEEDING
1. Compatible with breastfeeding
Drugs are classified as compatible with breastfeeding if there are no known or
theoretical contraindications for their use, and it is considered safe for the mother to
take the drug and continue to breastfeed.
(e.g. oxygen, paracetamol, allopurinol, colchicine, mebendazole, amoxicillin,
cetriaxone)
2. Compatible with breastfeeding. Monitor infant for side-effects
Drugs are classified in this way if they could theoretically cause side-effects in the
infant but have either not been observed to do so or have only occasionally caused
mild side-effects. Inform the mother about any possible side-effects, reassure her
that they are unusual, and ask her to return if they occur or if she is worried.
If side-effects do occur, stop giving the drug to the mother, and if necessary find an
alternative. If the mother cannot stop taking the drug, she may need to stop
breastfeeding and feed her baby artificially until her treatment is completed. Help her
to express her breastmilk to keep up the supply so that she can breastfeed again
after she stops taking the drug.
(e.g. morphine, chloroquine, phenytoin, anti-tuberculosis drugs)
3. Avoid if possible. Monitor infant for side-effects
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12
Drugs are classified in this way if they have been reported to cause side-effects in
the infant, especially if the side-effects could be serious. Use these drugs only when
they are really essential for the mothers treatment and when no safer alternative is
available. Allow the mother to continue breastfeeding but give her clear instructions
about observing the baby and arrange for frequent follow-up. If side-effects occur,
stop the drug. If it is not possible to stop giving the drug, stop breastfeeding and feed
the baby artificially until treatment is completed. Help her to express her breastmilk to
keep up the supply so that she can breastfeed again after stops taking the drug.
(e.g. metronidazole, haloperidol, , atenolol, metoclopramide, cimetidine)
4. Avoid if possible. May inhibit lactation
Drugs classified this way may reduce breastmilk production and, if possible, they
should be avoided. However, if a mother has to take one of these drugs for a short
period, she does not need to give artificial milk to her baby. She can offset the
possible decrease in milk production by encouraging her baby to suckle more
frequently.
(e.g. levodopa+carbidopa, some diuretics (amiloride,
furosemide,hydrochlorothiazide), hormonal contraceptives, estrogens)
5. Avoid
Drugs are classified in this way if they can have dangerous side-effects on the baby.
They should not be given to a mother while she is breastfeeding. If they are essential
for treating the mother, she should stop breastfeeding until treatment is completed. If
treatment is prolonged, she may need to stop breastfeeding altogether. There are
very few drugs in this category apart from anticancer drugs and radioactive
substances.
(e.g. cytotoxic drugs, tamoxifen, immunosuppressive drugs)
Source: UNICEF/World Health organization. Breastfeeding and Maternal Medication:
Recommended for Drugs in the Eleventh WHO Model List of Essential Drugs. Geneva:
WHO; 2002.
BOX 2.2 BREASTFEEDING AND MOTHERS MEDICATION
Breastfeeding contraindicated
Anti-cancer drugs (anti-metabolites);
Radio-active substances (stop breastfeeding temporarily)
Continue breastfeeding
Side-effects possible
Selected psychiatric drugs and anticonvulsants (see

individual drug)
Monitor baby for

drowsiness.
Use alternative drug if
possible.
Monitor baby for jaundice.
Use alternative drug.
Chloramphenicol, tetracyclines, metronidazole, quinolone

antibiotics (e.g. ciprofloxacin)
Sulfonamides, dapsone,
sulfamethoxazole+trimethoprim (cotrimoxazole),
sulfadoxine+pyrimethamine (fansidar)
Estrogens, including estrogen-containing contraceptives,
thiazide diuretics, ergometrine
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13
(may inhibit lactation)

Most commonly used drugs:
Analgesics and antipyretics: short courses of
Monitor baby.
paracetamol, acetylsalicylic acid, ibuprofen;
occasional doses of morphine and pethidine
Antibiotics: ampicillin, amoxicillin, cloxacillin and
other penicillins, erythromycin
Antituberculosis drugs, anti-leprosy drugs (see
dapsone above)
Antimalarials (except mefloquine, fansidar)
Anthelminthics, antifungals
Bronchodilators (e.g. salbutamol), corticosteroids,
antihistamines, antacids, drugs for diabetes,
most antihypertensives, digoxin
Nutritional supplements of iodine, iron, vitamins
Source: UNICEF/World Health organization. Breastfeeding and Maternal Medication:
Recommended for Drugs in the Eleventh WHO Model List of Essential Drugs. Geneva:
WHO; 2002.
Safe in usual dosage.
See Appendix 1 for additional list of medicines and their effects on breastfeeding.
Family planning for a breastfeeding woman

Health Benefits of Family Planning
Family planning has numerous health benefits for women, their sexual partners and
children. It helps save lives of women, children and adolescents.
It could prevent as many as one in every three maternal deaths, allowing to

delay mother hood, space births, avoid unintended pregnancies and abortions,
and stop childbearing when the desired family size is reached.
After giving birth, family planning can help women wait at least two years before
trying to become pregnant again, thereby reducing newborn, infant and child
deaths significantly.
Teen pregnancies pose health risks not only for the babies but also for the
young mothers, particularly those under age 18. Family planning can help young
women avoid having children during this high-risk time and also avoid the social
and economic consequences of early childbearing.
Many HIV-positive women and couples want to avoid becoming pregnant and
many effective methods are available to assist them. By averting unintended
and high-risk pregnancies, family planning reduces mother-to-child transmission
of HIV and the number of AIDS orphans, whose life chances are seriously
diminished because they have lost a parent, particularly the mother.
In addition to these health benefits, family planning helps governments achieve national
and international development goals. Governments around the world are focused on
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14
combating poverty and achieving a range of health and development goals, such as
those outlined in the United Nations Millennium Development Goals (MDGs). Family
planning can contribute to nearly all of these goals, including reducing poverty and
hunger, promoting gender equity and empowering women, reducing child mortality,
improving maternal health, combating HIV/AIDS, and ensuring environmental
sustainability.
Recommended Time Spacing for Children

The practice of timing the period childbirth has been identified as an important life saving
measure for mothers and children. The figure below shows the breakdown of
recommended practices leading to optimal child spacing.
Data from The Nutritional Institute of Central America and Panama (INCAP) suggest six
months exclusive breastfeeding, followed by at least 18 months additional breastfeeding
with complementary foods, and at least six months of neither breastfeeding nor
pregnancy for best child outcomes. This would be inter-birth spacing of 39 months.
(WHO, 2006; Merchant, Martorell, and Hass, 1990)
Lactation Amenorrhea Method
Breastfeeding has many benefits for the child as well as for the mother. Under certain
conditions, women may gain the benefit of birth spacing or delaying a new pregnancy
thru breastfeeding.
This is what is called the Lactation Amenorrhea Method. As the baby suckles breast
milk, messages are sent to the hypothalamus and anterior pituitary gland of the brain.
The suckling message results in changing levels of follicle stimulating hormone (FSH)
and luteinizing hormone (LH) which prevent ovulation and menstruation (leading to
amenorrhea). This condition is true only if the infant suckles frequently, with no more
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15
than 4-6 hours passing between any two breastfeeds. (Brown, 1982)
Criteria in using LAM
This method is indicated or suitable for :
1. lactating woman who choose to delay the use of another complementary method;
2. for the woman who wishes to take the time to decide between methods; and
3. for the woman whom chosen methods is not immediately available.
There are three conditions that must be met if a woman wishes to use LAM as a sole
methods of family planning. According to researches, LAM is more than 98% effective if
the 3 following criteria are met:
1. Amenorrhea (no menses) - no bleeding after 8 weeks of birth
2. Exclusive breastfeeding is practiced - no more than 4 hrs between breastfeeds
and no more than one 6-hour period (in 24 hrs) between breastfeeds (night and
day)
3. The infant is less than 6 months of age
At any point that the abovementioned criteria are not met, counsel the couple regarding
the need for other family planning method. The use of LAM and its efficacy is dependent
on intensity of the breastfeeding. This method therefore is not suitable for women who
for any reason cannot fully or nearly fully breastfeed her infant.
As soon as a woman relying on LAM for contraception no longer meets all three
criteria, she should start another family planning method.
Other family planning methods

Since LAM is only a short-term family planning method, the breastfeeding woman should
be counseled about the availability of complementary family planning methods. The
couple should be presented with the rightful information regarding these options and
should be allowed to choose freely the method they think is suitable to their needs.
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16
First Choice
Non-hormonal methods of contraception are First Choice methods in this case, as they
do not interfere with breast milk and do not enter the bloodstream. These methods
include the use of natural family methods, diaphragm, condoms, IUDs, spermicides, and
male/female sterilization.
Second Choice
Progestin-only methods are Second Choice methods, as the hormones may pass into
the breast milk with no evidence of adverse effect on the infant. With the use of this
method, milk production may be reduced prior to eight weeks. Progestin-only methods
include: progestin only pills (POPs) with 99.5% effectiveness; injectables (DMPA, NetEN) with 99.7% effectiveness; and Norplant Subdermal Implants with 99.9%
effectiveness.
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17
Third Choice
Third choice options include both estrogens and progestins. The estrogen in these
methods can reduce the production of breast milk, and decreased milk supply can lead
to earlier cessation of breastfeeding. However, breastfeeding can and should continue
during use as it supplies important health benefits for the infant. WHO recommends
delaying the use of this method for at least 6 months. The hormones may also pass into
the breast milk. These methods include: combined oral contraceptives (COCs) and
combined injectable hormones with 99.9% effectivity.
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18
References
Contents of this session are adapted from the modules of three existing infant and young
child feeding training packages:
1. UNICEF. The Community Infant and Young Child Feeding Counselling Package.
New York: UNICEF; 2011.
2. World Health Organization. Infant and Young Child Feeding Counselling: An
Integrated Course. Geneva: WHO; 2006.
3. World Health organization. Infant and Young Child Feeding: Model Chapter for
Textbooks for Medical Students and Allied Health Professional. Geneva: WHO;
2009.
Other references utilized are:
1. Brown R, Breast-feeding and family planning: a review of the relationships
between breast-feeding and family planning. Am J Clin Nutr 1982:(35): 162-171.
2. Merchant K, Martorell R, Haas JD. Consequences for maternal nutrition of
reproductive stress across consecutive pregnancies. Am J Clin Nutr 1990:52(4):
616-20.
3. Smith R, Ashford L, Gribble J, Clifton D. Population Reference Bureau. Family
Saves Lives Fourth Edition; 2009.
4. World Health Organization. Report of a WHO Technical Consultation on Birth
Spacing. Geneva: WHO; 2006.
5. DOH. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for
essential practice in Philippine setting. WHO publication: Geneva; 2003.
6. Food and Nutrition Research Institute Department of Science and Technology
(FNRI-DOST). Nutritional Status of Filipinos. DOST Complex, FNRI Bldg.,
Bicutan, Taguig City, Metro Manila, Philippines; 2011.
7. Food and Nutrition Research Institute Department of Science and Technology
(FNRI-DOST). Philippine Nutrition Facts and Figures 2008. DOST Complex,
FNRI Bldg., Bicutan, Taguig City, Metro Manila, Philippines; 2010.
8. RP-Congress of the Philippines. Republic Act No. 8976, An Act Establishing the
Philippine Food Fortification Program and For Other Purposes. Manila: 2000.
9. RP-Congress of the Philippines. An Act Promoting Salt Iodization Nationwide and
For Related Purposes. Manila: 1995.
10. RP-DOH (Republic of the Philippine- Department of Health). Administrative Order
No. 2008-0029: Implementing Health Reforms for Rapid Reduction of Maternal
and Neonatal Mortality. Manila: 2008.
11. RP-DOH (Republic of the Philippines-Department of Health). Administrative
Order No. 2010-0010: Revised Policy on Micronutrient Supplementation to
Support Achievement of 2015 MDG Targets to Reduce Under-Five and Maternal
Deaths and Address Micronutrient Needs of Other Population Groups. Manila:
2010.
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19
12. UNICEF/World Health organization. Breastfeeding and Maternal Medication:

Recommended for Drugs in the Eleventh WHO Model List of Essential Drugs.
Geneva: WHO; 2002.
Notes
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20
Session 3: The importance of IYCF and recommended practices
SESSION 3
THE IMPORTANCE OF INFANT AND YOUNG CHILD FEEDING AND
RECOMMENDED PRACTICES
Objectives
1. Discuss the importance of IYCF.
2. Describe the current status of IYCF.
3. Discuss recommended practices for IYCF.
Introduction
Exclusive breastfeeding for the first six months of life promotes optimal growth, development
and health. After this, breastfeeding with appropriate complementary foods will continue to
ensure the infant and young childs growth, development and health.
Low rates and early cessation of these practices have significant implications on the health and
development of not only children, but mothers and community as well (Leon-Cava et.al, 2002).
Importance of IYCF
Growth, health and development
Adequate nutrition during infancy and early childhood is essential to ensure the growth, health,
and development of children to their full potential.
The first 1,000 days from conception to two years of age provide a critical window of opportunity
for ensuring a childs appropriate growth and development through optimal feeding. Poor
nutrition increases the risk of illness and is linked to 1/3 of the estimated 9.5 M deaths in
children less than 5 years of age in 2006. Early nutritional deficits are linked to long-term
impairment in growth and health:
Malnutrition in the first two years of life causes stunting.
Studies suggest that adults who were malnourished in early childhood have impaired
intellectual performance and reduced capacity for physical work.
Women who were malnourished as children have reduced reproductive capacity and
higher risk of complicated deliveries.
The Global Strategy for IYCF

The Global Strategy for IYCF was adopted by WHO and UNICEF in 2002 to refocus attention
on the impact of feeding practices on nutritional status, growth and development, health and
survival.
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21
WHO and UNICEFs recommendations for optimal infant feeding are:

Exclusive breastfeeding for the first 180 days (6 months) an infant receives only breast
milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids
or solids, not even water, with the exception of oral rehydration solutions, drops or
syrups consisting of vitamins, mineral supplements or medicines.
Nutritionally adequate and safe complementary feeding starting from the age of 6
months with continued breastfeeding up to 2 years of age or beyond when breast milk
is no longer sufficient to meet the nutritional requirement of infants, other foods and
liquids are needed, along with breast milk. The target range is generally taken to be 6 to
23 months of age.
For infants and young children in exceptionally difficult circumstances, adaptations to these
recommendations will be discussed in Session 8.
Current status of IYCF
Poor breastfeeding and complementary feeding practices are still widespread. Worldwide, it is
estimated that only 34.8% of infants are exclusively breastfed for the first 6 months of life.
In the Philippines, exclusive breastfeeding and complementary feeding figures have been noted
to have significant increase in the past few years.
Trends in exclusive breastfeeding
The graph shows trends in EBF rates worldwide. Between 1996 and 2006, the rates of
exclusive breastfeeding for the first six months of life increased slightly from 33% to 37%.
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22
In the Philippines, there was a slight decrease in the mean duration of exclusive breastfeeding
among children 0-23 months old from 3 months in 2003 to 2.3 months in 2008. This slightly
increased to 3.7 months in 2011.
The mean duration of breastfeeding increased by about 2 months over the same 8-year period.
From 2003 to 2011, the proportion of exclusively breastfed infants, 0-5 months old, increased by
17 percentage points, to 46.7%.
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23
The practice of exclusive breastfeeding increased by 3.2 percentage points from 8.6% in 2008
to 11.8% in 2011. The practice of breastfeeding and giving complementary foods increased
from 29.9% in 2008 to 45.2% in 2011.
About half of mothers start to breastfeed within the recommended one hour after delivery
(51.9%), followed by one-third at less than one day after delivery (32.3%).
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24
Nearly half of infants 0-5 months old (48.9%) are exclusively breastfed. Breastfeeding with
complementary foods is highest when infant is 6-8 months old and declines at 9-23 months.
Recommended Feeding practices
Evidence for recommended feeding practices
1. Breastfeeding
Breastfeeding confers short-term and long-term benefits on both the child and the
mother.
Benefits for infants:
Infants who are not breastfed are 6 10 times more likely to die in the first
months of life than infants who are breastfed. Diarrhea and pneumonia are
responsible for many of these deaths.
Diarrheal illness is more common in artificially-fed infants even in situations with
adequate hygiene, as in Belarus and Scotland.
Other acute infections like otitis media, Haemophilus influenza meningitis, and
UTi, are less common and less severe in breastfed infants.
Artificially-fed children have an increased risk of long-term diseases with an
immunological basis, including asthma and other atopic conditions, Type I
diabetes, celiac disease, ulcerative colitis and Crohns disease, and even
childhood leukemia.
Obesity in later childhood and adolescence is less common among breastfed
children, with a longer duration of breastfeeding associated with a lower risk.
Several recent studies have linked artificial feeding with risks to cardiovascular
health, including increased blood pressure, altered blood cholesterol levels, and
atherosclerosis in later adulthood.
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25
A meta-analysis of 20 studies showed scores of cognitive function 3.2 points

higher on average among breastfed children compared to those who were
formula fed. This difference was greater among children born with low birth
weight.
Increased duration of brestfeeding has been associated with greater intelligence
in late childhood and adulthood.
For the mother:

The risk of postpartum hemorrhage may be reduced by breastfeeding
immediately after delivery
The risk of breast and ovarian cancers is less among women who breastfeed.
Exclusive breastfeeding can delay the return of fertility. Mothers who breastfeed
exclusively and frequently have less than a 2% risk of becoming pregnant,
provided that they still have amenorrhea.
Exclusive breastfeeding can accelerate recovery of pre-pregnancy weight.
2. Exclusive breastfeeding for 6 months

The advantages of exclusive breastfeeding compared to mixed feeding were recognized
in the 1980s, when evidence that the risk of death from diarrhea of partially breastfed
infants less than 6 months of age was 8.6 times the risk for exclusively breastfed
children, and 25 times that of exclusively breastfed children for those who received no
breast milk at all.
Other studies showed:
Partial breastfeeding had a 4.2 times increased risk of death, while no

breastfeeding at all had 14.2 times the risk.
Deaths from diarrhea and pneumonia could be reduced by 1/3 if infants were
exclusively instead of partially breastfed (Dhaka, Bangladesh)
Exclusive breastfeeding for 6 months has been found to reduce the risk of
diarrhea and respiratory illness compared with exclusive breastfeeding for 3 and
4 months respectively
Several studies have shown that healthy infants do not need additional water
during the first 6 months if they are exclusively breastfed, even in a hot climate.
Extra fluids displace breast milk, and do not increase overall intake. Giving water
and tea to infants has been associated with a two-fold increase in the risk of
diarrhea.
3. Complementary feeding from 6 months onward

From the age of 6 months, complementary feeding is necessary to fill an infants nutrient
and energy needs that can no longer be provided by breast milk alone.
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26
The period of 6-23 months coincides with the peak incidence of growth faltering,
micronutrient deficiencies and infectious illnesses in many countries.
Breastfeeding remains a critical source of nutrients and protective factors for the growing
child, even after complementary foods have been introduced. It provides around of an
infants energy needs up to one year of age. In the second year of life, it provides up to
1/3 of a childs energy needs
Complementary foods need to be:
Nutritionally adequate
Safe
Appropriately fed
Mothers and families need support to practice good complementary feeding. This will be
discussed further in Session 5.
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27
References
Contents of this session are adapted from the modules of three existing infant and young child
feeding training packages:
1. UNICEF. The Community Infant and Young Child Feeding Counselling Package. New
York: UNICEF; 2011.
2. World Health Organization. Infant and Young Child Feeding Counselling: An Integrated
Course. Geneva: WHO; 2006.
Textbooks for Medical Students and Allied Health Professional. Geneva: WHO;2009.
1. FNRI-DOST. Nutritional Status of Filipinos 2011. Taguig City: FNRI-DOST; 2012.
2. Len-Cava N, Lutter C, Ross J, Martin L. Quantifying the benefits of breastfeeding: a
summary of the evidence. Pan American Health Organization, Washington DC; 2002.
____________________________________________________________________________
28
Notes
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Session 4: The physiological basis of breastfeeding
29
SESSION 4
THE PHYSIOLOGICAL BASIS OF BREASTFEEDING
Objectives
1. Name the main parts of the breast and their functions.
2. Describe the hormonal control of breast milk production and ejection.
3. Discuss the feedback inhibition of lactation.
4. Explain how babys reflexes help in appropriate breastfeeding.
5. Describe the difference between good and poor attachment of a baby at the breast.
6. Describe the difference between effective and ineffective suckling.
7. Discuss the composition of breast milk.
8. Differentiate the colostrum and mature milk.
9. Explain the difference between the animal milk and infant formula.
Introduction
The Global Strategy for Infant and Young Child Feeding recommends that infants are
exclusively breastfed for the first six months of life. As health professionals, it is
important to understand the physiological basis of breastfeeding so as to help support
this advocacy.
Main Parts of the Breast and their Functions

Anatomy of the Breast
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30
The breast structure includes the nipple and areola, mammary tissue, supporting
connective tissue and fat, blood and lymphatic vessels, and nerves.
The mammary tissue This tissue includes the alveoli, which consist of small sacs
made of milk-secreting cells, and the ducts that carry the milk to the outside. Between
feeds, milk collects in the lumen of the alveoli and ducts. The alveoli are surrounded by a
basket of myoepithelial, or muscle cells, which contract and make the milk flow along the
ducts.
Nipple and areola The nipple has an average of nine milk ducts passing to the outside,
and also muscle fibres and nerves. The nipple is surrounded by the circular pigmented
areola, in which are located Montgomerys glands. These glands secrete an oily fluid
that protects the skin of the nipple and areola during lactation, and produce the mothers
individual scent that attracts her baby to the breast. The ducts beneath the areola fill with
milk and become wider during a feed, when the oxytocin reflex is active.
Hormonal Control of Milk Production
There are two hormones that directly affect breastfeeding:
Prolactin
Necessary for secretion of milk by the alveolar cells

Blood levels of prolactin increase markedly during pregnancy. This
stimulates the growth and development of mammary tissue in preparation
for milk production.
Milk is not secreted during pregnancy because progesterone and
estrogen block the action of prolactin. Milk secretion begins after delivery,
when levels of progesterone and estrogen fall rapidly
During the first two weeks, the more a baby suckles and stimulates the
nipple, the more prolactin is produced, and the more milk is produced.
More prolactin is produced at night, so breastfeeding at night is helpful for
keeping up the milk supply.
Oxytocin
Oxytocin causes the myoepithelial cells around the alveoli contract,

making the milk flow and fill the ducts
Oxytocin reflex is also called the let-down reflex or milk ejection reflex
Oxytocin reflex may be inhibited when a mother is in severe pain or

emotionally upset. If she receives support, is helped to feel comfortable
and lets the baby continue to breastfeed, the milk will flow again.
Oxytocin also causes contraction of the uterus and helps to reduce

bleeding. The contractions can cause severe pain when a baby suckles
during the first few days.
Oxytocin starts working when a mother expects a feed as well as when

the baby is suckling.
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31
The following are the signs of an active oxytocin reflex. The absence of
these signs does not mean the reflex is not active. The signs may not be
obvious, and the mother may not be aware of them.
Tingling sensation in the breast before or during a feed
Milk flowing from her breasts when she thinks of the baby or hears
him crying
Milk flowing from the other breast when the baby is suckling
Milk flowing from the breast in streams if suckling is interrupted
Slow deep sucks and swallowing by the baby, which show that
milk is flowing into his mouth
Uterine pain or a flow of blood from the uterus
Thirst during a feed
Psychological effects of oxytocin

Induces a state of calm and reduces stress
May enhance feelings of affection between mother and child, and
promote bonding
Skin-to-skin contact between mother and baby after delivery can
stimulate the secretion of oxytocin and prolactin
Feedback Inhibitor of Lactation

Milk production is also controlled in the breast by a substance called the feedback
inhibitor of lactation, or FIL (a polypeptide), which is present in breast milk. Sometimes
one breast stops making milk while the other breast continues, for example if a baby
suckles only on one side. This is because of the local control of milk production
independently within each breast. If milk is not removed, the inhibitor collects and stops
the cells from secreting any more, helping to protect the breast from the harmful effects
of being too full. If breast milk is removed the inhibitor is also removed, and secretion
resumes. If the baby cannot suckle, then milk must be removed by expression.
FIL enables the amount of milk produced to be determined by how much the baby takes,
and therefore by how much the baby needs. This mechanism is particularly important for
ongoing close regulation after lactation is established. At this stage, prolactin is needed
to enable milk secretion to take place, but it does not control the amount of milk
produced.
Reflexes in the baby
A babys reflexes are important for appropriate breastfeeding.
Rooting reflex if something touches a babys lip or cheek, s/he turns to find the
stimulus, opens his/her mouth, putting his/her tongue forward. The rooting reflex
is present from about the 32nd week of pregnancy.
Suckling reflex a baby starts to suck when something touches his/her palate.
The suckling reflex is developed at around 31 weeks of gestation.
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32
Swallowing reflex a baby swallows when his/her mouth fills with milk.
Coordination of rooting, suckling, swallowing and breathing appears between 32

and 35 weeks of pregnancy. A majority of infants can breastfeed fully at a
gestational age of 36 weeks.
Good and Poor Attachment

To stimulate the nipple and remove milk from the breast, and to ensure an adequate
supply and a good flow of milk, a baby needs to be well attached so that he or she can
suckle effectively. Difficulties often occur because a baby does not take the breast into
his or her mouth properly, and so cannot suckle effectively.
Good Attachment
The picture shows how a baby takes the breast into his or her mouth to suckle
effectively. This baby is well attached to the breast.
The points to notice are:
much of the areola and the tissues underneath it, including the larger ducts, are
in the babys mouth;
the breast is stretched out to form a long teat, but the nipple only forms about
one third of the teat;
the babys tongue is forward over the lower gums, beneath the milk ducts (the
babys tongue is in fact cupped around the sides of the teat, but a drawing
cannot show this);
the baby is suckling from the breast, not from the nipple.
As the baby suckles, a wave passes along the tongue from front to back, pressing the
teat against the hard palate, and pressing milk out of the sinuses into the babys mouth
from where he or she swallows it. The baby uses suction mainly to stretch out the breast
tissue and to hold it in his or her mouth. The oxytocin reflex makes the breast milk flow
along the ducts, and the action of the babys tongue presses the milk from the ducts into
the babys mouth. When a baby is well attached his mouth and tongue do not rub or
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33
traumatize the skin of the nipple and areola. Suckling is comfortable and often
pleasurable for the mother. She does not feel pain.
Poor Attachment
The picture shows what happens in the mouth when a baby is not well attached at the
breast.
The points to notice are:
only the nipple is in the babys mouth, not the underlying breast tissue or ducts;
the babys tongue is back inside his or her mouth, and cannot reach the ducts to
press on them.
Suckling with poor attachment may be uncomfortable or painful for the mother, and may
damage the skin of the nipple and areola, causing sore nipples and fissures (or
cracks). Poor attachment is the commonest and most important cause of sore nipple,
and may result in inefficient removal of milk and apparent low supply.
Signs of Good and Poor Attachment
Table 4.1 Signs of Good and Poor Attachment
Good Attachment
more of the areola is visible above the

babys top lip than below the lower lip;
the babys mouth is wide open;

the babys lower lip is curled outwards;
the babys chin is touching or almost
touching the breast.
Poor Attachment
more of the areola is visible below the
babys bottom lip than above the top lip
or the amounts above and below are
equal;
the babys mouth is not wide open;
the babys lower lip points forward or is
turned inwards;
the babys chin is away from the breast.
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34
Good Signs of Attachment: These signs show that the baby is close to the breast, and
opening his or her mouth to take in plenty of breast. The areola sign shows that the baby
is taking the breast and nipple from below, enabling the nipple to touch the babys
palate, and his or her tongue to reach well underneath the breast tissue, and to press on
the ducts. All four signs need to be present to show that a baby is well attached. In
addition, suckling should be comfortable for the mother.
Poor Signs of Attachment: If any one of these signs is present, or if suckling is painful or
uncomfortable, attachment needs to be improved. However, when a baby is very close
to the breast, it can be difficult to see what is happening to the lower lip. Sometimes
much of the areola is outside the babys mouth, but by itself this is not a reliable sign of
poor attachment. Some women have very big areolas, which cannot all be taken into the
babys mouth. If the amount of areola above and below the babys mouth is equal, or if
there is more below the lower lip, these are more reliable signs of poor attachment than
the total amount outside.
Causes of Poor Attachment

Use of a feeding bottle before breastfeeding is well established can cause poor
attachment, because the mechanism of suckling with a bottle is different. Functional
difficulties such as flat and inverted nipples, or a very small or weak infant, are also
causes of poor attachment.
However, the most important causes are inexperience of the mother and lack of skilled
help from the health workers who attend her. Many mothers need skilled help in the
early days to ensure that the baby attaches well and can suckle effectively. Health
workers need to have the necessary skills to give this help.
Positioning the Baby for Good Attachment
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35
Mother and baby need to be appropriately positioned for good attachment.
Mother needs to be relaxed and comfortable, with support for her back. She
should be able to hold the baby at her breast without leaning forward.
Babys body should be straight, not bent or twisted. His/her head can be slightly
extended at the neck.
S/he should be facing the breast. The baby should not be flat against the
mothers chest or abdomen, but turned slightly on his or her back able to see the
mothers face.
Babys body should be close to the mother, enabling him/her to be close to the
breast and to take a large mouthful.
Effective and Ineffective Suckling

Table 4.2 Signs of Effective and Ineffective Suckling
Effective Suckling
Baby takes slow, deep suckles followed

by a visible or audible swallow about
once per second
Babys cheeks remain rounded during
the feed
Suckling usually slows down towards
the end of a feed, with fewer deep
suckles and longer pauses between
them
The nipple may look stretched out for a
second or two, but it quickly returns to
its resting form.
Ineffective Suckling
Suckle quickly all the time, without

swallowing
Cheeks may be drawn in as s/he
suckles, showing that milk is not
flowing well into the babys mouth
The nipple may stay stretched out when

baby stops feeding, look squashed from
side to side, with a pressure line across
the tip
Consequences of Ineffective Suckling

When a baby suckles ineffectively, transfer of milk from mother to baby is inefficient. As
a result:
Breast engorgement, blocked ducts, or even mastitis
Breasts may be overstimulated by too much suckling, resulting in an oversupply
of milk
Insufficient intake of breast milk, resulting in poor weight gain
Frustration and refusal of baby to feed
Prolonged suckling that does not sate the baby, or very frequent feedings
The management of these problems will be discussed further in Session 9.
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36
Composition of Breast milk

Breast milk contains all the nutrients an infant needs in the first 6 months of life
(including fat, carbohydrates, proteins, vitamins, minerals and water) and bioactive
factors that augment the infants immune system.
Fats
Human milk contains 3.5 g fat / 100 mL o f milk which provides half the energy
content of the milk. The fat is secreted in small droplets, and the amount
increases as the feed progresses
Foremilk at the beginning of a feed contains less fat and looks bluish-grey
in color
Hindmilk is rich in fat and looks creamy white
Breast milk fat contains long chain polyunsaturated fatty acids DHA
(decosahexaenoic acid) and ARA (arachidonic acid) that are important for a
childs neurological development. They are added to some varieties of infant
formula, but this does not confer any advantage over breast milk, and may not be
as effective as those in breast milk
Carbohydrates
The main carbohydrate in human milk is the disaccharide lactose. Breast milk
contains about 7 g lactose/100 mL milk. Another kind of carbohydrate,
oligosaccharides, provide protection against infection
Protein
Breast milk contains 0.9 g protein/100mL milk, a lower concentration than animal
milks. The higher protein in animal milks can overload an infants immature
kidneys with waste nitrogen products. Breast milk contains less of the protein
casein. The casein in human breast milk has a different molecular structure,
forming softer, more easily-digested curds. Among the whey (or soluble)
proteins, human milk contains more alpha-lactalbumin; cows milk contains betalactoglobulin, to which infants can become intolerant.
Vitamin and Minerals

Breast milk normally contains sufficient vitamins for an infant, unless the mother
herself is deficient. Only exception is Vitamin D. To generate endogenous
Vitamin D, an infant needs exposure to sunlight. Minerals iron and zinc are
present in relatively low concentration, but bioavailability and absorption are high.
If maternal iron status is adequate, babies are born with a store of iron to supply
their needs. Only infants born with low birth weight may need supplements
before 6 months.
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37
Anti-infective Factors
Breast milk contains many factors that help to protect an infant against infection
including:
Immunoglobulin, principally secretory immunoglobulin A (sIgA), which
coats intestinal mucosa and prevents bacteria from entering the cells.
These were formed in the mothers body against the bacteria in her gut
and infections she has encountered, thus providing protection against
bacteria that are likely to be in the babys environment
White blood cells which can kill microorganisms;
Whey proteins (lysozyme and lactoferrin) which can kill bacteria, viruses
and fungi; and
Oligosaccharides which prevent bacteria from attaching to mucosal
surfaces
Other Bioactive Factors

Breast milk contains other bio-active factors such as bile-salt stimulated lipase
and epidermal growth factor.
Bile-salt stimulated lipase facilitates the complete digestion of fat once the
milk has reached the small intestine. Fat in artificial milks is less
completely digested.
Epidermal growth factor stimulates maturation of the lining of the infants
intestine, so that it is better able to digest and absorb nutrients, and is
less easily infected or sensitized to foreign proteins. It has been
suggested that other growth factors present in human milk target the
development and maturation of nerves and retina.
Differences Between Colostrum and Mature Milk

Colostrum is the special milk that is secreted in the first 23 days after delivery. It is
produced in small amounts, about 4050 ml on the first day, but is all that an infant
normally needs at this time.
Colostrum is rich in white cells and antibodies, especially sIgA, and it contains a larger
percentage of protein, minerals and fat-soluble vitamins (A, E and K) than later milk.
Vitamin A is important for protection of the eye and for the integrity of epithelial surfaces,
and often makes the colostrum yellowish in colour.
Colostrum provides important immune protection to an infant when he or she is first
exposed to the micro-organisms in the environment, and epidermal growth factor helps
to prepare the lining of the gut to receive the nutrients in milk. It is important that infants
receive colostrum, and not other feeds, at this time. Other feeds given before
breastfeeding is established are called prelacteal feeds.
Milk starts to be produced in larger amounts between 2 and 4 days after delivery,
making the breasts feel full; the milk is then said to have come in. On the third day, an
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38
infant is normally taking about 300400 ml per 24 hours, and on the fifth day 500800
ml. From day 7 to 14, the milk is called transitional, and after 2 weeks it is called mature
milk.
Differences Between Animal Milk and Infant Formula

Animal milks are very different from breast milk in both the quantities of the various
nutrients, and in their quality. For infants under 6 months of age, animal milks can be
home-modified by the addition of water, sugar and micronutrients to make them usable
as short-term replacements for breast milk in exceptionally difficult situations, but they
can never be equivalent or have the same anti-infective properties as breast milk. After 6
months, infants can receive boiled full cream milk.
Infant formula is usually made from industrially modified cow milk or soy products.
During the manufacturing process the quantities of nutrients are adjusted to make them
more comparable to breast milk. However, the qualitative differences in the fat and
protein cannot be altered, and the absence of anti-infective and bio-active factors
remain. Powdered infant formula is not a sterile product, and may be unsafe in other
ways. Life threatening infections in newborns have been traced to contamination with
pathogenic bacteria, such as Enterobacter sakazakii, found in powdered formula. Soy
formula contains phyto-oestrogens, with activity similar to the human hormone estrogen,
which could potentially reduce fertility in boys and bring early puberty in girls.
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39
References
2009.
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40
Notes
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41
SESSION 5
COMPLEMENTARY FEEDING
Objectives
1. Describe the important considerations in complementary feeding.
2. Describe good feeding practices Diet diversification.
3. Describe good feeding practices Meal Frequency.
4. Describe good feeding practices Responsive Feeding.
5. Describe good feeding practices Micronutrient supplementation.
6. Describe good feeding practices Handwashing, hygiene, sanitation and water safety.
Introduction
The term complementary feeding is used to emphasize that this feeding complements breast
milk rather than replacing it. Effective complementary feeding activities include support to
continue breastfeeding. These additional foods and liquids are called complementary foods, as
they are additional or complementary to breastfeeding, rather than adequate on their own as the
diet. Complementary foods must be nutritious foods and in adequate amounts so the child can
continue to grow.
The policy guideline on complementary feeding practices in the countrys National Policies on
IYCF through the DOH AO 2005-0014 states that infants shall be given appropriate
complementary foods at age six months in order to meet their evolving nutritional requirements.
This is in accordance with the global public health recommendation indicated in the Global
Strategy for Infant and Young Child Feeding that after exclusive breastfeeding for 6 months,
infants should receive nutritionally adequate and safe complementary foods while breastfeeding
continues for up to two years of age or beyond.
Considerations in complementary feeding

1. Age of infant/young child
Complementary feeding should be started when the baby can no longer get enough
energy and nutrients from breast milk alone. For most babies this is six completed
months of age.
The childs age must be taken into consideration during complementary feeding as
different children from different age group have different nutritional needs. The need of a
6-month old infant is different from that of a 12-month old.
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42
Our body uses food for energy to keep alive, to grow, to fight infection, to move around
and be active. Food is like the wood for the fire if we do not have enough good wood,
the fire does not provide good heat or energy. In the same way, if young children do not
have enough good food, they will not have the energy to grow and be active.
This graph shows the energy needed by the growing child and how much is provided by
effective breastfeeding. On this graph, each column represents the total energy needed
at that age. The columns become taller to indicate that more energy is needed as the
child becomes older, bigger and more active. The dark part shows how much of this
energy is supplied by breast milk.
You can see that from about six months onwards there is a gap between the total energy
needs and the energy provided by breast milk. The gap increases as the child gets
bigger.
As the young child gets older, breast milk continues to provide energy, however the
childs energy needs increase as the child grows. If these gaps are not filled, the child
will stop growing or grow only at a slow rate. The child who is not growing well may also
be more likely to become ill or to recover less quickly from an illness.
This graph is that of an average child and the nutrients supplied by breast milk from an
average mother. A few children may have higher needs and the energy gap would be
larger. A few children may have smaller needs and thus a smaller gap.
Therefore, for most babies, six months of age is a good time to start complementary
foods. Complementary feeding from six completed months helps a child to grow well and
be active and content. At six completed months of age it becomes easier to feed thick
porridge and mashed food because babies:
show interest in other people eating and reach for food
like to put things in their mouth
can control their tongue better to move food around their mouth
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43
start to make up and down munching movements with their jaws
In addition, at this age, babies digestive systems are mature enough to begin to digest a
range of foods. Adding complementary foods too soon may:
take the place of breast milk, making it difficult to meet the childs nutritional
needs
result in a diet that is low in nutrients if thin, watery soups and porridges are used
increase the risk of illness because less of the protective factors in breast milk
are consumed
increase the risk of diarrhea because the complementary foods may not be as
clean or as easy to digest as breast milk
increase the risk of wheezing and other allergic conditions because the baby
cannot yet digest and absorb non-human proteins well
increase the mothers risk of another pregnancy if breastfeeding is less frequent.
However, starting complementary foods too late is also a risk because the child:
does not receive the extra food required to meet his/her growing needs
grows and develops more slowly
might not receive the nutrients to avoid malnutrition and deficiencies such as
anemia from lack of iron
2. Frequency of foods
Meal frequency or the number of times that the child is fed complementary foods should
be increased as the child gets older (PAHO/WHO, 2003). The appropriate number of
feedings depends on the energy density of the local foods and the usual amounts
consumed at each feeding. A growing child needs 2-4 meals a day plus 1-2 snacks if
hungry.
For the average healthy breastfed infant, meals of complementary foods should be
provided (PAHO/WHO, 2003):
2-3 meals plus frequent breastfeeds at 6 months
2-3 meals plus frequent breastfeeds from 6 up to 9 months, 1-2 snacks may
be offered
3-4 meals plus frequent breastfeeds from 9 up to 12 months, 1-2 snacks may
be offered
3-4 meals plus frequent breastfeeds from 12 up to 24 months, 1-2 snacks
may be offered
If a child is less than 24 months and is not breastfed, 1-2 extra meals should be added
and 1-2 snacks may be offered (UNICEF, 2011).
Meal frequency will be discussed more during the discussion of good feeding practices.
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3. Amount of foods
The amount of foods varies from each age group as the childs total energy
requirements also vary. The amount of energy that should be provided by
complementary foods is estimated by subtracting the average energy intake from breast
milk from total energy requirements at each age.
But in practice, caregivers will not know the exact amount of breast milk intake, and they
will not compute the energy content of complementary foods to be offered. The amount
of food to be offered should therefore be based on the principles of responsive feeding
(PAHO/WHO, 2003).
When a child starts to eat complementary foods, he needs time to get accustomed to the
new taste and texture of the foods. A child needs to learn the skill of eating. Start at 6
months of age with small amounts of food and gradually increase the amount as the
infant gets older, while maintaining breastfeeding.
A 6-month old infant may start with 2-3 tablespoons per feeds starting with tastes. From
6 up to 9 months of age, 2-3 tablespoons per feed can be gradually increased to half of
a 250 mL cup/bowl. From 9 up to 12 months of age, give half of a 250 mL cup/bowl per
feed. From 12 up to 24 months of age, give three-quarters to one 250 mL cup/bowl per
feed. If a child is less than 24 months and is not breastfed, the same amount is
recommended according to age group (UNICEF, 2011). Children vary in their appetite
and these are just guidelines.
4. Texture (thickness/consistency)
Food consistency and variety should be gradually increased as the infant gets older,
adapting to the infants requirements and abilities. The neuromuscular development of
infants dictates the minimum age at which they can ingest particular types of foods
(WHO/UNICEF, 1998). Semi-solid or pureed foods are needed at first, until the ability for
munching (up and down mandibular movements) or chewing (use of teeth) appears.
When foods of inappropriate consistency are offered, the child may be unable to
consume more than a trivial amount, or may take so long to eat that food intake is
compromised.
Let us say that the child will have lugaw (or rice porridge). The food may be thin and
runny or it may be thick and stay on the spoon. Often families are afraid that thick foods
will be difficult to swallow, be stuck in the babys throat, or give the baby constipation.
Therefore, they add extra liquid to the foods to make it easier for the young child to eat.
Sometimes extra liquid is added so that it will take less time to feed the baby. Food that
is too thin and watery will fill the babys stomach before he gets the energy he needs to
grow.
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45
The food should be thick enough to stay easily on the spoon without running off when
the spoon is tilted. If families use a blender to prepare the babys foods this may need
extra fluid to work. It may be better to mash the babys food instead so that less fluid is
added. Porridge or food mixtures that are so thin that they can be fed from a feeding
bottle, or poured from the hand or that the child can drink from a cup, do not provide
enough energy or nutrients. The consistency or thickness of foods makes a big
difference to how well that food meets the young childs energy needs. Foods of a thick
consistency help to fill the energy gap.
As the child develops and learns the skills of eating, he progresses from very soft,
mashed food, to foods with some lumps that need chewing, and to family foods. Some
family foods may need to be chopped for longer if the child finds them difficult to eat.
5. Variety of foods
Infants and young children should be fed a variety of foods to ensure that nutrient needs
are met.
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Meat, poultry, fish or eggs should be eaten daily, or as often as possible. Vegetarian
diets cannot meet nutrient needs at this age unless nutrient supplements or fortified
products are used (PAHO/WHO, 2003). Vitamin A-rich fruits and vegetables should be
eaten daily.
Provide diets with adequate fat content because it provides essential fatty acids,
facilitates absorption of fat soluble vitamins, and enhances dietary energy density and
sensory qualities. Avoid giving drinks with low nutrient value, such as tea, coffee and
sugary drinks such as soda. Tea and coffee contain compounds that can interfere with
iron absorption. Sugary drinks, such as soda, should be avoided because they
contribute little other than energy, and thereby decrease the childs appetite for more
nutritious foods. Limit the amount of juice offered so as to avoid displacing more nutrientrich foods. Excessive juice consumption can also decrease the childs appetite for other
foods, and may cause loose stools.
Most adults and older children eat a mixture or variety of foods at mealtime. In the same
way, it is important for young children to eat a mix of good complementary foods. Often
the food preparations of the family meals include all or most of the appropriate
complementary foods that young children need.
When you build on the usual food preparations in a household, it is easier for families to
feed their young children a diet with good complementary foods.
Children across age groups are recommended to be given a variety of foods:

Breast milk (breastfeed as often as the child wants)
Animal foods (such as meat, poultry, fish and internal organs such as liver)
Staples (such as porridge, rice, corn, sweet potato and potato)
Legumes (such as string beans, hyacinth bean or bataw, lima beans or patani
and peanuts)
Fruits and vegetables including vitamin A-rich fruits (such as mango, papaya,
dalandan, green and leafy vegetables, carrot, squash) as well as other fruits
and vegetables (such as banana, pineapple, tomato, avocado, eggplant and
cabbage)
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47
If a child is less than 24 months and is not breastfed, the same is recommended in
addition to 1 to 2 cups of milk per day and 2 to 3 cups of extra fluid especially in hot
climates (UNICEF, 2011).
The giving of variety of foods will be discussed more during the separate section on the
good feeding practice of diet diversification.
6. Active or responsive feeding
During the period of complementary feeding, the young child gradually becomes
accustomed to eating family foods. Feeding includes more than just the foods provided.
How the child is fed can be as important as what the child is fed.
Active or responsive feeding should be practiced, applying the principles of psychosocial care. Specifically, this means (PAHO/WHO, 2003):
feed infants directly and assist older children when they feed themselves, being
sensitive to their hunger and satiety cues
feed slowly and patiently, and encourage children to eat, but do not force them
if children refuse many foods, experiment with different food combinations,
tastes, textures and methods of encouragement
minimize distractions during meals if the child loses interest easily
remember that feeding times are periods of learning and love - talk to children
during feeding, with eye to eye contact
Responsive feeding will be discussed in more detail during a separate section on the
good feeding practice of responsive feeding.
7. Hygiene
Attention to hygienic practices during food preparation and feeding is critical for
prevention of gastrointestinal illness. The peak incidence of diarrheal disease is during
the second half year of infancy, as the intake of complementary foods increases
(PAHO/WHO, 2003; Martinez et al., 1992).
In general, good hygiene and proper food handling include:
washing caregivers and childrens hands before food preparation and eating
storing foods safely and serving foods immediately after preparation
using clean utensils to prepare and serve food
using clean cups and bowls when feeding children
avoiding the use of feeding bottles, which are difficult to keep clean
Additional details will be discussed later during the separate section on handwashing,
hygiene, sanitation and water safety.
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Good Feeding Practices

1. Diet Diversification
The quality of childrens diets can have consequences for their physical growth and
cognitive development (Ogunba, 2010).
The second policy guideline on complementary feeding practices in the countrys National
Policies on IYCF through the DOH AO 2005-0014, states that appropriate complementary
feeding interventions shall encourage diversified approaches to ensure access to foods that
will adequately meet energy and nutrient needs of growing children, such as use of homeand community-based technologies to enhance nutrient density, bioavailability and the
micronutrient content of local foods.
Diet diversification is a food-based strategy that aims to improve the availability, access,
and consumption of foods with a high content and bioavailability of micronutrients
throughout the year (Gibson and Hotz, 2001). It involves changes in food production
practices, which may include home gardening and small animal production, and dietary
modifications which include food selection patterns, and traditional household methods for
preparing and processing indigenous foods. Diet diversity ensures that the nutritional needs
of children are met to achieve optimal nutritional status as diet diversity has the potential of
increasing the intake of multiple food components simultaneously (Bhutta et al., 2008).
Ensuring a 4-star diet

Continue to breastfeed (for at least 2 years) and try to give a variety of foods at
each meal or a 4 star**** diet. A 4-star diet is created by including different types of
locally available foods from the following categories:
Staples: grains such as rice, corn and wheat and wheat products such as
bread; roots and tubers such as potatoes, sweet potatoes and cassava (1
star*)
Animal-source foods: including meat, chicken, fish, liver; and eggs and milk,
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and milk products (1 star*)

Legumes: such as string beans, hyacinth bean or bataw, lima beans or patani
and peanuts (1 star*)
Vitamin A-rich fruits and vegetables: such as papaya, mango, dalandan,
dark-green leaves, carrots, squash and yellow sweet potato and other fruits
and vegetables such as banana, pineapple, avocado, watermelon, tomatoes,
eggplant and cabbage (1 star*)
Diet diversity ensures that the nutritional needs of children are met.
There is little iron from breast milk. After 6 months the babys iron needs must be met by
the food he/she eats. Giving animal foods such as liver, lean meats and fish provides best
sources of iron. Plant sources such as beans, peas, legumes and other dark green leafy
vegetables are a source of iron as well.
Best sources of vitamin A are yellow-colored fruits and vegetables such as papaya,
mangoes, oranges, squash, carrots, yellow sweet potato. Dark green leaves and organ
foods from animals such as liver; milk and food made from milk such as butter and cheese.
2. Meal Frequency
A baby is already eating a full bowl of food at each meal. There is no space in his stomach
for more food at mealtimes.
In order to fill the energy gap of the baby, his family can give him some food more often.
They do not need to cook more meals. They can give some extra foods between meals that
are easy to prepare. These extra foods are in addition to the meals they should not
replace them.
These extra foods are often called snacks. However, they should not be confused with foods
such as sweets, crisps or other processed foods (give examples), which may include the
term snack foods in their name. These extra foods may be easy to give, however the child
still needs to be helped and supervised while eating to ensure the extra foods are eaten.
Good snacks provide both energy and nutrients. Fruits such as ripe mango, papaya, banana
or avocado; bread or biscuits with cheese or spread with butter, margarine, peanut butter or
honey; boiled potatoes or boiled sweet potatoes are all good snacks. Poor value snacks are
ones that are high in sugar but low in nutrients. Examples of these are fizzy drinks (sodas),
sweet fruit drinks, sweets/candy, and sweet biscuits.
These snacks may be easy to give, however the child still needs to be helped and
supervised while eating to ensure that snacks are eaten.
Frequency of feeding
A growing child needs 2-4 meals a day plus 1-2 snacks if hungry: give a variety of
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foods.
Frequency of feeding a non-breastfed child
A child who does not have breast milk needs special attention to ensure he receives
sufficient food.
A child who is not taking any breast milk and is eating enough complementary foods
will still have a very large gap for energy.
One way to increase the energy intake is to give the child 1-2 cups of milk (where
one cup is equal to 250ml) and an extra 1-2 meals per day in addition to the amounts
of food recommended.
If no animal-source foods are included in the diet, fortified complementary foods or
nutrient supplements are needed for a child to meet his nutrient needs.
Summary of considerations during complementary feeding per age group (Age,

Frequency, Amount, Texture, Variety)
In the previous sections, the important points to consider during complementary feeding were
discussed. Let us review the recommendations for the first five points:
A - Age
F Frequency
A - Amount
T - Texture
V - Variety
Babies have small stomachs and can only eat small amounts at each meal so it
important to feed them frequently throughout the day.
When baby reaches 6 months, continue breastfeeding and give 2-3 meals in addition to
frequent breastfeeding.
Start with small amount of foods about 2-3 tablespoons per feeds starting with tastes.
Start with the staple cereal to make porridge (e.g. rice, corn, wheat, potatoes). The
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consistency of the porridge should be thick enough.

When possible, use milk instead of water to cook the porridge.
Give a variety of foods to ensure that nutrient needs are met.
Animal source foods are very important and can be given to babies and young children.
Use iodized salt when preparing complementary food.
From 6 up to 9 months, continue breastfeeding and give 2-3 meals per day in addition
to frequent breastfeeding. Additional 1-2 nutritious snacks (such as fruit or bread) may
be added.
The 2 to 3 tablespoonfuls per feed can be gradually increased to half () of a 250 ml
cup or bowl.
Mash and soften the added foods so your baby/child can easily chew and swallow.
Any food can be given to children after 6 months as long as it is mashed/chopped.
Children do not need teeth to consume foods such as eggs, meat, and green leafy
vegetables.
Add colorful (variety) foods to enrich the staple including beans, peanuts, peas, lentils
or seeds; orange/red fruits and vegetables (such ripe mango, papaya, and carrots,
squash); dark-green leaves, avocado. Soak beans and legumes before cooking to
make them more suitable for feeding children
Add animal-source foods: meat, chicken, fish, liver; and eggs and milk, and milk
products (whenever available)
Use iodized salt when preparing complementary food
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From 9 up to 12 months, continue breastfeeding and increase frequency of feeds to 3-4

meals per day in addition to frequent breastfeeding. Additional 1-2 nutritious snacks
(such as fruit or bread) may be added.
Give of 250 ml cup or bowl per feed.
Children may be given food with some lumps such as finely chopped family foods,
sliced foods and finger foods.
squash); dark-green leaves, avocado.
Animal source foods are very important and can be given to young children: cook well
and cut into very small pieces
products (whenever available)
By 9 months the baby should be able to eat finger foods. It is important to give finger
foods to children to eat by themselves only after they are able to sit upright.
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From 12 up to 24 months, continue breastfeeding and give 3-4 meals per day in
addition to frequent breastfeeding. Additional 1-2 nutritious snacks (such as fruit or
bread) may be added.
Give three-quarter () to one cup of 250 ml cup/bowl.
Give family foods.
squash); dark-green leaves, avocado.
products every day at least in one meal (or at least 3 times /week)
A non-breastfed child should receive 1 to 2 extra meals and offered 1 to 2 additional

snacks, i.e. 4 meals/day of family food
Should receive the amount of food per feed and texture of food as recommended for
breastfed children per age group
Should have extra water each day, particularly in hot climates to ensure that their thirst
is satisfied: 2-3 cups in a temperate climate and 4-6 in hot climates
Should have essential fatty acids in their diet from animal-source foods, fish, avocado,
vegetable oil, and nut pastes.
Should have adequate iron. If they are not receiving animal-source foods then fortified
foods or iron supplements should be considered.
Non-breastfed children should receive 1-2 cups of milk per day
3. Responsive Feeding
Active/responsive feeding is being alert and responsive to the babys signs that he or she is
ready-to-eat; actively encourage, but dont force the baby to eat.
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When feeding him/herself, a child may not eat enough. He or she is easily distracted.
Therefore the young child needs help. When a child does not eat enough, he or she will
become malnourished.
Responsive feeding practices:
1. Assist children to eat, being sensitive to their cues or signals.

Children need to learn to eat. Eating solid foods is a new skill and, at first, the child will
eat slowly and may make a mess. It takes lots of patience to teach children to eat. The
child needs help and time to develop this new skill, to learn how to eat, to try new food
tastes and textures.
At first, the young child may push food out of the mouth. This is because he/she does
not have the skill of moving it to the back of his/her mouth to swallow it. Caregivers may
think that this pushing out of food means the child does not want to eat. Talk with them
about children needing time to learn to eat, just as they need time to learn to walk and to
learn other skills.
A childs ability to pick up a piece of solid food, hold a spoon, or handle a cup increases
with age and practice. Children under two years of age need assistance with feeding.
However, this assistance needs to adapt so that the child has opportunities to feed
himself, as he is able.
A child may eat more if he is allowed to pick up foods with his newly learned finger skills
from about 9-10 months of age. The child may be at least 15 months old before he can
eat a sufficient amount of food by self-feeding. At this age, he is still learning to use
utensils and will still need assistance.
Families tend to feed their young children in one of three different ways:
a. One way is high control of the feeding by the caregiver who decides when and
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how much the child eats. This may include force-feeding. Children may not learn
to regulate their intake, which may lead to obesity and food refusal later. The
child may feel eating is very frightening and uncomfortable. He may feel scared.
b. Another feeding style is that the children are left to feed themselves. The
caregiver believes that the child will eat if hungry. The caregiver may also believe
when the child stops eating that he has had enough to eat. If the child has a
poor appetite or is too young to manage the skills of eating, this can result in
malnutrition. The child may feel eating is very difficult. He may be hungry or
sad.
c. The third style is feeding in response to the childs cues or signals using
encouragement and praise. The childs cue or signal that he is hungry may
include restlessness, reaching for food, or crying. Cues or signals that he does
not want to eat more may include turning away, spiting out food or crying.
Caregivers need to be aware of their childs cues, interpret them accurately, and
respond to them promptly, appropriately and consistently.
2. Feed slowly and patiently, encourage but do not force.

Good responsive feeding practices:
Sit down with the child, be patient and actively encourage him/her to eat
Respond positively to the child with smiles, eye contact and encouraging words
Feed the child slowly and patiently with good humor
Feed the child as soon as he or she starts to show early signs of hunger
Try different food combinations, tastes and textures to encourage eating
Give finger foods that the child can feed him/herself
If your young child refuses to eat, encourage him/her repeatedly; try holding the
child in your lap during feeding
Do not insist if the child does not want to eat. Do not force feed.
Wait when the child stops eating and then offer again
Minimize distractions if the child loses interest easily
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Stay with the child through the meal and be attentive.

Help older child to eat
3. Talk to children during feeding with eye-to-eye contact.

Feeding times are periods of learning and love. Children may eat better if feeding times
are happy. Feed when the child is alert and happy. If the child is sleepy or over-hungry
and upset, he may not eat well. Regular mealtimes and the focus on eating without
distractions may also help a child to learn to eat.
Children are more likely to eat well if they like the person who is feeding them. Give
positive attention for eating not just attention when eating poorly.
Older siblings may help with feeding but may still need adult supervision to ensure the
young child is actively encouraged to eat and that the sibling does not take his food.
The overall feeding environment may also affect food intake. This includes:
to sit with the family or other children at mealtimes so the child sees them eating
to sit with others eating to provide an opportunity to offer extra food to the young
child
to use a separate bowl for the child so the caregiver can see the amount eaten
to talk with the child
to encourage all the family to help with responsive feeding practices.
4. Micronutrient supplementation
During our earlier discussion about diet diversification and meal frequency, we saw how it
can be hard for children to meet the needs for some micronutrients, particularly iron and
vitamin A.
Fortified foods such as fortified flours, pasta, cereals, oil or instant foods made for children,
help to meet these nutrient needs. Micronutrient supplements also ensure that the childrens
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micronutrient needs are met. Micronutrient deficiencies continue to be prevalent in the

country especially among infants and young children.
Interventions to combat micronutrient deficiencies
Micronutrient supplementation is one of the three strategies identified by the
government to combat micronutrient deficiency problems in the country along with
diet diversification and food fortification.
The DOH has issued AO No. 2010-0010, the revised policy on micronutrient
supplementation. This reiterates the provisions of AO No. 2007-0045 on Zinc
Supplementation and Reformulated Oral Rehydration Salt in the Management of
Diarrhea.
The policy guideline of the National Policies on IYCF through the DOH AO 20050014, also identified micronutrient supplementation as one of the interventions to
improve the nutritional status, growth and development of children.
Micronutrient supplementation interventions
The micronutrient supplementation interventions for infants and young children
identified in the program are (DOH/FHI 360/USAID, 2011):
Vitamin A supplementation which has been shown to reduce the risk of allcause child mortality by 24% (Bhutta et al., 2008). It is also considered to be
one of the most cost-effective public health measure in improving survival,
growth and development of children. It protects children against severity of
subsequent infections and reduces the complications of existing infections.
Iron supplementation which has been shown to reduce the occurrence of
anemia from 62% to 38% in areas where malaria is not endemic and from
32% to 6% in areas where malaria is endemic (Bhutta et al., 2008). It
improves the cognitive and motor development of anemic preschool children.
Zinc supplementation in the management of diarrhea has been shown to
reduce the duration of diarrhea and the number of episodes of diarrhea
(Bhutta et al., 2008).
Micronutrient Powder (MNP) is a premix of vitamins and minerals in powder
form which may be added once daily into any semi-solid food without
changing the color, taste or texture of the food. It has been shown that MNP
package which comes in 60-sachets improves hemoglobin concentrations
and iron stores in a large proportion of children (DOH/FHI 360/USAID, 2011).
MNP comes in a preparation containing 15 micronutrients:

Micronutrient
Amount
Micronutrient
Amount
Vitamin A
400 ug
Folic Acid
150 ug
Vitamin C
30 mg
Niacin
6 mg
Vitamin D
5.0 ug
Iron
10 mg
Vitamin E
5 mg a-TE
Zinc
4.1 mg
Vitamin B1
0.5 mg
Copper
0.56 mg
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58
Vitamin B2
0.5 mg
Iodine
90 ug
Vitamin B6
0.5 mg
Selenium
17.0 ug
Vitamin B12
0.9 ug
Although results of the initial studies on the use of MNP are encouraging, the DOH needs
time and resources to establish the support mechanisms to ensure its accessibility to target
groups nationwide.
Micronutrient supplementation guideline for infants
Age
Guidelines
0-11 months old
1. Routine iron and vitamin A supplementation should be given to all

6-11 month-old infants because they have high need for iron and
vitamin A due to rapid growth and development. This involves
routine supplementation of iron drops once a day for 3 months and
single dose of vitamin A capsule. If MNP is already available, iron
requirement will be in the form of MNP.
2. Start regular vitamin A and iron supplementation at 6 months of
age since micronutrient stores and vitamin A from breast milk are
no longer sufficient to meet their needs.
3. Give therapeutic dose of iron to 6-11 month old infants clinically
diagnosed with iron deficiency anemia (IDA).
4. Give iron supplements to low birth weight (LBW) infants at 2
months. LBW infants have lower iron supply and are at high risk of
iron deficiency even if exclusively breastfed.
5. Give therapeutic vitamin A dose to infants diagnosed with high-risk
conditions such as measles, severe pneumonia, severely
underweight, persistent diarrhea, and xerophthalmia. These
conditions rapidly deplete vitamin A stores and present increased
mortality rate.
6. Treat 0-11 month-old infants with diarrhea with reformulated ORS
and zinc.
7. Do not give iodine supplements to infants. Use iodized salt in the
preparation of complementary food.
Appendix 2 of the Manual shows the table for routine and therapeutic
supplementation for 0-11 month old infants.
12-59 months
old (1-<5 year
old)
1. Prioritize 12-23 month-old children for iron and vitamin A

supplement. This age group is likely to have deficient iron and
vitamin A intakes from inadequate complementary feeding, has
increased demand for iron and vitamin A due to rapid growth and
higher incidence of illness, and has high prevalence of IDA.
2. Give iron to those who are clinically diagnosed with anemia.
3. Ensure that children 12-59 months old receive 2 doses of vitamin A
each year. Give the vitamin A supplements every 6 months.
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4. Give vitamin A therapeutic dose to children who are clinically

diagnosed with xerophthalmia, severe pneumonia, measles,
persistent diarrhea and severe underweight.
5. Treat 12-59 month old children with diarrhea with reformulated
ORS and zinc.
6. Encourage the use of iodized salt and consumption of other
fortified foods with Sangkap Pinoy Seal.
5. Handwashing, hygiene, sanitation and water safety

The introduction of complementary foods, although promotes quality and optimal nutrition for
children, also risks them to food borne diseases if the needed sanitation and hygiene
practices are not taken into consideration. Contamination of food including drinking water
with pathogens is considered one of the leading causes of diarrhea in children.
There are many possible sources of food contamination (Motarjemi, Y, 2000).
Diarrhea and other food borne diseases can cause anorexia, abdominal pain, fever and loss
of nutrients that will lead to nutritional deficiencies with serious and hazardous
consequences for the growth and development of children.
Good Hygiene practices
Handwashing
Good hygiene practices, particularly, handwashing with soap and water at critical moments
can reduce the incidence of diarrhea and respiratory infections (UNICEF, 2011).
Wash hands with soap and water before preparing foods and feeding baby. Wash hands
and babys hands before eating. Wash your hands with soap and water after using the toilet
and washing or cleaning babys bottom. Foods intended to be given to the child should
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always be stored and prepared in hygienic conditions to avoid contamination, which can
cause diarrhea and other illnesses.
5 Keys to safer food
Keep clean
Wash your hands before handling food and often during food preparation.
Wash your hands after going to the toilet, changing the baby or in contact with
animals.
Wash very clean all surfaces and equipment used for food preparation or
serving.
Use a clean spoon or cup to give foods or liquids to the baby.
Do not use bottles, teats or spouted cups since they are difficult to clean and can
cause your baby to become sick.
Protect kitchen areas and food from insects, pests and other animals.
Separate raw from cooked foods

Separate raw meat, poultry and seafood from other foods.
Use separate equipment and utensils such as knives and cutting boards for
handling raw foods.
Store foods in covered containers to avoid contact between raw and prepared
foods.
Use fresh foods and cook thoroughly
Cook food thoroughly, especially meat, poultry, eggs and seafood.
Bring foods like soups and stews to boiling point. For meat and poultry, make
sure juices are clear not pink.
Reheat cooked food thoroughly. Bring to the boil or heat until too hot to touch.
Stir while re-heating.
Keep food at safe temperatures
____________________________________________________________________________
61
Do not leave cooked food at room temperature for more than 2 hours.
Do not store food too long, even in a refrigerator.
Do not thaw frozen food at room temperature.
Food for infants and young children should ideally be freshly prepared and not
stored at all after cooking.
Use safe water and raw materials
Use safe water or treat it to make it safe.
Choose fresh and wholesome foods.
Use pasteurized milk.
Wash fruits and vegetables in safe water, especially if eaten raw.
Do not use food beyond its expiry date.
Other sanitary and hygienic practices
Other sanitary and hygienic practices should be practiced to prevent other sources of
food contamination:
Keeping food covered to protect it from flies and other insects.
Proper use of toilet and sanitary disposal of human excreta. Demand to put a
stop to open defecation.
Use of safe storage system for drinking water and making sure that it is covered.
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62
References
Contents of this session are adapted from the modules of two existing infant and young child
York: UNICEF; 2011.
2. World Health Organization. Infant and Young Child Feeding Counselling: An Integrated
Course. Geneva: WHO; 2006.
Other references used for this session are:
1. Bhutta ZA, Ahmed T, Black RE et al. Maternal and Child Undernutrition 3. What works?
Interventions for maternal and child undernutrition and survival. Lancet. 2008;371:417
440.
2.
Brown KH, et al. Effects of common illnesses on infants energy intakes from breast milk
and other foods during longitudinal community-based studies in Huascar (Lima), Peru. Am
J Clin Nutr 1990;52:1005-13.
3.
Brown,KG and Dewey, KG. Update on technical issues concerning complementary

feeding of young children in developing countries and implications for intervention
programs. Food and Nutrition Bulletin 2003;24:5-28
4.
Dewey KG, Brown KH. Update on technical issues concerning complementary feeding of
young children in developing countries and implications for intervention programs. Food
Nutr Bull 2003;24:5-28.
5. DOH/FHI 360/USAID. Micronutrient Supplementation Manual of Operations: Manila: DOH;
2011.
6. Gibson, R. and Hotz, C. Dietary diversification/modification strategies to enhance
micronutrient content and bioavailability of diets in developing countries. British Journal of
Nutrition 2001;85:S159-S166 doi:10.1079/ BJN2001309
7. Giugliani, ERJ and Victora, CG. Complementary Feeding. Journal de Pediatria
2000;76:253-262
8. Malacaan Palace. Executive Order No. 51: Adopting a National Code of Marketing of
Breast - Milk Substitutes, Breastmilk Supplements and Related Products, Penalizing
Violations Thereof, and for Other Purposes. Manila: 1986.
9. Martinez BC, de Zoysza I, Glass RI. The magnitude of the global problem of diarrhoeal
disease: a ten-year update. Bull WHO 1992;70:705-14.
10. Molbak K, Gottschau A, Aaby P, Hojlyng N, Ingholt L, da Silva AP. Prolonged breast
feeding, diarrhoeal disease, and survival of children in Guinea-Bissau. BMJ
1994;308:1403-06.
11. Motarjemi, Y. Research Priorities on Safety of Complementary Feeding. Pediatrics.
2000:106;1304-1305
12. Ogunba, BO. Diet Diversity in Complementary Feeding and Nutritional Status of Children
Aged 0 to 24 Months in Osun State, Nigeria : A Comparison of the Urban and Rural
Communities. ICAN: Infant, Child, & Adolescent Nutrition 2010;2:330
____________________________________________________________________________
63
13. PAHO/WHO (Pan American Health Organization/World Health Organization). Guiding

Principles for Complementary Feeding of the Breastfed Child: Geneva: WHO; 2003.
14. Prentice AM, Paul AA. Fat and energy needs of children in developing countries. Am J
Clin Nutr 2000;72:1253S-65S.
15. RP-Congress of the Philippines (Republic of the Philippines-Congress of the Philippines).
Republic Act No. 10028: Expanded Breastfeeding Promotion Act of 2009. Manila: 2010.
16. RP-Congress of the Philippines. Republic Act No. 8976: An Act Establishing the Philippine
Food Fortification Program and for Other Purposes. Manila: 2000.
17. RP-Congress of the Philippines. Republic Act No. 8172: An Act Promoting Salt Iodization
Nationwide and for Related Purposes. Manila: 1995.
18. RP-Congress of the Philippines. Republic Act No. 7600: An Act Providing Incentives to All
Government and Private Health Institutions with Rooming In and Breastfeeding Practices
and for Other Purposes. Manila: 1992.
19. RP-DOH (Republic of the Philippines-Department of Health). Administrative Order No.
2010-0010: Revised Policy on Micronutrient Supplementation to Support Achievement of
2015 MDG Targets to Reduce Under-Five and Maternal Deaths and Address Micronutrient
Needs of Other Population Groups. Manila: 2010.
20. RP-DOH. Administrative Order No. 2008-0012: Department of Health (DOH) Partnership
with Department of Labor and Employment (DOLE) for Strengthening Support for
Workplace Health Programs. Manila: 2008a.
21. RP-DOH. Administrative Order No. 2008-0029: Implementing Health Reforms for Rapid
Reduction of Maternal and Neonatal Mortality. Manila: 2008b.
22. RP-DOH. Administrative Order No. 2007-0017: Guidelines on the Acceptance and
Processing of Foreign and Local Donations During Emergency and Disaster Situations.
Manila: 2007a.
23. RP-DOH. Administrative Order No. 2007-0026: Revitalization of the Mother-Baby Friendly
Hospital Initiative in Health Facilities with Maternity and Newborn Care Services. Manila:
2007b.
24. RP-DOH. Administrative Order No. 2007-0045: Zinc Supplementation and Reformulated
Oral Rehydration Salt in the Management of Diarrhea. Manila: 2007c.
25. RP-DOH. Administrative Order No. 2006-0012: Revised Implementing Rules and
Regulations of Executive Order No. 51, otherwise known as the Milk Code, Relevant
International Agreements, Penalizing Violations Thereof, and for Other Purposes. Manila:
2006.
26. RP-DOH. Administrative Order No. 2005-0014: National Policies on Infant and Young
Child Feeding. Manila: 2005.
27. UNICEF. News note: Clean hands save lives Global Handwashing Day 2011 is
celebrated by millions of people worldwide. Available at:
http://www.unicef.org/media/media_60084.html. Accessed on: 14 October 2012. New
York: UNICEF; 2011.
28. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant
Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in
less developed countries: a pooled analysis. Lancet 2000; 355:451-55.
29. WHO/UNICEF. Complementary feeding of young children in developing countries: a
review of current scientific knowledge. Geneva: World Health Organization,
WHO/NUT/98.1, 1998.
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64
30. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding: Geneva: World
Health Organization; 2003.
31. WHO. Complementary feeding: report of the global consultation, and summary of guiding
principles for complementary feeding of the breastfed child. Geneva: World Health
Organization; 2002.
32. WHO. Complementary feeding counselling: training course. Geneva: World Health
Organization; 2004.
____________________________________________________________________________
65
Notes
____________________________________________________________________________
66
Session 6: Management and support of Infant Feeding in Maternity Facilities
SESSION 6
MANAGEMENT AND SUPPORT OF INFANT FEEDING IN MATERNITY
FACILITIES
Objectives
1. Describe how the Mother-and-Baby-Friendly hospital initiative evolved.
2. Define the criteria for a Mother-and-Baby-Friendly hospital.
3. Explain the 10 Steps to Successful Breastfeeding and related indicators.
Introduction
Previous sessions have dealt with the significance of breastfeeding in providing optimal
nutrition for infants and its link to decreased infant and maternal mortality and morbidity.
Maternity practices in the hospital and birth centers can influence breastfeeding
behaviors during a period critical to successful establishment of lactation (DiGirolamo
and Grummer-Strawn, 2001). Professional and other formal health workers in all health
care facilities should make every effort to protect, promote and support breastfeeding,
and to provide expectant and new mothers with objective and consistent advice in
practices of infant feeding (WHO/UNICEF, 1989).
Development of the mother-and-baby friendly hospital initiative in the Philippines

A mothers decision to breastfeed is formed during the antenatal period. Health workers
and health facilities providing maternity and newborn care services play a key role in
ensuring that a mother makes this important decision.
In the mid-1970s, a landmark study by Dr. Natividad R. Clavano compared morbidity
rates of infants who were exclusively breastfed to those of infants given mixed feeding
and milk formula (Clavano, 1982). To do this, she initiated drastic changes in the policies
of the Pediatrics Department of Baguio General Hospital and Medical Center. These
included the closing of the nursery, rooming-in of babies with their mothers, promoting
breastfeeding on demand, and limiting the use of infant formula. The incidences of
diarrhea and death were markedly reduced (by 94% and 95% respectively) in the
exclusively breastfed group.
During the late 1970s to late 80s, the promotion of breastfeeding and rooming in for
babies born through normal vaginal delivery were instituted at the Dr. Jose Fabella
Memorial Hospital (UNICEF/AED, 2009). At the same time, the giving of milk formula to
infants was phased out and breastfeeding or the feeding of expressed breast milk was
encouraged for infants in the neonatal intensive care unit (NICU). These efforts
____________________________________________________________________________
67
coincided with the crafting of the International Code of Marketing of Breast Milk
Substitutes and its local counterpart, Executive Order 51 (the Milk Code).
In 1991, the Baby-Friendly Hospital Initiative (BFHI) was launched by UNICEF and the
World Health Organization (WHO). The Initiative concretized the plan of action of the
1990 Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding.
The Initiative called for the provision of a supportive environment for breastfeeding in
health facilities providing maternity and newborn care through its Ten Steps to
Successful Breastfeeding. The initiative was successfully implemented in thousands of
hospitals in 156 countries.
The Philippines was chosen to be one of the 12 starter countries to implement the
BFHI. Republic Act 7600 (The Rooming-In and Breastfeeding Act) was passed in 1992,
giving the legal framework for the adoption of BFHI in the country. In 3 short years, over
4,000 were trained. From a mere 139 accredited Baby-Friendly Hospitals in 1993, the
number ballooned to 1,427 by 1999, or 83% of the target hospitals (UNICEF/AED, 2009).
These early gains were eroded in the early years of the new millennium. In late 1999,
the reorganization of the Department of Health paved the way for the transfer of key
personnel to non-related positions. At the same time, donor support for BFHI trainings
and accreditations decreased. As a result, there were very little trainings conducted in
the years 2000 2003 (UNICEF/AED, 2009). Previously accredited Baby-Friendly
Hospitals were poorly compliant with the Ten Steps to Successful Breastfeeding.
The Global Strategy for Infant and Young Child Feeding published jointly by the WHO
and UNICEF provided the motive force for revitalizing programs promoting optimal IYCF
practices (WHO/UNICEF, 2003).. Using the WHO assessment protocol, IYCF practices
in the country rated poor to fair in the following indices: early initiation of breastfeeding,
rates of exclusive breastfeeding, median duration of breastfeeding, and adequacy and
timing of complementary feeding (UNICEF/AED, 2009).
To address these issues, a National IYCF Plan of Action was drawn up. In the following
years, Administrative Orders that focused on improving IYCF practices were issued.
These include:
AO 2005 0014, National Policies on IYCF

AO 2006 0012, the Revised Implementing Rules and Regulations (RIRR) of
Executive Order 51, Otherwise Known as the Milk Code, Relevant
International Agreements, Penalizing Violations Thereof, and Other Purposes
AO 2007 0026, the Revitalization of the Mother-Baby Friendly Hospital
Initiative in Health Facilities with Maternity and Newborn Care Services
The Unang Yakap (First Embrace) campaign was launched by the DOH soon
after. It encompasses evidence-based Essential Newborn Care practices that
improve infant survival and reduce neonatal mortality. One of the four steps
enshrined in the Unang Yakap is the non-separation of mother and newborn
for the early initiation of breastfeeding.
In 2009, the Expanded Breastfeeding Promotion Act (RA 10028) was passed.
It mandated the setting up of lactation stations in all establishments and
provided for the certification of compliant establishments as mother-baby
friendly. It also advocated for continuing education, re-education and training
of health workers, public education and awareness campaigns on the
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68
benefits of breastfeeding, and the integration of breastfeeding in curricula at

different levels.
Definition of mother-and-baby friendly hospital
Baby-friendly hospital
A Baby-Friendly Hospital is one that implements the Ten Steps to Successful

Breastfeeding.
The aims of the Baby-Friendly Hospital Initiative are as follows:
To implement 10 Steps to Successful BF
To end the distribution of free and low-cost supplies of breast milk
substitutes to health facilities
The concept of BHFI is no longer limited to implementing the Ten Steps to
Successful Breastfeeding in maternity facilities, but has been expanded to
include other parts of the health system: maternal care, pediatrics, health clinics,
doctors offices; and even communities, commercial sectors, and agricultural or
educational systems (UNICEF/WHO, 2009).
Mother-friendly hospital
AO 2007 -0026 lists additional criteria for a hospital to be certified as mother-friendly.
These include incorporating mother-friendly labor and birthing practices, (such as
offering a mother access to a birth companion of her choice, the freedom to walk and
move about and assume a birthing position of her choice), the inclusion of non-drug
methods of pain relief to minimize the use of analgesics and anesthetics, and the
rationalization of instrumentation and procedures that may inhibit breastfeeding.
____________________________________________________________________________
The Ten Steps to Successful Breastfeeding

Box 6.1 Ten Steps to Successful Breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all health care
staff.
Indicator: Implementation of a breastfeeding protocol that has been
communicated to all staff during orientation or during department level meetings.
2. Train all health care staff in skills necessary to implement this policy.
Indicator: Schedule of staff that will attend in-service trainings that teach the
skills necessary to implement the breastfeeding protocol.
3. Inform all pregnant women about the benefits and management of breastfeeding.
Indicators: Written, non-commercial pre-natal information on breastfeeding.
Schedule of parents referred to breastfeeding/ childbirth education classes.
4. Help mothers initiate breastfeeding within a half-hour of birth.
Indicator: Infant is placed on mothers chest to initiate pre-feeding sequence of
behavior that leads to proper latching and sucking.
5. Show mothers how to breastfeed, and maintain lactation even if they should be
separated from their infants.
Indicator: A breast pump should be available for expressing milk. Mothers who
do are not able to directly breastfeed their infants express milk at least 8 times in
24 hours. A milk bank is available in the hospital facility for the collection and
storage of breast milk.
6. Give newborn infants no food or drink other than breast milk unless medically
indicated.
Indicator: No sterile water, glucose water or milk formula in the clinical wards.
7. Practice rooming in - allow mothers and infants to remain together 24 hours a day.
Indicator: All babies are roomed-in and only pathologic babies are placed in a
nursery (NICU).
8. Encourage breastfeeding on demand.
Indicator: Mothers are behavioral feeding cues for them to feed their infants on
cue for 8 to 12 times each 24 hours.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding
infants.
Indicator: No artificial nipples and pacifiers or feeding paraphernalia in the wards.
10. Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital or clinic.
Indicator: Organized breastfeeding support groups supervised by a lactation
consultant/ staff nurse.
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69
70
References
Contents of this session are adapted from the modules of three existing infant and young child
York: UNICEF; 2011.
Textbooks for Medical Students and Allied Health Professional. Geneva: WHO; 2009.
1. Clavano, NR. Mode of feeding and its effect on infant mortality and morbidity. Journal
of Tropical Pediatrics. 1982. 28 (6): 287-293.
2. Congress of the Philippines. The Rooming-In and Breastfeeding Act of 1992. Republic
Act 7600. 1992.
3. Congress of the Philippines. An Act Expanding the Promotion of Breastfeeding,
Amending for the Purpose Republic Act No. 7600, otherwise known as An Act
providing incentives to all government and private health institutions with rooming-in
and breastfeeding practices and for other purposes. Republic Act 10028. 2009.
4. Department of Health. The Revised Implementing Rules and Regulations (RIRR) of
Executive Order 51, Otherwise Known as the Milk Code, Relevant International
Agreements, Penalizing Violations Thereof, and Other Purposes. A.O. 2006 0012.
Office of the Secretary. May 15, 2006.
5. Department of Health. Revitalization of the Mother-Baby Friendly Hospital Initiative in
Health Facilities with Maternity and Newborn Care Services. A.O. 2007-0026. Office of
the Secretary. July 10, 2007.
6. DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternity care practices: implications
for breastfeeding. Birth 2001;28:94-100.
7. National Statistics Office and ICF Macro. National Demographic and Health Survey
2008. Calverton, Maryland. 2009.
8. Power point presentation delivered at the workshop of the CFC Research Initiative,
held in Rio de Janeiro, Brazil, from March 18-21 2009. Available at
www.childfriendlycities.org/pdf/indicators_philippines.pdf.
9. RP-DOH. Administrative Order No. 2005-0014: National Policies on Infant and Young
Child Feeding. Manila: 2005.
10. UNICEF/WHO. Baby-Friendly Hospital Initiative: Revised, Upgraded and Expanded for
Integrated Care. Geneva. 2009.
11. UNICEF Nutrition Section/ Academy for Educational Development (AED). Infant and
Young Child Feeding Programme Review, Case Study: The Philippines. New York.
2009.
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71
12. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding. Geneva. 2003.
13. WHO/UNICEF. Protecting, promoting and supporting breastfeeding:the special role of
maternity services. Geneva. 1989.
Notes
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72
Session 7: Continuing support for Infant and Young Child Feeding
SESSION 7
CONTINUING SUPPORT FOR INFANT AND YOUNG CHILD FEEDING
Objectives
1. Discuss the importance of providing continuing support for breastfeeding and
complementary feeding to mothers in the community.
2. Discuss ways to support optimal infant and young child feeding practices in the
community through IYCF counseling:
a. Using good communication and support skills
b. Assessing the situation
c. Managing problems and supporting good feeding practices
d. Follow-up
Introduction
The Global Strategy for Infant and Young Child Feeding recommends the development
of community-based support networks to help ensure appropriate infant and young child
feeding to which hospitals and clinics can refer mothers on discharge.
These community-based support networks are a welcome extension of the health care
system and can participate actively in planning and provision of care.
Support for mothers in the community
Health workers do not always have the opportunity to ensure the establishment of
successful breastfeeding:
Mothers often give birth at home

Mothers are discharged from a hospital or health facility within a day or so after
delivery
Difficulties may arise in the first few weeks after breastfeeding, or later on, when
complementary foods are introduced
Mothers need continuing support to maintain exclusive breastfeeding and to establish

adequate complementary feeding when a child is 6 months old. A mother may need
support from a skilled health worker during periods of illness.
Key points of contact to support optimal feeding practices
There should be no missed opportunities for supporting feeding in any contact that a
mother and her child have with the health system. The following box shows the key
points of contact that a mother may have with a health worker knowledgeable in infant
and young child feeding.
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73
Family members and friends are often a mothers source of information on feeding
practices. Some of these may be based on misconceptions. Health care providers
should also talk to other family members when helping a mother, show respect for their
ideas and help them to understand advice on optimal feeding.
IYCF Counselling
IYCF counselling is the process by which a health worker can support mothers and
babies to implement good feeding practices and overcome difficulties. A health worker
should:
a. Use good communication and support skills
b. Assess the situation
c. Manage problems and reinforce good feeding practices
d. Follow-up
A.
Using good communication and support skills

A health worker should have good communications skills in order for him/her to
effectively counsel a mother. Communication skills encompass two groups of
skills:
Listening and learning skills
Use helpful non-verbal communication shows that the health worker

respects the mother and is interested in her. Helpful non-verbal
communication includes keeping your head at the same level as the
mothers, making eye contact, nodding and smiling, making sure there
are no barriers between you and the mother, making sure that you do
not seem to be in a hurry, and touching her or the baby in a culturally
appropriate way.
Ask open questions questions that start with who, what, why,
how, when, to encourage a person to talk.
Use responses and gestures that show interest responses like Oh,
dear, Really, Go on and gestures like nodding and smiling show
interest and encourage a mother to say more.
Reflect back what the mother says reflect back using slightly
different words to show that you are listening
Empathize show that you understand her feelings from her point of
view. Use phrases appropriately, such as that is very hard for you,
you were upset, you are worried, or you must feel pleased.
Avoid words that sound judging words such as good, bad, right,
wrong, enough, properly may make the mother feel doubtful or
that she may be doing something wrong. It is better to ask How are
you feeding your baby? How about your breastmilk?
Building confidence and giving support skills
Accept what a mother thinks and feels accepting involves

responding to a mother in a neutral way: not disagreeing, and not
____________________________________________________________________________
74
B.
agreeing with an incorrect idea. The correct information should be

given at a later time.
Recognize and praise what the mother and baby are doing right - this
helps reinforce the correct practices and build a mothers confidence
Give practical help helping a mother or caregiver in ways other than
talking, such as giving water and helping her into a more comfortable
position. This kind of practical help may be the best way to show you
understand, and she may be more receptive to new information and
suggestions.
Give a little relevant information after listening to a mother or
caregiver, think about her situation and decide what information is
relevant and most useful at the time. Avoid telling her too much, as
this may confuse her and make her forget what is most important.
Use simple language give information in simple, everyday words
that a person can easily understand.
Make suggestions, not commands giving suggestions allows a
mother to discuss whether or not she can follow it. If she voices her
doubts, other suggestions and practical alternatives may also be
discussed with her.
Assess the situation

Assessing a childs growth
Assessing a childs growth provides important information on the adequacy of a
childs nutritional status and health. Measures to assess growth include the
following:
Weight-for-age
Weight-for-length/height
Height-for-age
Mid upper arm circumference (MUAC)
Proper recording and interpretation of results are important.

1. Measures for assessing a childs growth: Weight for age
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75
Weight-for-age reflects body weight relative to a childs age on a given day.

Serial measurements of weight-for-age can show if a childs weight increases
over time, and is a useful indicator of growth. The three points on the growth
chart above show that the childs growth does not parallel the ideal growth
curve for his age.
However, it cannot distinguish between acute malnutrition and chronic low
energy and nutrient intake.
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76
2. Measures for assessing a childs growth: Weight for length/height
Weight-for-length/height reflects body weight in proportion to attained length

or height.
Helps identify children with low weight-for-height who may be wasted or
severely wasted, or at risk of becoming overweight or obese.
Useful in situations where childrens ages are unknown.
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77
3. Measures for assessing a childs growth: Length/height for age
Helps identify children who are stunted (or short) due to prolonged
undernutrition or repeated illness.
4. Measures for assessing a childs growth: Mid-upper arm circumference
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78
5. Identifying problems from plotted points
Growth problems can be identified by interpreting the plotted points on a

childs growth record.
Plotted points are read as follows:
A point between the z-score lines -2 and -3 is below -2.
A point between the z-score lines 2 and 3 is above 2.
A point directly on the z-score line is considered to be in the less severe
category.
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79
Identifying problems from plotted points: Growth problems
Common Problems
Low weight-for-age a child is underweight if his/her weight falls below the 2 z-score line, and severely underweight if his/her weight falls below the -3 zscore line. A child who is severely underweight is at risk for severe
malnutrition and urgently needs attention.
Growth faltering if a childs weight is not increasing, or if it is increasing

more slowly than the standard curve for 1 month in babies less than 4 months
of age, or 2 months in older children. It is common in the first 2 years of life,
and may be the first sign of inadequate feeding in an otherwise healthy child
Loss of weight a child with a falling growth curve may be afflicted with an
illness. S/he should be assessed according to the IMCI guidelines and
referred accordingly.
Rapid rise in growth curvean increase in weight is expected in a child who

has been ill or undernourished during the re-feeding period as part of catchup growth. However, a sharp increase in growth may also indicate
inappropriate feeding practices that can lead to overweight.
6.
Taking a feeding history: Infants 0-6 months of age

It is important to ask how feeding is progressing during any contact with a
mother and/or child. The Feeding History Job Aids below list relevant
questions to be asked.
The Feeding History Job Aid for infants 0 6 months covers key topics to be
discussed in a counselling session with a mother of an infant below 6 months.
Not all questions need to be asked at all times. Concentrate on those that are
relevant to a childs age and situation.
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80
Box 7.1 Feeding History Job Aid, Infants 0 6 months

Age of child
Particular concerns about feeding of child
Feeding
Milk (breast milk, formula, cow milk, other)
Frequency of milk feeds
Length of breastfeeds/ quantity of other milks
Night feeds
Other foods in addition to milk (when started, what, frequency)
Other fluids in addition to milk (when started, what, frequency)
Use of bottles and how cleaned
Feeding difficulties (breastfeeding/ other feeding)
Health
Growth chart (birth weight, weight now, length)
Urine frequency per day (6 times or more, if less than 6 months)
Stools (frequency, consistency)
Illnesses
Pregnancy, birth, early feeds (where applicable)
Antenatal care
Feeding discussed at antenatal care
Delivery experience
Rooming-in
Pre-lacteal feeds
Postnatal help with feeding
Mothers condition and family planning
Age
Health- including nutrition and medications
Breast health
Family planning
Previous infant feeding experience
Number of previous babies
How many breastfed and how long
If breastfed exclusive or mixed-fed
Other feeding experiences
Family and social situation
Work situation
Economic situation
Familys attitude to infant feeding practices
Source: World Health organization. Infant and Young Child Feeding: Model Chapter for
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81
7. Taking a feeding history: Children 6 23 months of age

Additional relevant questions on feeding history for children 6 23 months of
age are outlined in the Feeding History Job Aid, 6 23 months.
Box 7.2 Feeding History Job Aid, children 6-23 months
Is the child still breastfed?

How many times per day? Day and night?
If using expressed breast milk, how is the milk stored and given?
What other foods are the child receiving?

How many meals and snacks each day?
How much food at each meal?
What is the consistency of the main meals?
Do meals include animal-source foods, dairy products, dark green vegetables or red
or orange fruits or vegetables, pulses (beans, lentils, peas, nuts), oil?
Who helps the child to eat?
What bowl does the child get from (his or her own bowl, or the family pot)?
Is the child given any vitamin or mineral supplements?
How does the child eat during sickness?
8. Observing Breastfeeding
At all contacts with lactating mothers of infants below 2 years, observe a

breastfeed.
Ask the mother to offer her baby the breast and to breastfeed in her usual
way.
Try to observe a complete feed, to see how long the baby suckles and if
s/he releases the breast by her/him-self.
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82
Box 7.3 Breastfeed Observation Job Aid

Mothers name :
________________________
Date _________________________
Babys name:
__________________________
Babys age ______________________
Signs that breastfeeding is going well

GENERAL
Mother
Mother looks healthy
Mother relaxed and comfortable
Signs of bonding between mother and baby
Signs of possible difficulty
Baby
Baby looks healthy
Baby calm and relaxed
Baby reaches or roots for breast if hungry
Baby
Baby looks sleepy or ill
Baby is restless or crying
Baby does not reach or root
BREASTS
Breasts look healthy
No pain or discomfort
Breast well supported with fingers away
from nipple
Nipple stands out, protractile
Mother
Mother looks ill or depressed
Mother looks tense and uncomfortable
No mother/baby eye contact
Breasts look red, swollen, or sore

Breast or nipple painful
Breast held with fingers on areola
Nipple flat, not protractile
BABYS POSITION
Babys head and body in line
Baby held close to mothers body
Babys whole body supported
Baby approaches breast, nose opposite
nipple
Babys neck and head twisted to feed

Baby not held close
Baby supported by head and neck
Baby approaches breast, lower lip to
nipple
BABYS ATTACHMENT
More areola seen above babys top lip
Babys mouth open wide
Lower lip turned outwards
Babys chin touches breast
More areola seen below bottom lip

Babys mouth not open wide
Lips pointing forward or turned in
Babys chin not touching breast
SUCKLING
Slow, deep sucks with pauses
Cheeks round when suckling
Baby releases breast when finished
Mother notices signs of oxytocin reflex
Rapid shallow sucks

Cheeks pulled in when suckling
Mother takes baby off the breast
No signs of oxytocin reflex noted
Textbooks for Medical Students and Allied Health Professional. Geneva: WHO; 2009
____________________________________________________________________________
83
Assessing the health of the child

During feeding counselling it is important to assess a childs health status using
the IMCI guidelines.
Decide if the child shows signs of infection (cough/difficult breathing,
diarrhea, fever, ear problems) or malnutrition and anemia
Recognize signs of severe illness requiring immediate referral (lethargy or
loss of consciousness, severe malnutrition, inability to eat or drink,
inability to breastfeed, vomiting after all feeds)
Check for conditions that can interfere with breastfeeding (blocked nose,
jaundice, thrush, cleft lip or palate, tongue tie)
Assessing the health of the mother
It is also important to inquire about a mothers health, her mental health, social
situation and employment, which may affect her ability to care for her child.
3. Manage problems and reinforce good feeding practices
The results of the assessment are used to classify the mother and baby
according to their situation and to decide on management. Three different actions
may be required, namely:
1. Refer urgently
2. Help with difficulties and poor practices, and refer if necessary
3. Support good feeding practices
____________________________________________________________________________
84
Figure 7.1 Assessing and classifying infant and young child feeding
Assess the situation

1. Assess the childs growth
2. Take a feeding history
3. Observe a breastfeed
4. Assess the childs health
and assess the mothers
condition
Refer urgently:
If the child:
Is unconscious or
lethargic
Is severely
malnourished
Is not able to
breastfeed
despite help with
attachment
Vomits copiously
after all feeds
Help with difficulties and

poor practices
Refer if necessary
If you find:
Growth faltering
Low weight-for-age
Poor attachment or
feeding pattern
Non-exclusive
breastfeeding (infants <
6 months)
Breast condition
Breastfeeding difficulty
Inappropriate
complementary feeding
Mother has a health
problem such as
HIV/AIDS
No family planning
Support good feeding

practices
If you find:
Adequate growth
Exclusive
breastfeeding with
good practices
(infants 0-6 months)
Continued
breastfeeding
(children 6-23
months)
Adequate
complementary
feeding practices
(children 6-23
months)
Child healthy
Mother healthy
Appropriate family
planning
____________________________________________________________________________
85
Help with difficulties and poor practices

Most feeding difficulties can be managed with outpatient care or care in the
community. The management of common feeding difficulties will be discussed in
more detail in the subsequent session.
Non-urgent referral may be necessary in the following situations:
Poor growth that continues despite health center care or community care
Breastfeeding difficulties that do not respond to the usual management
Abnormalities including cleft lip and palate, tongue tie, Down syndrome,
cerebral palsy
For problems in complementary feeding, refer to the Food Intake Reference

Tool.
The first column contains questions about the childs intake for the past 24 hours,
the second column shows the ideal practice, and the third column identifies key
messages to be discussed with the mother.
Box 7.4 Food Intake Reference Tool, children 6 23 months
KEY MESSAGE TO USE IN
FEEDING PRACTICE
IDEAL PRACTICE
COUNSELLING THE
MOTHER
Growth curve rising?
Growth follows the
Explain childs growth curve
reference curve
and praise good growth
Child received breast
Frequently, on demand, day Breastfeeding for 2 years or
milk?
and night
longer helps a child to develop
and grow strong and healthy
Child received sufficient 6 8 months: 2-3 meals A growing child needs to eat
number of meals and
plus 1 -2 snacks, if
often, several times a day
snacks yesterday, for his
hungry
according to age
or her age?
9 23 months: 3-4
meals, plus 1-2 snacks,
if hungry
Quantity of food eaten at 6 8 months: start with A growing child needs
main meal yesterday
a few spoons, then
increasing amounts of food
appropriate for childs
gradually increase to
age?
approximately cup
each meal
9 11 months:
approximately cup at
each meal
12 23 months:
approximately to
cup at each meal
6 8 months: 2 3
meals
How many meals of a
Foods that are thick enough to

thick consistency did the
stay on the spoon give more
child eat yesterday?
energy to the child
How many meals of a
69 823months:
Foods that are thick enough to
months:2 3 3 4
____________________________________________________________________________
thick consistency
did
the
meals
stay on the spoon give more
meals
Maternal and Young Child
Nutrition for Medical and Allied Professionals
child eat yesterday?
energy to the child
9 23 months: 3 4
meals
86
Child ate an animalsource food (meat/

fish/bird/ eggs)
yesterday?
Child ate a dairy product
yesterday?
Child ate seeds/ nuts/
legumes yesterday?
Child ate red or orange

vegetable or fruit, or a
dark green vegetable
yesterday?
Animal-source foods should

be eaten daily
Give dairy products daily
If meat is not eaten, seeds,
nuts or legumes should be
eaten daily with vitaminrich fruits to help absorb
iron
A dark green vegetable or
red or orange vegetable or
fruit should be eaten daily
Animal-source foods are

especially good for children to
help them grow strong and
lively
Milk, cheese and yogurt are
especially good for children
Peas, beans, and nuts help
children to grow lively,
especially if eaten with fruit
Dark green leaves and red or
orange colored fruits and
vegetables help a child to have
healthy eyes and fewer
infections
Oil gives a child more energy,
but is only needed in small
amounts
A child needs to learn to eat:
encourage and give help
responsively and with lots of
patience
Small amount of oil

added to childs food
yesterday?
Mother assisted the
child at meal times?
A little oil or fat should be

added to a meal each day
Child had his or her own

bowl, or ate from family
pot?
Child should have his or her

own bowl of food
If a child has his/her own bowl,

it makes it easier to see how
much the child has eaten
Child took any vitamin or

mineral supplements?
Vitamin and mineral

supplements may be
needed if childs needs are
not met by food intake
Continue to feed during
illness and recovery
Explain how to use vitamin and

mineral supplements if they
are needed
Child ill or recovering

from illness?
Mother assists and

encourages a child to eat,
but does not force
Encourage a child to eat and

drink during illness, and
provide extra food after illness
to help the child recover
quickly
Support good feeding practices
An important part of counselling a mother is active support and reinforcement of
good feeding practices.
____________________________________________________________________________
87
Box 7.5 Support good feeding practices

If the infant is less than 6 months old:
If the baby is growing well, point this out to the mother and praise her and the baby.
Check breastfeeding position and attachment, and that the infant is suckling
effectively.
Check that the pattern of breastfeeding is optimal: feeding on demand day and
night; letting the baby come off the breast by him- or herself; finishing the first
breast and then offering the other one.
Praise the mothers good practices, and encourage her to continue them,
Explain about exclusive breastfeeding, remind the mother that she does not need to
give anything else before the baby is 6 months old, and that feeding bottles are
dangerous.
Explain that this way of feeding the baby helps her to make plenty of milk.
Explain about family planning methods and breastfeeding.
At about 5 months of age, start to discuss complementary foods.
Introduce complementary foods from 6 months (180 days) of age.
If the infant is more than 6 months old:
Praise the mother if the infant:
is growing well, and is healthy
is still breastfeeding
Praise the mother or caretaker fro the following good practices:
if the infant has meals and snacks with sufficient frequency and quantity
if the quality of feeds is adequate, with appropriate variety of foods and adequate
consistency
if she is assisting the baby to feed appropriately
if she is giving the child his or her own bowl
if she gives extra food to a child recovering from illness
Remind the mother when to bring the child for immunization.
Remind the mother when to bring the child to a qualified health provider for signs of illness.
4.
Follow-up
Follow-up and continuing care of all children is important, whether they have
feeding difficulties or not. Follow-up may take place at a health facility or on a
home visit.
____________________________________________________________________________
88
Follow-up of the infant or young child with feeding difficulties

When to follow-up infants or children with feeding difficulties
For a newborn with feeding difficulties, reassess after 1 2 days

For an infant older than one month, reassess after 2 5 days
For an infant or child over 6 months, follow-up after 5 7 days
Reassessment on follow-up should include an updating of the information taken

on initial assessment, including:
inquiring about progress, the mothers experience trying suggestions

given,
weighing the child and assessing growth,
observation of a breastfeed,
examination of the mothers breast, and
assessment of the infants/childs health.
Refer if a child has not gained weight on two consecutive visits or within one
month (2 months if more than 6 months of age).
If a child has gained weight and feeding difficulties are resolved, follow-up should
be scheduled at the same frequency as a child with no feeding difficulty.
Follow-up of the infant or young child with no feeding difficulties
Suggested intervals for feeding counselling and growth assessment for healthy
full-term babies are:
Within 6 hours of delivery, and again within 2 3 days

On Day 7
At 4 weeks of age
Around 6 weeks of age
At 3 and 4 months of age
Around 5 6 months of age
At 8 9 months, and 11 12 months
Every 2 -3 months, up to at least 2 years of age
At other contacts with health care workers (immunization, when a child is
sick)
____________________________________________________________________________
89
References
3. WHO. Infant and Young Child Feeding: Model Chapter for Textbooks for Medical
Students and Allied Health Professional. Geneva: WHO; 2009.
1. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding. Geneva:
WHO; 2003.
____________________________________________________________________________
90
Notes
____________________________________________________________________________
Session 8A: Appropriate Feeding in Exceptionally Difficult Circumstances:

Low-Birth Weight Babies
91
SESSION 8
APPROPRIATE FEEDING IN EXCEPTIONALLY DIFFICULT
CIRCUMSTANCES
SESSION 8A
LOW BIRTH WEIGHT BABIES
Objectives
1. Describe problems associated with low birth weight infants.
2. Discuss feeding options and supportive care for LBW infants of different gestational
ages (> 36 weeks, 32-36 weeks, < 32 weeks).
3. Describe the breastfeeding positions appropriate for LBW babies.
Introduction
One of the key priorities of the Global Strategy for Infant and Young Child Feeding is
ensuring optimal nutrition for children in difficult circumstances (WHO/UNICEF, 2003).
Low birth weight can be a consequence of preterm birth (before 37 completed weeks of
gestation) or related to a small size for gestational age (SGA, defined as weight for
gestation <10th percentile), or both (WHO, 2006).
Feeding the low birth weight infant involves decisions about what milk to feed, what
nutritional supplements to give, how to feed, how much and how frequently to feed, what
support is needed, and how to monitor (WHO, 2006).
Low Birth Weight Infants

Definition
Low-birth-weight (LBW) babies are babies weighing less than 2500 grams at
birth
Very low birth weight (VLBW) babies are babies weighing less than 1500
grams at birth
____________________________________________________________________________

92
LBW can be a consequence of any of the following:
Pre-term birth (birth before 37 weeks of completed gestation)

Small for gestational age (SGA) usually caused by intrauterine growth
retardation (IUGR), a smaller than normal velocity of growth
Or a combination of both
Being born with LBW is a disadvantage for an infant.
LBW directly or indirectly may contribute to 60 80% of neonatal deaths.

LBW infants are at higher risk of early growth retardation, infection,
developmental delay, and death during infancy and childhood.
Appropriate care of LBW infants (feeding, temperature maintenance, hygienic cord and
skin care, early detection and treatment of infections) can substantially reduce excess
mortality.
Feeding options for LBW babies

A babys own mothers milk is best for LBW infants of all gestational ages. Breast milk is
nutritionally adapted to the needs of LBW infants. Studies consistently show that feeding
a mothers own milk is associated with lower infection rates and better long-term
outcomes.
Infants born at less than 36 weeks of gestation are often unable to breastfeed directly in
the first few days of life. For these infants, breast milk or other feeds have to be given by
an alternative oral feeding method (cup/ spoon/ direct expression into mouth) or by intragastric tube feeding. In these situations, the options available for feeding the LBW infant,
in order of preference, are:
a. expressed breast milk (EBM) from his/her own mother;
b. donor breast milk;
c. infant formula (standard formula for infants with birth weight > 1500 grams; preterm formula for infants with birth weight < 1500 grams)
Infants who cannot breastfeed usually need to be placed in a special newborn care unit.
It is important to encourage the mother to spend as much time as possible with the
infant. Opportunities for skin-to-skin contact between mother and infant should be
maximized to help both bonding and breastfeeding.
A mother will need skilled help to establish lactation, ideally within 6 hours of birth. She
should be encouraged to express breastmilk at least 8 times in 24 hours. The EBM can
be given every 1 -3 hours, depending on the age and weight of the baby.
____________________________________________________________________________

Table 8A.1 Feeding low-birth-weight babies

>36 WEEKS
32-36 WEEKS
GESTATIONAL AGE GESTATIONAL AGE
WHAT
Breast milk
Breast milk,
expressed or suckled
from the breast
HOW
Breastfeeding
Cup, spoon, paladai
(in addition to feeding
at the breast)
WHEN
Start within one
Start within one
hour of birth
hour of birth or as
soon as the baby is
Breastfeed at least
clinically stable
every 3 hours
Feed every 2-3
hours
HOW MUCH Feed on demand
See Table 8A.2
93
<32 WEEKS
GESTATIONAL AGE
Expressed breast milk
Intra-gastric tube
Start 12-24 hours

after birth
Feed every 1-2
hours
See Table 8A.2
Feeding LBW Babies less than 32 weeks
Babies less than 32 weeks gestational age usually need to be fed by gastric tube.
They should not receive any enteral feeds for the first 12 24 hours.
Table 8A.2 shows the daily quantity of milk needed by a LBW baby fed by gastric
tube.
Table 8A.2 Recommended feed volumes for LBW infants

DAY OF LIFE
FEED VOLUMES (ml)

2000-2500 g
(3-Hourly)
1500-2000 g
(3-Hourly)
1000-1500 g
(Every 2 Hours) *
Day 1
17
12
Day 2
22
16
Day 3
17
20
Day 4
32
24
Day 5
37
28
11
Day 6
40
32
13
Day 7
42
35
16
____________________________________________________________________________

94
If the baby is cup feeding, add 5 ml per feed to allow for spillage and variability of infants
appetite.
* For infants with birth weight <1250 g who do not show signs of feeding readiness, start
with small 1-2 ml feeds every 1-2 hours and give the rest of the fluid requirement as
intravenous fluids.
Discharge and Follow-up of LBW babies

A LBW baby can be discharged from hospital when s/he is:
Breastfeeding effectively or the mother is confident using an alternative feeding

method
Maintaining his/her own temperature between 36.5 C and 37.5 C for at least 3
consecutive days
Gaining weight, at least 15 g/kg for 3 consecutive days
The mother is confident in her ability to care for the baby
Follow-up of LBW babies
At least once 2 5 days after discharge

At least weekly until fully breastfeeding and weighing more than 2.5 kg
Breastfeeding positions for LBW babies
____________________________________________________________________________

95
Infants born at 36 weeks of gestation or older are able to breastfeed directly. The
underarm position or supporting the baby with the arm opposite the breast are the
best positions for breastfeeding LBW babies.
When a LBW baby first suckles, he or she may pause quite often and for longer
periods, and may continue feeding for more than an hour. It is important not to
take the baby off the breast during these pauses.
If a baby has difficulty suckling effectively, tires quickly at the breast or does not gain
adequate weight, offer expressed milk by cup after the breastfeed, or give alternate
breast and cup feeds.
Babies 32 to 36 weeks of gestational age need to be fed fully or partly on EBM by

cup or spoon until full breastfeeding can be established. To stimulate breastfeeding,
these babies should be allowed to suckle or lick the breast as much as they wish.
Reduce cup feeds slowly if the baby starts suckling well. Bottle feeding should be
avoided, as it may interfere with the baby learning to breastfeed.
Kangaroo Mother Care
A mother can give her LBW or small baby the benefits similar to those provided by
an incubator through Kangaroo mother care (KMC).
Skin-to-skin thermal protection (kangaroo mother careKMC) fosters greater

involvement of mothers in the care of LBW babies and reduces reliance on
equipment.
Evidence indicates that using KMC for preterm babies results in stability of cardiac
and respiratory function, lower rates of severe infection, increased breastmilk
supply, higher rates of exclusive breastfeeding, and better weight gain
(AED/USAID, 2006).
____________________________________________________________________________

96
KMC is a gentle, effective method that leads to shorter stay and earlier discharge
for hospitalized babies, encourages frequent observation of the baby by the
mother, and fosters bonding.
All medically stable LBW babies are eligible for KMC. For most LBW babies, KMC
can start immediately after birth. However, very preterm babies who are acutely ill
may require specialized care until they are medically stable and ready for KMC.
The three key elements of Kangaroo Mother Care are (AED/USAID, 2006):
1. Position. During KMC, the baby (wearing only a diaper/nappy, hat, and
socks) is placed between the mothers naked breasts and secured in a pouch
or cloth tied around the mothers chest. The baby is carried continuously in
this skin-to-skin position. The mother sleeps and rests in a semi-reclined
position. Heat loss is avoided by keeping the baby in skin-to-skin contact
inside the mothers clothing.
2. Nutrition. KMC is conducive to early and exclusive breastfeeding. The
mother can offer the breast in response to the babys cues. When KMC is first
started, some preterm babies are unable to suckle at the breast. A mother
can express her breastmilk directly into the babys mouth, or the mothers
expressed breastmilk can be given by cup or other appropriate feeding
method.
3. Support. Mother and baby are rarely separated. The mother can observe
any changes in the baby that may require follow-up care. The father or
another family member can provide KMC some of the time.
References
Textbooks for Medical Students and Allied Health Professional. Geneva:
WHO;2009.
1. WHO. Optimal feeding of low-birth-weight infants: technical review. Geneva.
2006.
____________________________________________________________________________

97
2. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding. Geneva.
2003.
3. ACCESS Program. Kangaroo Mother Care Training Manual. Baltimore: 2006.
4. Academy for Educational Development/USAID. 2006. Facts for Feeding- Feeding
Low Birth weight Babies. Retrieved November 20, 2012 from
http://www.linkagesproject.org/media/publications/FFF_LBW_3-30-06.pdf.
____________________________________________________________________________

98
Notes
____________________________________________________________________________
Session 8B: Appropriate Feeding in Exceptionally Difficult Circumstances:

Relactation
99
SESSION 8B
RELACTATION
Objectives
1. Describe what relactation is.
2. Describe indications for relactation.
3. Discuss the physiological basis of lactation.
4. Describe the necessary measures for successful relactation.
Introduction
Evidence shows that breastfeeding for the first 6 months and continued breastfeeding
with appropriate complementary feeding is the most effective way to ensure optimal
nutrition for children. Infants who have not breastfeed or who have stopped
breastfeeding are at increased risk of illness, malnutrition and death.
In instances where mothers stopped breastfeeding for some reasons, it is a known fact
that breastfeeding can be re-established. A woman who has stopped breastfeeding her
child, recently or in the past, can resume the production of breastmilk for her own or an
adopted infant, even without a further pregnancy. This potentially life-saving measure is
called relactation (WHO, 1998).
Relactaction
Relactation is the re-establishment of lactation after a gap of several weeks, months or
years (Hormann, 2006).
The re-establishment of breastfeeding is an important management option in emergency
situations, and for infants who are malnourished or ill.
A woman needs to be:
Highly motivated
Well supported by health care workers
Supported by family and friends, mother support groups, traditional birth attendants
Most women can relactate any number of years after their last child, but it is easier for
women who stopped breastfeeding recently.
____________________________________________________________________________

Relactation
100
Indications for Relactation

When a woman stopped breastfeeding for reasons like illness, work, disappointment in
early weaning and others and her childs health at risk from inadequate feeding,
relactaton is an important option.
The following are the possible indications for resuming lactation (WHO, 1998):
1.
for case management of sick infants
2.
for infants who were low birth weight,
3.
for infants who are unaccompanied; those who were artificially fed before the
emergency; and those for whom breastfeeding has been interrupted. As
many infants as possible should be enabled to resume or continue
breastfeeding to help prevent diarrhea, infection and malnutrition. A woman
can relactate to feed one or more unaccompanied infants.
individual situations,
7.
for example because they or their mothers required hospitalization.
in emergency situations,
6.
particularly those under 6 months of age, whose mothers had difficulty

establishing lactation or whose breastmilk production has decreased
significantly as a result of poor technique or mismanagement.
for infants who have been separated from their mothers,
5.
and who were unable to suckle effectively in the first weeks of life, and who
required gavage or cup feeding.
for infants with feeding problems,
4.
such as those under 6 months of age with acute or persistent diarrhea, those
who stopped breastfeeding before or during an illness, and those who have
been artificially fed but cannot tolerate artificial milks.
for example when a mother who chose to feed her infant artificially changes
her mind or, in the case of adoption, to enhance mother-infant bonding as
well as providing other advantages of breastfeeding.
when a woman is unable to breastfeed her infant,
for example because she is severely ill or has died or because she is HIV
positive and chooses, after counselling, not to breastfeed her infant. One
option in these situations is for someone in the same community, such as a
grandmother, to relactate to feed the child.
____________________________________________________________________________

Relactation
101
Physiological basis of Relactation

Stimulation of the breasts
Relactation is dependent on the physiology behind sufficient breastmilk production
that requires the following (See Session 4 for discussion):
growth of secretory alveoli in the glandular tissue of the breast
secretion of milk by the cells of the secretory alveoli
removal of milk by the infant or by expression
Stimulation of the breasts is essential for relactation

If infant is willing to suckle, at least 8 12 times every 24 hours
If infant is not willing to suckle, gentle breast massage followed by 20 30
minutes of hand expression 8 12 times a day
Mother and infant must be together all the time.
Skin-to-skin contact is helpful.
Signs of milk production

Breast milk production may start in a few days or a few weeks. Signs include:
Breast changes (breasts feel fuller or firmer), milk leaks or can be expressed
Infant takes less supplement while continuing to gain weight
Infants stools become softer, and more like stools of a breastfed infant
Measures for successful Relactation

Health care workers must know what measure to educate the mother who is considering
relactation. The following are the principal recommendation on how to establish
relactation (WHO, 1998).
1. Counselling the mother
It is important to talk to the mother and identify the reasons why breastfeeding
was interrupted or relactation is being considered using the Counselling skills in
Session 7. After identifying the reason why breastfeeding was interrupted,
appropriate management is needed for relactation to be effective.
The health care professional or breastfeeding counsellor should:
1. Ensure that the mother or foster mother is fully informed about:
the benefits of breastfeeding for both the child's health and
nutrition and the mother-infant relationship and the reasons she
might want to consider relactation.
how relactation works, how long it may take and the commitment,
____________________________________________________________________________

Relactation
102
patience and persistence that she needs.

practical details of how to relactate.
how particular difficulties can be overcome, and any special help
or treatment required.
the need to stop or change any factor which can reduce suckling
or breastmilk production.
2. Ensure that the mother or foster mother is adequately motivated.

The breastfeeding counsellor should give the woman relevant information
and encouragement and try to build her confidence, but should not put
pressure on her to relactate if she is unwilling. It may be helpful to
introduce her to other women who have relactated, and who can talk to
her about their experience.
3. Inquire about the support that the woman is likely to receive from home. If
possible, the breastfeeding counsellor should explain the importance and
the process of relactation to other family members and counteract any
misinformation. She needs to discuss the woman's need for their
continuing support and what they might do to ensure that she has enough
rest and relief from other jobs while she re-establishes a breastmilk
supply. Contact with other mothers who have relactated may also be
helpful.
2. Stimulation of the nipple and breast by:
a. The infants suckling
Encourage the woman to:
put the infant to the breast frequently, as often as he or she is

willing. This should be every 1-2 hours if possible and at least 8-12
times every 24 hours.
sleep with the infant to breastfeed at night, to allow the infant easy
access to the breast while minimizing disruption of the mother's
rest. Night breastfeeds increase the production of prolactin and the
extra contact may increase the infant's willingness to suckle.
let the infant suckle on both breasts, and for as long as possible at
each feed at least 10-15 minutes on each breast. The mother can
offer each breast more than once if the infant is willing to continue
suckling.
ensure that the infant is well attached to the breast, to prevent
nipple trauma, and to remove effectively any breastmilk that is
produced.
avoid using a pacifier or bottle and teat as this reduces nipple
stimulation and is likely to make the infant less willing to suckle
from the breast.
feed the infant supplements separately, using a cup (See Figure
8B.1).
____________________________________________________________________________

Relactation
103
Figure 8B.1 Feeding a baby by cup

Box 8B.1 How to feed a baby by cup
Wash your hands.

Hold the baby sitting upright or semi-upright on your lap.
Place the estimated amount of milk for one feed into the cup.
Hold the small cup of milk to the baby's lips.
Tip the cup so that the milk just reaches the baby's lips.
The cup rests lightly on the baby's lower lip, and the edges of the cup
touch the outer part of the babys upper lip.
The baby becomes alert, and opens his mouth and eyes.
A low-birth-weight (LBW) baby starts to take the milk into his mouth with his
tongue.
A full term or older baby sucks the milk, spilling some of it.
DO NOT POUR the milk into the baby's mouth. Just hold the cup to his lips and let
him take it himself.
When the baby has had enough, he closes his mouth and will not take any more. If
he has not taken the calculated amount, he may take more next time, or you may
need to feed him more often.
Measure his intake over 24 hours - not just at each feed.
b. Mechanical or hand expression

Hand expression is the most useful way to express milk. It needs no
appliance, so a woman can do it anywhere, at any time. A woman should
express her own breast milk. The breasts are easily hurt if another person
tries.
____________________________________________________________________________
104

Relactation
If you are showing a woman how to express, show her on your own body
as much as possible, while she copies you. If you need to touch her to
show her exactly where to press her breast, be very gentle.
Figure 8B.2 How to hand express breast milk

Box 8B.2 How to express breast milk by hand
Teach a mother to do this herself. Do not express her milk for her. Touch her only to
show her what to do, and be gentle. Teach her to:
Wash her hands thoroughly.
Sit or stand comfortably, and hold the container near her breast.
Put her thumb on her breast ABOVE the nipple and areola, and her first finger on the
breast BELOW the nipple and areola, opposite the thumb. She supports the breast with
her other fingers.
Press her thumb and first finger slightly inwards towards the chest wall. She should
avoid pressing too far or she may block the milk ducts.
Press her breast behind the nipple and areola between her finger and thumb. She
should press on the larger ducts beneath the areola. Sometimes in a lactating breast it
is possible to feel the ducts. They are like pods, or peanuts. If she can feel them, she
can press on them.
Press and release, press and release. This should not hurt - if it hurts, the technique is
wrong.
At first no milk may come, but after pressing a few times, milk starts to drip out. It may
flow in streams if the oxytocin reflex is active.
Press the areola in the same way from the SIDES, to make sure that milk is expressed
from all segments of the breast.
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105
Avoid rubbing or sliding her fingers along the skin. The movement of the fingers should
be more like rolling.
Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express the milk.
It is the same as the baby sucking only the nipple.
Express one breast for at least 3-5 minutes until the flow slows; then express the other
side; and then repeat both sides. She can use either hand for either breast, and change
when they tire.
c. Skin-to-skin contact
Skin-to-skin contact is a mother holding her naked baby against her own
skin. Skin-to-skin with mother keeps newborn warm and helps stimulate
bonding or closeness, and brain development. Skin-to-skin helps stimulate
the "let down" of milk.
3. Provision of a temporary milk supplement for the infant without using a
bottle
While the mother's breastmilk supply is becoming established, it is essential to
ensure that the infant receives adequate nourishment.
If expressed breastmilk is available, this is usually the best alternative.
If an infant is not willing to suckle at a non-productive breast, the
supplement can be given through a breastfeeding supplementer.
If the infant is willing to suckle at a non-productive breast, the supplement
can be given separately.
Supplementary feeds
Temporary supplementary feeds for the infant, in order of preference:
Expressed breast milk

Donor milk
Infant formula
Supplementary suckling technique

This technique usually needs to be practiced under supervision at a health
facility. A breastfeeding supplementer consists of:
A cup of supplement
A tube leading from the cup to the breast, goes along the nipple and into
the infants mouth
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Relactation
Figure 8B.3 Supplementary suckling technique

Box 8B.3 How to help a mother to use a breastfeeding supplementer
Show the mother how to:
Use a fine nasogastric tube or other fine plastic tubing and a cup to hold the milk. If
there is no very fine tube, use the best available.
Cut a small hole in the side of the tube, near the end of the part that goes into the
infants mouth (this is in addition to the hole at the end). This helps the flow of milk.
Prepare a cup of milk (expressed breastmilk or artificial milk) containing the amount
of milk that her infant needs for one feed.
Put one end of the tube along her nipple, so that her infant suckles the breast and
the tube at the same time. Tape the tube in place on her breast.
Put the other end of the tube into the cup of milk.
Tie a knot in the tube if it is wide or put a paper clip on it, or pinch it. This controls the
flow of milk, so that the infant does not finish the feed too fast.
Control the flow of milk so that the infant suckles for about 30 minutes at each feed if
possible. (Raising the cup makes the milk flow faster, lowering the cup makes the
milk flow more slowly).
Let the infant suckle at any time that he is willing not just when she is using the
supplementer.
Clean and sterilise the tube of the supplementer and the cup or bottle, each time she
uses them.
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Relactation
107
Drop and drip technique

In the "drop and drip" technique (See Figure 8B.3), milk is dripped from a dropper
or a cup directly onto the breast while the infant is suckling (WHO, 1998). This
technique can be used to persuade a reluctant infant to start suckling at the
breast. It is less satisfactory when the infant is well attached to the breast,
because the milk does not go into the infant's mouth so easily. Because the
technique is easier with three hands, it can be difficult for a mother who has no
one to help her.
Figure 8B.3 Drop and drip technique
Quantity of supplements
A term baby requires 150 ml/ kg body weight a day

Divide this amount into 6 12 feeds, depending on the infants age and
condition
When infant is gaining weight and there are signs of breast milk
production, reduce the supplements by 50 ml/ day every few days
4. Other measures (Lactogogues)

Lactagogues
Drugs called lactagogues that help stimulate milk production may be given if the
above steps are insufficient.
Metoclopramide (10 mg 3 times a day for 7 14 days)

Domperidone (20 40 mg 3 times a day for 7 10 days)
Drugs only help when a woman receives adequate help and her breasts are
stimulated by her infant suckling.
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Relactation
References
2009.
1. WHO. Relatation: A review of experience and recommendations for practice.
Geneva: WHO; 1998.
2. Hormann, E. Breastfeeding an Adopted Baby and Relactation. La Leche League
International, Schaumburg, IL: 2006.
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109
Notes
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Session 8C: Appropriate Feeding in Exceptionally Difficult Circumstances:

IYCF in Emergencies
110
SESSION 8C
INFANT AND YOUNG CHILD FEEDING IN EMERGENCIES
Objectives
1. Discuss the importance of IYCF in Emergencies (IYCF-E).
2. Understand the risks of infant formula feeding during emergencies.
3. Understand the existing laws and policies that will help protect IYCF practices
during emergencies situations.
4. Be familiar with the tools in assessing IYCF-.
Introduction
IYCF in emergencies concerns the protection and support of optimal feeding for
infants and young children in all emergencies, wherever they happen in the world.
Sub-optimal IYCF practices increase vulnerability to under-nutrition, disease and
death. The risks are heightened in emergencies and the youngest are most
vulnerable. Infants and young children in exceptionally difficult circumstances,
such as HIV prevalent populations, orphans, low birth weight (LBW) infants, those
who are severely malnourished, and non-breastfed infants are particularly at risk
(NutritionWorks, Emergency Nutrition Network & Global Nutrition Cluster, 2011)
Legal Bases
Populations affected by any form of disaster whether natural or man-made including the
situation of armed conflict have the right to appropriate assistance and protection based
on the International Humanitarian Law, International Human Rights Law, Refugee Law
and Code of Conduct for the International Red Cross.
Why IFE matters?
The Philippines is a disaster-prone country considering that we experience almost all
forms of calamities such as typhoons, earthquakes, floods, volcanic eruptions,
landslides, tidal waves, fires, and armed conflict.
The risks of artificial feeding during emergency and disaster are high because:
Water or a source of safe water is lacking, cooking utensils are inadequate, there
is shortage of fuel;
Daily survival activities take more time and energy;

There is uncertain, unsustainable supplies of breast milk substitutes; and
Lack of knowledge on preparation and use of breast milk substitutes
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111
These make our children vulnerable in times of emergencies. In general, the

younger the children are, the more vulnerable they are. Inappropriate feeding increases
their risks of diseases and death.
This graph was taken from the Refugee Information System at WHO, Geneva, 1998 and
1999. It shows increased deaths among under-fives children in selected countries during
emergencies. The white graph represents people of all ages, while the black or dark
graph represents the children 5 years and below.
Death among under-fives is very high in countries like Chad, Liberia and Sierra Leone.
The graph shows that children under five are the most vulnerable during emergencies
for the rest of all countries in this graph.
Risks to Infant and Young Child Feeding During Emergencies
During emergencies, protection, promotion and support of breastfeeding are critical.
Illness and death rates can be as great as 20 times the usual level, a result of increased
exposure to infection and inadequate infant feeding and care.
The risk of artificial feeding dramatically increased due to:
poor sanitation and hygiene
limited and contaminated water
limited fuel
unpredictable delivery of breast milk substitute
Why Not Formula?

There are many examples showing why formula is not suitable feeding method during
emergencies:
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IYCF in Emergencies
United States of America: April 11, 2002, US Food and Drug Administration
(USFDA) wrote to Health Care Professionals: One study tested milk-based
powdered infant formula products obtained from different countries and found
that Enterobacter sakazakii could be recovered from 20 (14%) of 141 samples.
The majority of cases of E. sakazakii infection reported in the peer reviewed
literature have described neonates with sepsis, meningitis and necrotizing
enterocolitis, and the case-fatality rate among infected neonates was as high as
33%.
Germany: May 13, 2002, Federal Institute for Consumer Health Protection states:
Mortality is very high (bet. 50-75%) in the large numbers of cases of meningitis
caused by powdered infant formula contaminated by E. sakazakii. The warning
indicated that powdered infant formulas are not sterile.
Strict food safety procedures should be followed in preparation of feeds because
bacteria develop in prepared formula if it is kept warm for more than 40 minutes.
Formula milk should be monitored for bacterial contamination.
Belgium: May 21, 2002, the Counseil Superieur d Hygiene, or Food Safety
Counsel circulated an order which emphasized that powdered infant formula is
not a sterile product and recommends that all kitchens in hospitals and maternity
wards should comply with food safety regulations. In addition, breast milk should
be used in these services.
Canada: Although premature infants and those with underlying medical
conditions may be at highest risk, healthy infants are not immune to E. sakazakii
infections.
Health Canada draws attention to the fact that:
Powdered infant formulas are not commercially sterile products.
Human milk fortifiers which are added to preterm breast milk are also
available in powdered form. Likewise, formula milk for infants with metabolic
conditions are available only in powdered form.
Powdered soy-based infant formulas may also become contaminated with E.
sakazakii.
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113
Unfortunately, during emergencies, breastfeeding support rarely happens. More

commonly, there are large donations of infant formula and bottles brought in to areas.
Existing Laws And Policies That Protect IYCF Practices During Emergency
Situations
Milk Code (EO 51)
The Milk Code protects breastfeeding. This helps prevent spill-over of breast milk
substitutes to mothers currently breastfeeding their babies. Accurate and adequate
information as well as proper and safe preparation must be taught only by health
workers to mothers/carers/camp managers who will feed babies who might need Breast
milk substitutes and breast milk supplements.
The Code applies even during emergencies and disasters. It covers not only milk and
other milk products but also foods and beverages including complementary foods. Milk
companies may donate other items (not covered by the Law), but they should request for
a permit from the DOH. This is to avoid the use of donations as an opportunity to
promote their products.
A.O. No. 2007 0017
Administrative Order No. 2007-0017, Guidelines on the Acceptance & Processing of
Foreign & Local Donations During Emergency & Disaster Situations was formulated
because of the following:
Accepted donations turn out to be inappropriate to address the needs during
emergencies and disasters.
Acceptance and distribution experience unnecessary delays.
There were no procedures and protocol for handling and administering
donations.
There was a lack of information whether donated items reach the desired
beneficiaries.
Guidelines for Acceptance
The guideline on acceptance and processing of foreign and local donations during
emergency and disaster situations specifically states that any of the following items shall
not be accepted for donation:
infant formula,
breast milk substitutes,
feeding bottles,
artificial nipples and teats.
Safety of recipients of foodstuffs is to be guarded. Expiration dates should be properly
inspected. Donations of food stuffs in emergency and disaster situations should also
have a shelf life of three months from the time of arrival in the Philippines.
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IYCF in Emergencies
IYCF Guidelines During Emergencies

The principles and recommendations for feeding infants and young children in
emergency situations are exactly the same as for infants in ordinary
circumstances.
The policy on IYCF should always be observed during emergencies.
Newborns have to be initiated to breastfeeding within the first hour. The newborn
must be placed skinto-skin with the mother to keep him warm, for bonding,
and to facilitate release of oxytocin and early latching on.
To ensure that the infant receives the optimum nutrition from 0-6 months, only
breast milk must be given. It is noted that not even water should be given. This
is the safest and the most appropriate food for this age.
After 6 months, the infant needs more energy and breast milk has to be
complemented with appropriate food.
Complementary Feeding Guidelines During Emergencies
Complementary feeding must start from 6 months to two years, while
breastfeeding is continued.
Complementary feeding should be properly fed, adequate in amount, safely and
hygienically prepared and at the right time.
Small children will eat food that they get accustomed to. This is the age where
we have to make them enjoy what they are eating in a timely manner, free from
contamination and in adequate amounts of nutritious food.
Complementary foods must be locally available so that we are assured that it is
always available any time of the year and cheaper.
Use of blended foods and fortified foods can be useful and the use of local
ingredients is encouraged. Donations of complementary foods must also be
approved by the Food and Drug Administration.
Agreed Criteria for Use of Alternatives to Mothers Milk
There are circumstances when breastfeeding is temporarily not feasible and therefore
alternative feeding is warranted:
In the event that the mother has died right after giving birth or is unavoidably
absent;
Mother may be very ill and that breastfeeding her infant is impossible;
When mother is relactating, for a short period while waiting for the relactation to
take place;
Mother might be known to be HIV positive and decided to use breast milk
substitute. However, certain conditions should be met (these conditions will be
discussed in a subsequent session), otherwise the baby might be exposed to
greater danger;
When a mother is in unstable emotional/psychological condition and rejects her
infant. For instance, when the mother is experiencing postpartum blues, it will be
dangerous for the baby to be with the mother;
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115
Infants who were fully dependent on artificial feeding even before the emergency
(use BMS to at least six months or use temporarily until relactation is achieved.
Before resulting to the alternatives, all efforts must be exerted to look for sources of
mothers milk like wet nurses or milk banks.
Preferred Options Safer than Infant Formula
There are occasions when mothers cannot breastfeed her baby. However, formula
feeding is not the correct immediate answer. There are other options which are safer
than feeding the baby formula milk such as:
Relactation, bringing back the flow of milk when it has stopped for some
reasons. There are ways of doing this and skilled help is needed to assist the
mother.
Wet nursing or having the baby be fed by another lactating/nursing mother.
Expressed human milk or getting human milk from the milk bank.
Tools in Assessing IYCF-E

During emergencies, health workers need to know what conditions must exist in order to
support breastfeeding during emergencies. These are necessary in order for them to
conduct proper assessment, identify the perceived need/problem and provide timely and
suitable intervention/help. The following are the conditions that health workers should
know to support breastfeeding during emergencies:
How breastfeeding works
Effective suckling
Evaluating attachment and positioning
Milk supply
Supportive care for women
Adequate Nutrition
Maternity services
Health services
Assessment of infant feeding
Simple, rapid, or full assessment
Providing help to improve infant feeding
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IYCF in Emergencies
Basic help
More skilled help for breastfeeding
Low birth weight babies
Thin and underweight
The malnourished mother
Other breast milk options
Special cultural issues
Deciding Who Needs Help
The diagram explains how health workers can be guided in deciding who needs help.
This starts with simple rapid assessment to identify what continuing support should be
provided. If the assessment shows a more complex need or problem, the succeeding
step involves a full assessment so as to gather supplementary data needed to provide
both basic aid and further help.
Simple Rapid Assessment (Age-Appropriate Feeding)
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IYCF in Emergencies
117
The simple rapid assessment focuses on age-appropriate feeding. It is important to get

the age and food fed to the baby.
Full assessment and referral is necessary when:
Baby is not breastfed
Breastfeeding but not age-appropriate
Under 6 months, not exclusively breastfed
Over six months, given no complementary feeding
Simple Rapid Assessment (Breastfeeding Case)
Ask the mother whether the baby is able to suckle the breast or whether the mother is
experiencing difficulties in breastfeeding. The baby should be fully assessed if not able
to suckle, if mother has difficulties in breastfeeding and when mother is requesting for
breast milk.
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IYCF in Emergencies
Simple Rapid Assessment (Looking at Babys Condition)
Now, look at the baby and determine if the baby looks very thin, lethargic or seems ill.
These are reasons to refer the baby for full assessment at higher level of care.
Full Assessment
This is the summary of the steps in conducting the full assessment during emergencies.
Notice that you are asked to apply the knowledge and skills you learned in IYCF
Counselling or Lactation Management training.
Observe a mother while breastfeeding her baby. Take note of the correct
positioning and attachment.
You should apply the communications skills that you have learned.
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119
It is very important that you observe infants receiving artificial feeding because
they need greater care and attention, and their mothers need necessary support
in terms of the available resources and how well they know how to provide
appropriate, adequate and safe feeding.
Philippines promoting and protecting breastfeeding
When everyone is so busy attending to other needs during emergency, peer counselors
(PCs) are critical people that must be available to support breastfeeding and nonbreastfeeding mothers.
Peer counselors are mothers themselves with successful breastfeeding experience. The
PCs provide the necessary counselling needed by mothers in order to ensure that
infants and young children will not be deprived of the optimum nutrition they need even
in emergency or disaster situations.
The PCs also assist camp managers in evacuation centers in terms of other concerns
that they have been trained to. The PCs are in close coordination with professional
trained health workers in health centers and in hospitals.
Some mothers who have not been formally trained in peer counselling can also help to
support mothers of infants and young children as long as they have successful
experience in breastfeeding and are willing to coordinate and discuss or report issues to
health workers.
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IYCF in Emergencies
Being Prepared
A plan of action must be prepared and this must be made known to all those involved in
emergencies and disaster management. The plan of action should include a list of
trained staff and volunteers on IYCF/Breastfeeding.
The designated location of the feeding center must be made known to the team.
Assessment is necessary to isolate those who will be needing help. The
emergency/disaster team must follow the protocol that is available locally. Clean/safe
water is important.
For a short time, mothers might be in shock and other sources of breast milk might not
be available. In rare/extreme cases, temporary giving of formula might be necessary
while supply of breast milk is not yet available. There my also be young children
dependent on formula, so clean and safe water must be available.
An emergency would come as a surprise. But now that you have been trained on
LMT/IYCF counselling course, it is expected that you will be ready and prepared for
emergency situations. Help protect breastfeeding and protect the infants and young
children.
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121
References
Contents of this session are adapted from the following modules:
1. DOH Philippines. Protecting Infant And Young Child Feeding During
Emergencies (IYCF-E) Training Module. August 2012.
Notes
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Session 8D: Appropriate Feeding in Exceptionally Difficult Circumstances:

Infants of HIV-positive mothers
122
SESSION 8D
INFANTS OF HIV-POSITIVE MOTHERS
Objectives
1. Explain when the HIV virus can be transmitted from mother to child and explain the risk
of transmission with and without interventions.
2. Describe infant feeding in the context of HIV (dependent on National Policy).
3. Describe feeding a child from 6 up to 24 months when an HIV-infected mother
breastfeeds or does NOT breastfeed.
4. Describe counselling for infant feeding in relation to HIV.
5. Outline counselling for infant feeding decisions.
Introduction
HIV infection and AIDS have become major problems in many countries. A very sad
aspect of the epidemic is the number of young children who are infected. This is one
cause of the increasing number of child deaths.
It is important to remember that the best way to prevent infection of children is to help
their fathers and mothers to avoid becoming infected in the first place, and to avoid
infecting each other.
Defining HIV and AIDS
People infected with HIV feel well at first and usually do not know they are infected.
They may remain healthy for many years as the body produces antibodies to fight HIV.
But the antibodies are not very effective. The virus lives inside the immune cells and
____________________________________________________________________________

slowly destroys them. When these cells are destroyed, the body becomes less able to
fight infections.
The person becomes ill and after a time develops AIDS. Eventually he or she dies.
A special blood test can be done to see if people have HIV antibodies in their blood. A
positive test means that the person is infected with HIV. This is called HIV-positive or
sero-positive.
Once people have the virus in their body, they can give the virus to other people. HIV
is passed from an infected man or woman to another person through:
Exchange of HIV-infected body fluids such as semen, vaginal fluid or blood
during unprotected sexual intercourse
HIV-infected blood transfusions or contaminated needles. HIV can also pass
from an infected woman to her child during pregnancy at the time of birth or
through breastfeeding. This is called mother-to-child transmission or MTCT.
Risk of mother-to-child transmission of HIV
Young children who get HIV are usually infected through their mothers:
during pregnancy across the placenta
at the time of labor and birth through blood and secretions
through breastfeeding
This is called mother-to-child transmission of HIV or MTCT. Not all babies born to HIVinfected mothers become infected with HIV.
About two-thirds of infants born to HIV-infected mothers will not be infected, even with
no intervention, such as anti-retroviral prophylaxis or caesarean section. 15-25% of
infants born to HIV- infected mothers are infected during pregnancy, labor and
delivery. A smaller proportion, 5-20%, are infected through breastfeeding. The risk
continues as long as the mother breastfeeds, and is more or less constant over time.
Exclusive breastfeeding during the first few months of life carries a lower risk of HIV
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123
124

transmission than mixed feeding. Research has shown that the transmission risk at six
months in exclusively breastfed babies is lower than in mixed fed babies.
If the prevalence of HIV infection among the women in your district is known to be 20%
and you see 100 women, 20 of these 100 women are likely to be HIV-positive. The
other 80 will probably be HIV-negative. We used a prevalence rate of 20% for this
example. Use your local rates when talking with the mother.
The mother-to-child transmission rate is about 15-25% during pregnancy or delivery.

We use 20% for this example. Four infants of the 20 HIV-positive mothers will probably
be infected during pregnancy or delivery.
Here we have a figure of 100 mothers. 20% of them are HIV-positive (mothers with a
red cross). 20% of their infants, or 4 infants, are likely to be infected during pregnancy
or delivery.
____________________________________________________________________________

The transmission rate through breastfeeding is about 5-20% of the infants who are
breastfed for several months by mothers who are HIV-positive. Let us use 15% for this
example. Assuming all the infants are breastfeeding, about three of the infants, of the
HIV-positive mothers, are likely to be infected by breastfeeding.
In a group of 100 mothers in an area with a 20% prevalence of HIV infection among
mothers, about three babies are likely to be infected with HIV through breastfeeding. If
all HIV-positive mothers were breastfeeding exclusively, the number of infected infants
would be less.
If pregnant women are not tested, you cannot predict which babies will be infected. So,
if a mother does not know her HIV status, she should be encouraged to breastfeed.
She should also be assisted to protect herself against infection with HIV.
Factors which affect maternal-to-child transmission (MTCT) of HIV through
breastfeeding
Recent infection with HIV
If a woman becomes infected with HIV during pregnancy or while breastfeeding, she
has higher levels of virus in her blood, and her infant is more likely to be infected. It is
especially important to prevent an HIV-negative woman from becoming infected at this
time because then both the woman and her baby are at risk. All sexually active people
need to know that unprotected extramarital sex exposes them to infection with HIV.
They may then infect their partners, and their baby too will be at high risk, if the
infection occurs during pregnancy or while breastfeeding.
Severity of HIV infection
If the mother is ill with HIV-related disease or AIDS and is not being treated with drugs
for her own health, she has more virus in her body and transmission to the baby is
more likely.
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125
126

Duration of breastfeeding
The virus can be transmitted at any time during breastfeeding. In general, the longer
the duration of breastfeeding the greater the risk of transmission.
Exclusive breastfeeding or mixed feeding
There is evidence that the risk of transmission is greater if an infant is given any other
foods or drinks at the same time as breastfeeding. The risk is less if breastfeeding is
exclusive. Other foods or drinks may cause diarrhea and damage the gut, which might
make it easier for the virus to enter the babys body.
Condition of the breast
Nipple fissure (particularly if the nipple is bleeding) mastitis or breast abscess may
increase the risk of HIV transmission through breastfeeding. Good breastfeeding
technique helps to prevent these conditions, and may also reduce transmission of HIV.
Condition of the babys mouth
Mouth sores or thrush in the infant may make it easier for the virus to get into the baby
through the damaged skin.
This list of factors suggests several strategies that would be useful for all women,
whether they are HIV-positive or HIV-negative. They provide ways to reduce the risk of
HIV transmission, which can be adopted for everyone, and they do not depend on
knowing womens HIV status. Other strategies, such as the avoidance of
breastfeeding, can be harmful for babies, so they should only be used if a woman
knows that she is HIV-positive.
Prevention of MTCT
Antiretroviral drugs (ARV) are used to reduce the amount of HIV in the body. It has
been shown that if a short course of ARVs are given at the end of pregnancy and at
the time of delivery, the risk of transmission at that time can be reduced by about half.
There are several different short ARV regimens, which can be used in different ways.
These are used to reduce the amount of HIV in the body. Some names that you may
have heard of are AZT (azidothymidine) and ZDV (zidovudine), which are two names
for the same drug, and nevirapine.
It has been shown that a short course of ARVs given at the end of pregnancy and at
the time of delivery, halves the risk of transmission. There are several short ARV
regimens, which can be used in different ways.
Most countries have developed initiatives to provide one of these drug regimes to
women who are HIV-positive and some are providing them for long-term treatment. In
some regimens, the baby is also given one or more of the ARVs for a short time.
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Infant feeding in the context of HIV
Infants born to HIV positive mothers, like other infants, may also fall ill and die from
causes other than HIV/AIDS. They may also contract neonatal sepsis, pneumonia, and
diarrhea. Exclusive breastfeeding is a protective factor against these other causes of
infant mortality. A comparison of these risks is depicted in the Table above. EBF is the
best option even for HIV-infected women because of the significantly lower risk of
mortality and morbidity due to causes other than HIV.
A mother who is HIV-positive may decide that breastfeeding is her best option and she
should be supported to establish and maintain it. If a woman does breastfeed, it is
important for her to breastfeed exclusively. This gives protection for the infant against
common childhood infections and also reduces the risk of HIV transmission. An HIVinfected mother who chooses to breastfeed needs to use a good technique to prevent
nipple fissure and mastitis, both of which may increase the risk of HIV transmission.
Replacement feeding is only advised if certain conditions are met. An HIV-infected
mother who chooses to give replacement feeding to her infant should be adequately
supported in order to ensure that the replacement feeding is hygienically prepared
adequate to meet the infants nutritional requirements.
Mixed feeding is the worst option, as it increases the risk of HIV transmission as well
as exposing the infant to the risks of illness from contaminated formula made with dirty
water and given in dirty bottles, and contaminated foods and other liquids.
All HIV-infected mothers should receive counselling, which includes provision of
general information about the risks and benefits of various infant feeding options, and
specific guidance in selecting the option most likely to be suitable for their situation.
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127

128
Infant Feeding Recommendations

Infant feeding recommendations can vary according to national policy. The
national policy can either be exclusive breastfeeding for 6 months, or replacement
feeding if the mother opts out of exclusive breastfeeding.
The most appropriate infant feeding option for a mother should continue to depend on
her individual circumstances, including her and the childs health status and the local
situation, but should take greater consideration of the health services available and the
counselling and support she is likely to receive. These are the recommended feeding
options given the aforementioned considerations.
HIV un-infected mother or mother of unknown status:

Exclusively breastfeed for up to 6 months, add complementary foods at 6
months and continue breastfeeding for 2 years and beyond.
HIV-infected mother whose infant is HIV uninfected or of unknown HIV

status. (The mother has two main options for feeding her baby depending
on the national policy).
Exclusively breastfeed together with ARVs for mother OR infant
Exclusive breastfeeding in the first six months helps to significantly
reduce the babys risk of illness, malnutrition and death, and carries a
relatively low average risk of transmission in the first six months as
compared to mixed feeding.
Same recommended breastfeeding practices that apply for HIVnegative mother and mother of unknown status
Breastfeeding and ARVs should continue until 12 months
Exclusively breastfeed even when no ARVs are available .

The 2010 WHO Guidelines on HIV and Infant Feeding, Principles and
recommendations for infant feeding in the context of HIV and a
summary of evidence state: When a national authority has decided to
promote and support breastfeeding and ARVs, but ARVs are not yet
available, mothers should be counselled to exclusively breastfeed in
the first six months of life and continue breastfeeding thereafter unless
environmental and social circumstances are safe for, and supportive of
replacement feeding.
In circumstances where ARVs are unlikely to be available, such as
acute emergencies, breastfeeding of HIV-exposed infants is also
recommended to increase survival.
Cessation of breastfeeding at 12 months
WHO recommends against early, abrupt or rapid cessation of
breastfeeding. Mothers known to be HIV-infected who decide to stop
breastfeeding at any time should stop gradually within one month.
Mothers or infants who have been receiving ARV prophylaxis should
____________________________________________________________________________

continue prophylaxis for one week after breastfeeding is fully stopped.

HIV-infected mother whose infant is HIV-infected
Exclusively breastfeed for up to 6 months, add complementary foods at 6
months and continue breastfeeding for 2 years and beyond
Box 8D.1 Infant Feeding Recommendations Guidelines, 2010
Known HIV
Positive mothers who decide to stop breastfeeding should do so gradually
within one month. Mothers or infants who are receiving ARV prophylaxis
should continue prophylaxis for one week after breastfeeding is fully
stopped.
Stopping breastfeeding abruptly is not advisable.
When mothers known to be HIV-infected decide to stop breastfeeding,
infants should be provided with safe and adequate replacement feeds.
Alternatives to breastfeeding for infants less than 6 months:

Commercial milk formula (make sure conditions a f in next slide are met)
Heat-treated, expressed breast milk
Home-modified animal milk is not recommended as a replacement food
in the first six months of life.
Alternatives to breastfeeding for children over 6 months of age:
Commercial infant formula milk (make sure conditions a f below are met)
Animal milk (boiled for infants below 12 months), as part of a diet providing
adequate nutrient intake. Meals should be provided 4 or 5 times a day.
Conditions needed to safely formula feed:

a. Safe water and sanitation are assured at the household and community level
b. The mother or other caregiver can reliably provide sufficient infant formula
milk to support normal growth and development of the infant
c. The mother or caregiver can prepare it cleanly and frequently enough so
that it is safe and carries a low risk of diarrhea and malnutrition
d. The mother or caregiver can, in the first six months, exclusively give formula
milk
e. The family is supportive of this practice
f. The mother or caregiver can access health care that offers comprehensive
child health services.
Mothers known to be HIV-infected may consider expressing and heat-treating

breast milk as an interim feeding strategy.
In special circumstances (when the baby is ill or born with LBW)
When the mother is unwell and temporarily unable to breastfeed
To assist mothers to stop breastfeeding
If ARVs are temporarily unavailable
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130

Counselling for Infant Feeding in Relation to HIV
As infant feeding counselors, you will not be expected to give general counselling
for HIV unless you have special training to do this. If you have not been trained,
you need to know where to refer women for this service.
Guidelines for voluntary counselling and testing for HIV are defined in the
Department of Healths Administrative Order No. 2010-0028. AO 2009-0016
discusses the policies and guidelines for the prevention of MTCT of HIV.
For Women Who Have Not Been Tested or Do Not Know Their Results:
Talk to them about the advantages of HIV testing for them and their families.
Refer them to a convenient HIV testing and counselling centre if they would like
a test.
In the absence of a test result, provide counselling about their concerns and
encourage them to feed their babies as if they were HIV-negative, that is to
breastfeed exclusively for six months and to continue breastfeeding with
adequate complementary feeding up to two years or beyond.
If a woman does not know her HIV status, it is usually safer for her baby if she
breastfeeds. Babies who do not breastfeed are at greater risk of illness.
When you counsel a woman who does not know her HIV status about infant
feeding, she may need reassurance that breastfeeding is the safest option for
her baby.
Women who give birth at home may be offered testing and counselling when they are
in contact with the health service. Traditional birth attendants, community health
workers or infant feeding counselors can provide women with information and
encourage them to think about testing.
____________________________________________________________________________

A woman may believe that she is HIV-positive despite a negative test. She needs
counselling to discuss her worries and generally should be encouraged to breastfeed.
For Women Who Have Been Tested and are HIV-negative:
Talk to them of the risks of becoming infected during pregnancy or while
breastfeeding.
Suggest that they have a repeat test if they think they have been exposed to
HIV since the last test.
Suggest that they feed their babies as per the general population
recommendation.
For Women Who Have Been Tested and are HIV-positive:
You will need to discuss with the woman her possible infant feeding options
from birth to six months.
You will need to counsel her again as the child approaches six months of age,
to discuss feeding options from 6 months onwards.
Counselling Flowchart
Most HIV-positive women are not ready to discuss infant feeding options at their
first post-test counselling session. They will need to be referred specifically for
that later. The infant feeding counselor may be a different person from the person
who gives general counselling.
Infant Feeding Counselling for HIV-Positive Women may be needed:
before a woman is pregnant

during her pregnancy
soon after her baby is born
soon after receiving the results of her babys HIV test
when her baby is older
when a woman fosters a baby whose mother is very sick or has died.
As her baby gets older, or if her situation changes, an HIV-positive mother may need
on-going infant feeding counselling. She may want to change her method of feeding
and to discuss this with the infant feeding counselor.
Each woman's situation is different, so health workers need to be able to discuss all
the various feeding options as previously discussed.
In order to help the woman without telling her what to do, you will need to follow a
systematic process for providing information and support. The figure below outlines the
counselling process.
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132

Counseling Flowchart for HIV-Positive Women
Source: World Health Organization. Infant and Young Child Feeding Counselling: An
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References
3. World Health Organization. Infant and Young Child Feeding: Model Chapter for
2009.
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133
134

Notes
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Session 8E: Appropriate Feeding in Exceptionally Difficult Circumstances:

Non-breastfeeding Children 6-23 Months of Age
135
SESSION 8E
FEEDING NON-BREASTFED CHILDREN 6-23 MONTHS OF AGE
Objectives
1. Explain the guiding principles in feeding non-breastfed children 6-23 months of age.
2. Discuss schedule of follow-up of infants and young children who are not breastfed.
Introduction
Sometimes young children between the ages of 6 months and 2 years are not breastfed.
Reasons include when their mother is unavailable, or has died, or is HIV-positive. These
children need extra food to compensate for not receiving breast milk, which can provide one
half of their energy and nutrient needs from 6 to 12 months, and one third of their needs
from 1223 months.
Guiding Principles in Feeding Non-breastfed Children 6-23 Months of Age

To feed children aged 623 months satisfactorily, all the principles of safe, adequate
complementary feeding apply, as described in Session 5. However, to cover the
requirements that would otherwise be covered by breast milk, a child needs to be fed a
larger quantity of the foods containing high-quality nutrients. This can be achieved by
giving the child:
Amount of food needed

Food consistency
Meal frequency and Energy density
Nutrient content of foods
Micronutrients supplements
Fluid Needs
Box 8E.1 Guiding Principles in Feeding Non-breastfed Children 6-23 Months of Age
1. Amount of food needed
Ensure that energy needs are met. These needs are approximately 600 kcal per
day at 6-8 months of age, 700 kcal per day at 9-11 months of age, and 900 kcal
per day at 12-23 months of age.
Please see Box 8E.2 Quantities of foods that meet estimated energy needs
by age interval in South Asia for examples of diet for different age groups (6-8
months, 9-11 months and 12-23 months).
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136

Non-breastfed Children 6-23 Months of Age
2. Food consistency
Gradually increase food consistency and variety as the infant gets older,
adapting to the infants requirements and abilities.
Infants can eat pureed, mashed and semi-solid foods beginning at six months.
From 9 up to 12 months, most infants can also eat finger foods. And by 12
months, most children can eat family foods.
3. Meal frequency and Energy density
For the average healthy infant, meals should be provided 4-5 times per day, with
additional nutritious snacks (such as pieces of fruit or bread) offered 1-2 times
per day, as desired.
The appropriate number of feedings depends on the energy density of the local
foods and the usual amounts consumed at each feeding.
If energy density or amount of food per meal is low, more frequent meals may be
required.
4. Nutrient content of foods
Feed a variety of foods to ensure that nutrient needs are met.
Meat, poultry, fish or eggs should be eaten daily, or as often as possible,
because they are rich sources of many key nutrients such as iron and zinc. Milk
products are rich sources of calcium and several other nutrients. Diets that do not
contain animal- source foods (meat, poultry, fish or eggs, plus milk products)
cannot meet all nutrient needs at this age unless fortified products or nutrient
supplements are used.
Dairy products are important to provide calcium. A child needs 200400 ml of
milk or yoghurt every day if other animal source foods are eaten, or 300500 ml
per day if no other animal source foods are eaten.
Foods of thick consistency or with some added fat, help to ensure an adequate
intake of energy for a child. Foods of animal origin some meat, poultry, fish, or
offal should be eaten every day to ensure that the child gets enough iron and
other nutrients.
The child should be given legumes, seeds and nuts daily to help provide iron and
vitamins, with vitamin C-rich foods to help iron absorption. The child should also
be given orange and yellow fruits and dark-green leafy vegetables to provide
vitamin A and other vitamins.
5. Micronutrients supplements
If the child receives no foods of animal origin, then it is necessary to give vitamin
and mineral supplements to ensure sufficient intake, particularly of iron, zinc,
calcium and vitamin B12.
6. Fluid Needs
Plain, clean (boiled, if necessary) water should be offered several times per day
to ensure that the infants thirst is satisfied.
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Non-breastfeeding Children 6-23 Months of Age
137
Box 8E.2 Quantities of foods that meet estimated energy needs by age interval in South
Asia [Quantities (g/day)]
6-8 months
Foods
Diet 1
9-11 months
Diet 2
Diet 3
Diet 1
12-23 months
Diet 2
Diet 3
Diet 1
Diet 2
Diet 3
Milk
200
200
340
200
200
340
270350
310
75
Egg
50
50
50
50
20-50
50
Meat,
poultry, fish,
or liver
35-70
35-75
20-75
Rice or
wheat
0-30
0-30
0-30
0-30
0-30
0-30
0-70
20-40
20-70
Lentils
80
80
80
80
80
80
80
80
80
Potato
70-125
125
125
125
125
125
125
125
125
Spinach
40
40
40
40
40
40
40
40
40
Pumpkin
130
130
130
130
130
130
130
0-130
130
Onion
20
20
0-10
20
20
20
0-20
20
Guava
25
25
25
25
25
25
0-25
25
0-5
0-5
0-5
Oil
Source: WHO. Guiding principles for feeding non-breastfed children 624 months of age.
Geneva, World Health Organization, 2005.
Follow-up Schedule of Non-breastfed Children 6-23 Months of Age

The same principles of follow-up and referral apply to non-breastfed children as to breastfed
children. They should be followed up regularly for at least 2 years to ensure that their
feeding is adequate, and that they are growing and remaining well-nourished.
All infants of HIV-positive mothers, at whatever age they stop breastfeeding, should be
followed up for at least 2 years to ensure that their feeding is adequate, and to establish if
they are HIV-positive themselves.
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Non-breastfed Children 6-23 Months of Age
138
References
2009.
2. WHO. Guiding principles for feeding non-breastfed children 624 months of age.
Geneva, World Health Organization, 2005.
Notes
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Session 8F: Appropriate Feeding in Exceptionally Difficult Circumstances:

Severe Malnutrition
139
SESSION 8F
SEVERE MALNUTRITION
Objectives
1. Explain the guiding principles in feeding non-breastfed children 6-23 months of
age.
2. Discuss schedule of follow-up of infants and young children who are not
breastfed.
Introduction
Severe malnutrition is both a medical and a social disorder. Malnutrition is the end result of
chronic nutritional and, frequently, emotional deprivation by carers who, because of poor
understanding, poverty or family problems, are unable to provide the child with the nutrition
and care he or she requires. Successful management of the severely malnourished child
requires that both medical and social problems be recognized and corrected (WHO, 1999).
Assessment of the malnourished child
1. Nutritional status
Assess for the following nutritional status to determine whether a child is malnourished or
not:
a. Weight-for-height (or length)
See Session 7 or WHO/UNICEF publications regarding child growth standards and the
identification of severe acute malnutrition (WHO. WHO child growth standards and the
identification of severe acute malnutrition in infants and children. Geneva: 2009.)
b. Height (or length)-for-age
See Session 7 or WHO/UNICEF publications regarding child growth standards and the
identification of severe acute malnutrition (WHO. WHO child growth standards and the
identification of severe acute malnutrition in infants and children. Geneva: 2009.)
c. Edema
Edema is swelling from excess fluid in the tissues. Edema is usually seen in the feet
and lower legs and arms. In severe cases it may also be seen in the upper limbs and
face.
2. History and physical examination
a. History
Ask for the following information about the child: usual diet as before current
episode of illness, breastfeeding history, food and fluids taken in past few days,
recent sinking of eyes, duration and frequency of vomiting or diarrhea,
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Severe Malnutrition
140
appearance of vomit or diarrheal stools, time when urine was last passed,
contact with people with measles or tuberculosis, any deaths of siblings, birth
weight, milestones reached and immunizations.
b. Physical Examination
Assess for the following data: weight and length or height, edema, enlargement
or tenderness of liver, jaundice, abdominal distention, bowel sounds, abdominal
splash, severe pallor, signs of circulatory collapse, temperature, thirst, eyes,
ears, skin, respiratory rate and type of respiration and appearance of feces.
3. Laboratory tests
Refer the child for the following tests: blood glucose, blood smear by microscopy,
hemoglobin, urinalysis, feces examination, chest x-ray, skin test for tuberculosis,
serum proteins, HIV testing and electrolytes level.
Severe Malnutrition (<6-59 months)
Children 6 59 months of age can be classified under severe malnutrition if

he/she meets the following criteria:
Weight-for-height less than -3 z-scores
Presence of edema in both feet, OR
Mid-upper arm circumference of < 115 mm.
Children < 6 months of age can be classified under severe malnutrition if he/she
meets the following criteria:
Visible wasting AND edema
+ difficulties in breastfeeding
(No MUAC cut-off points for this age group)
Management of infants and young children with severe malnutrition

Complications of Severe Malnutrition
Higher risk of life threatening complications in severely malnourished children:
Hypoglycemia
Hypothermia
Serious infections
Dehydration
Severe electrolyte disturbances
They should be assessed clinically to look for associated complications and be able to
receive treatment accordingly.
Management in Severe Malnutrition Hospital
Admit the child to the hospital if:
Child has severe malnutrition + an infection or other complication
____________________________________________________________________________

Severe Malnutrition
INITIAL IN-PATIENT MANAGEMENT:

Prevention or treatment of hypoglycemia, hypothermia, dehydration and infection
Provision of special therapeutic diet- F-75 (frequent small feeds of low osmolality
and low lactose).
75 kcal/100 ml
0.9 g protein/ 100 ml
Advice mother to continue breastfeeding.
If intake is satisfactory, treatment may be continued at home, with weekly or bi-weekly
follow-up.
Management in Severe Malnutrition Community
The child who is assessed to be malnourished will have community management if:
Appetite is maintained.
There are no complications and the general condition of the child is good.
Age > 6 months.
The following are measures that can be done in the community:
Encourage mother to continue breastfeeding (Advise mother on relactation if
needed).
Advice to continue complementary feeding.
Give Ready-to-use therapeutic food (RUTF).
RUTF is energy-dense vitamin- and mineral-enriched foods equivalent in
formulation to Formula 100 (F100) with 100 kcal/100 ml, 2.9 g protein/100
ml.
It is usually oil-based and has low water activity that is microbiologically
safe.
When eaten uncooked, there is less micronutrient breakdown.
It is available in compressed biscuits or lipid-based spreads.
How to Use RUTF:
As full replacement of normal diet, give 150 220 kcal/kg per day
until child has gained 15 20% of his or her weight
Advice weekly or bi-weekly follow-up.
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141

Severe Malnutrition
142
References
2. WHO. Training course on the management of severe malnutrition. Geneva, World
Health Organization, 2002.
3. WHO. Management of severe malnutrition: a manual for physicians and other senior
health workers. Geneva, World Health Organization, 1999.

1. WHO. WHO child growth standards and the identification of severe acute malnutrition in
infants and children. Geneva, World Health Organization, 2009.
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Severe Malnutrition
143
Notes
____________________________________________________________________________
Session 9: Management of Breast Conditions and Other Breastfeeding Difficulties
144
SESSION 9
MANAGEMENT OF BREAST CONDITIONS AND OTHER
BREASTFEEDING DIFFICULTIES
Objectives
1. Identify causes, symptoms and management of different breast conditions.
2. Explain causes, symptoms and management of other breastfeeding difficulties.
Introduction
Significant consequences of infant feeding problems are malnutrition and its effects on a
childs physical and psychosocial development. In order to prevent these problems, it is
important to identify and manage them at the earliest possible time.
Some of the identified problems for infant feeding are breastfeeding difficulties,
psychological and physical factors affecting the mother and certain conditions of the
baby. Many of this problems are preventable and can be solved using family and
community resources.
Causes, Symptoms and Management of Different Breast Conditions

Different Breast Conditions
There are many reasons why mothers stop breastfeeding or start to mix feed, even if
they decided, antenatally, to breastfeed exclusively. Breast conditions are among these
reasons.
Diagnosis and management of these breast conditions - breast engorgement, blocked
duct, mastitis, sore/fissured nipple, inverted, flat, large and long nipples, and candida
infection are both important to relieve the mother and enable breastfeeding to continue.
1. Breast Engorgement
In breast engorgement, the breasts are swollen and edematous, and the skin
looks shiny and diffusely red. Usually the whole of both breasts are affected,
and they are painful. The woman may have a fever that usually subsides in
24 hours.
The nipples may become stretched tight and flat which makes it difficult for
the baby to attach and remove the milk. The milk does not flow well.
This condition is caused by the failure to remove breast milk, especially in the
first few days after delivery when the milk comes in and fills the breast, and at
____________________________________________________________________________
the same time blood flow to the breasts increases, causing congestion.
The common reasons why milk is not removed adequately are delayed
initiation of breastfeeding, infrequent feeds, poor attachment and ineffective
suckling.
Management of breast engorgement includes the following:
The mother must remove the breast milk. If the baby can attach well
and suckle, then she should breastfeed as frequently as the baby is
willing. If the baby is not able to attach and suckle effectively, she
should express her milk by hand or with a pump a few times until the
breasts are softer, so that the baby can attach better, and then get
him or her to breastfeed frequently.
She can apply warm compresses to the breast or take a warm shower
before expressing, which helps the milk to flow. She can use cold
compresses after feeding or expressing, which helps to reduce the
edema.
Engorgement occurs less often in baby-friendly hospitals which
practice the Ten Steps and which help mothers to start breastfeeding
soon after delivery.
2. Blocked Duct
Blocked duct presents with tenderness and localized lump in one breast, with
redness in the skin over the lump.
It is caused by failure to remove milk from part of the breast, which may be
due to infrequent breastfeeds, poor attachment, tight clothing or trauma to the
breast. Sometimes the duct to one part of the breast is blocked by thickened
milk.
The following are the management for this condition:
Improve removal of milk and correct the underlying cause.
The mother should feed from the affected breast frequently and gently
massage the breast over the lump while her baby is suckling.
Some mothers find it helpful to apply warm compresses and to vary
the position of the baby across her body or under her arm).
Sometimes after gentle massage over the lump, a string of the
thickened milk comes out through the nipple, followed by a stream of
milk, and rapid relief of the blocked duct.
3. Mastitis
In mastitis, there is a hard swelling in the breast, with redness of the overlying
skin and severe pain. Usually only a part of one breast is affected, which is
different from engorgement, when the whole of both breasts are affected. The
woman has fever and feels ill. Mastitis is commonest in the first 23 weeks
after delivery but can occur at any time.
An important cause is long gaps between feeds, for example when the
mother is busy or resumes employment outside the home, or when the baby
starts sleeping through the night. Other causes include poor attachment, with
incomplete removal of milk; unrelieved engorgement; frequent pressure on
one part of the breast from fingers or tight clothing; and trauma.
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145
146
Mastitis is usually caused in the first place by milk staying in the breast, or
milk stasis, which results in non-infective inflammation. Infection may
supervene if the stasis persists, or if the woman also has a nipple fissure that
becomes infected. The condition may then become infective mastitis.
To manage this condition:
Improve the removal of milk and try to correct any specific cause that
is identified.
Advise the mother to rest, to breastfeed the baby frequently and to
avoid leaving long gaps between feeds. If she is employed, she
should take sick leave to rest in bed and feed the baby. She should
not stop breastfeeding.
She may find it helpful to apply warm compresses, to start
breastfeeding the baby with the unaffected breast, to stimulate the
oxytocin reflex and milk flow, and to vary the position of the baby.
She may take analgesics (if available, ibuprofen, which also reduces
the inflammation of the breast; or paracetamol).
If symptoms are severe, if there is an infected nipple fissure or if no improvement

is seen after 24 hours of improved milk removal, the treatment should then
include penicillinase-resistant antibiotics (e.g., flucloxacillin). However antibiotics
will not be effective without improved removal of milk.
4. Breast Abscess
Breast abscess occurs with a painful swelling in the breast, which feels full of
fluid. There may be discoloration of the skin at the point of the swelling.
This is identified to be usually secondary to mastitis that has not been
effectively managed.
To manage this condition, an abscess needs to be drained and treated with
penicillinase-resistant antibiotics. When possible drainage should be either by
catheter through a small incision, or by needle aspiration (which may need to
be repeated). Placement of a catheter or needle should be guided by
ultrasound. A large surgical incision may damage the areola and milk ducts
and interfere with subsequent breastfeeding, and should be avoided.
The mother may continue to feed from the affected breast. However, if
suckling is too painful or if the mother is unwilling, she can be shown how to
express her milk, and advised to let her baby start to feed from the breast
again as soon as the pain is less, usually in 23 days. She can continue to
feed from the other breast. Feeding from an infected breast does not affect
the infant (unless the mother is HIV-positive,
Sometimes milk drains from the incision if lactation continues. This dries up
after a time and is not a reason to stop breastfeeding.
5. Sore or Fissured Nipple
Sore or fissured nipple is characterized by severe nipple pain when the baby
is suckling. There may be a visible fissure across the tip of the nipple or
around the base. The nipple may look squashed from side- to-side at the end
of a feed, with a white pressure line across the tip.
The main cause of sore and fissured nipples is poor attachment. This may be
____________________________________________________________________________
due to the baby pulling the nipple in and out as he or she suckles, and
rubbing the skin against his or her mouth; or it may be due to the strong
pressure on the nipple resulting from incorrect suckling.
The mother should be helped to improve her babys position and attachment.
Often, as soon as the baby is well attached, the pain is less. The baby can
continue breastfeeding normally. There is no need to rest the breast the
nipple will heal quickly when it is no longer being damaged.
6. Inverted, flat, large and long nipples
Nipples naturally occur in a wide variety of shapes that usually do not affect a
mothers ability to breastfeed successfully. However, some nipples look flat,
large or long, and the baby has difficulty attaching to them.
Most flat nipples are protractile if the mother pulls them out with her fingers,
they stretch, in the same way that they have to stretch in the babys mouth. A
baby should have no difficulty suckling from a protractile nipple.
Sometimes an inverted nipple is non-protractile and does not stretch out
when pulled; instead, the tip goes in. This makes it more difficult for the baby
to attach.
Protractility often improves during pregnancy and in the first week or so after
a baby is born. A large or long nipple may make it difficult for a baby to take
enough breast tissue into his or her mouth. Sometimes the base of the nipple
is visible even though the baby has a widely open mouth.
Different nipple shapes are a natural physical feature of the breast. An
inverted nipple is held by tight connective tissue that may slacken after a
baby suckles from it for a time.
The same principles apply for the management of flat, inverted, large or long
nipples as follows:
Antenatal treatment is not helpful. If a pregnant woman is worried
about the shape of her nipples, explain that babies can often suckle
without difficulty from nipples of unusual shapes, and that skilled help
after delivery is the most important thing.
As soon as possible after delivery, the mother should be helped to
position and try to attach her baby. Sometimes it helps if the mother
takes a different position, such as leaning over the baby, so that the
breast and nipple drop towards the babys mouth. The mother should
give the baby plenty of skin-to-skin contact near the breast, and let the
baby try to find his or her own way of taking the breast, which many
do.
If a baby cannot attach in the first week or two, the mother can
express her breast milk and feed it by cup.
The mother should keep putting the baby to the breast in different
positions, and allowing him or her to try. She can express milk into the
babys mouth, and touch the lips to stimulate the rooting reflex and
encourage the baby to open his or her mouth wider.
As a baby grows, the mouth soon becomes larger, and he or she can
attach more easily.
Feeding bottles or dummies, which do not encourage a baby to open
the mouth wide, should be avoided.
For flat or inverted nipples, a mother can use a 20 ml syringe, with the
adaptor end cut off and the plunger put in backwards to stretch out the
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147
148
nipple just before a feed (See Figure 9.1)

Figure 9.1 Preparing and using a syringe for treatment of inverted nipples
7. Candida Infection
Candida infection or thrush can affect the mother ad the baby. In the mother it
is characterized by a sore and itchy nipples and with a shiny red area of skin
on the nipple and areola. This can often follow the use of antibiotics to treat
mastitis, or other infections. Some mothers describe burning or stinging,
which continues after a feed. Sometimes, the pain shoots deep into the
breast. A mother may say that it feels as though needles are being driven into
her breast.
In the baby, there are white spots inside the cheeks or over the tongue, which
look like milk curds, but they cannot be removed easily. Some babies feed
normally, some feed for a short time and then pull away, some refuse to feed
altogether, and some are distressed when they try to attach and feed,
suggesting that their mouth is sore.
This is an infection with the fungus Candida albicans, which often follows the
use of antibiotics in the baby or in the mother to treat mastitis or other
infections.
Treatment is with gentian violet or nystatin. If the mother has symptoms, both
mother and baby should be treated. If only the baby has symptoms, it is not
necessary to treat the mother.
TREATMENT FOR CANDIDA INFECTIONS
____________________________________________________________________________
Gentian Violet paint:

Apply 0.25% solution to babys mouth daily for 5 days, or until 3 days after lesions heal.
Apply 0.5% solution to mothers nipples daily for 5 days.
Nystatin:
Nystatin suspension 100,000 IU/ml; apply 1 ml by dropper to childs mouth 4 times daily
after breastfeeds for 7 days, or as long as the mother is being treated. Nystatin cream
100,000 IU/ml; apply to nipples 4 times daily after breastfeeds. Continue to apply for 7
days after lesions have healed.
Causes, Symptoms and Management of Other Breastfeeding Difficulties

1. Not enough milk
One of the most common reasons for a mother to stop breastfeeding is that she
thinks that she does not have enough milk. Usually, even a mother thinks that
she does not have enough breast milk, her baby is, in fact, getting all that he
needs.
Almost all mothers can produce more than their babies need. Sometimes a baby
does not get enough breast milk. But it is usually because he is not suckling
enough, or not suckling effectively. It is rarely because his mother cannot
produce enough.
The first step in helping mothers with insufficient milk is to confirm if the baby is
receiving enough breast milk or not.
Reliable signs that a baby is note getting enough milk:
For the first six months of life, a baby should gain at least 500g in weight
each month.
One kilogram is not necessary, and not usual.
If a baby does not gain 500g in a month he is not gaining enough weight.
Look at the babys growth chart if available, weigh the baby now, and
arrange to weigh him again in one weeks time.
An exclusively breastfed baby who is getting enough milk usually passes
dilute urine at least 6-8 times in 24 hours.
A baby who is not getting enough breast milk passes urine less than six
times a day (often less than four times a day).
His urine is also concentrated, and may be strong smelling and dark
orange in color.
If a baby is having other drinks, for example water, as well as breast milk,
you cannot be sure he is getting enough milk if he is passing lots of urine.
Possible signs that a baby is not getting enough milk
Once you have decided, using the reliable signs, that a baby is not getting
enough breast milk, it is important to find out why, before you can help the
mother.
____________________________________________________________________________
149
150
Box. 9.1 REASONS WHY A BABY MAY NOT GET ENOUGH BREAST MILK
BREASTFEEDING
FACTORS
MOTHER:
PSYCHOLOGICAL
FACTORS
MOTHER: PHYSICAL
CONDITION
BABYS
CONDITION
Delayed start
Feeding at fixed
times
Infrequent feeds
No night feeds
Short feeds
Poor attachment
Bottles, pacifiers
Other foods
Other fluids (water,
teas)
Lack of confidence
Worry, stress
Dislike of feeding
Rejection of baby
Tiredness
Contraceptive pill,
diuretics
Pregnancy
Severe malnutrition
Alcohol
Smoking
Retained piece of
placenta (rare)
Poor breast
development (very
rare)
Illness
Abnormality
These are COMMON
These are NOT COMMON
The reasons in the first two columns (Breastfeeding factors and Mother:
psychological factors) are common. Psychological factors are often behind the
breastfeeding factors, for example, lack of confidence causes a mother to give
bottle feeds. Look for these common reasons first.
The reasons in the second two columns (Mother: physical condition and Baby's
condition) are not common. So it is not common for a mother to have a physical
difficulty in producing enough breast milk. Think about these uncommon reasons
only if you cannot find one of the common reasons.
Babies who are not getting enough milk:
Use your counselling skills to take a good feeding history.

Assess a breastfeed to check positioning and attachment; to look for bonding
or rejection.
Use your observation skills to look for illness or physical abnormality in the
mother or baby.
What you suggest to the mother as solutions will depend upon the cause of
the insufficient milk.
Always remember to arrange to see the mother again soon. If possible see
the mother and baby daily until the baby is gaining weight and the mother
feels more confident. It may take 3-7 days for the baby to gain weight.
Babies who are getting enough milk but the mother

thinks they are not:
Use your counselling skills to take a good feeding history.

Try to learn what may be causing the mother to doubt her milk supply.
Explore the mothers ideas and feelings about her milk and pressures
____________________________________________________________________________
she may be experiencing from other people regarding breastfeeding.

Assess a breast feed to check positioning and attachment; to look for
bonding or rejection.
Praise the mother about good points about her breastfeeding
technique and good points about her babys development.
Correct mistaken ideas without sounding critical.
Always remember to arrange to see the mother again soon. These mothers
are at risk of introducing other foods and fluids and need a lot of support
until their confidence is built up again.
2. Other Breastfeeding Difficulties

The baby refuses to breastfeed and may cry, arch his/her back, and turn
away when put to the breast. A mother may feel rejected and frustrated, and
be in great distress.
A baby may refuse to breastfeed because of the following:
a. Physical reasons (illness/infection, pain)
b. Baby has difficulty attaching or frustration
c. Baby is upset by a change in environment/ routine
If a cause is identified, it should be treated or removed, if possible.
The mother should consider how she can reduce the time she spends away
from baby, or avoid other changes that may be upsetting.
The mother should be helped to improve her breastfeeding technique.
An infant or child who is ill may want to breastfeed more often than usual.
Local symptoms (blocked nose or oral thrush) may interfere with suckling.
The infant may suckle for a short time only and not get enough milk.
The infant may be too weak to suckle adequately, or may not suckle at all.
During surgery an infant may not receive oral or enteral feeds.
Management:
If an infant or child is ill, he/she should continue to breastfeed as often
as possible while s/he receives other treatment. Breast milk is the
ideal food during illness, especially for infants less than 6 months old,
and will help them recover.
The mother should express her milk to keep up supply if the baby is
too ill to breastfeed. The EBM may be cup fed or stored for later use
Mothers whose milk supplies decrease during their babies illness
should be encouraged to relactate. With support and encouragement,
they should be able to breastfeed exclusively in 1 2 weeks after the
illness.
____________________________________________________________________________
151
152
References
2009.
____________________________________________________________________________
Notes
____________________________________________________________________________
153
Session 10: Policy, Health System and Community Actions
154
SESSION 10
POLICY, HEALTH SYSTEM AND COMMUNITY ACTIONS
Objectives
1. Global Framework
a. Describe existing international policy instruments concerning infant and young child
feeding
2. Executive Order No.51
a. Discuss how EO No. 51 helps protect breastfeeding
b. Summarize the main points of EO No. 51
c. Explain the guidelines in monitoring for violations to EO No. 51
3. R.A. 10028.
a. Discuss how RA 10028 helps protect breastfeeding
b. Summarize the main points of RA 10028
c. Discuss roles of health workers in IYCF peer support and other community actions.
Introduction
There are several policies and laws that serve as guidelines to achieving the goals and
objectives of our health system in terms of Infant and Young Child Feeding, from the
global framework down to republic acts and executive orders.
Policy and Health Systems
1. Global Framework: Global Strategy for IYCF
The Global Strategy for Infant and Young Child Feeding is the overarching
framework for action by governments and all concerned parties to ensure that the
health and other sectors are able to protect, promote and support appropriate
infant and young child feeding practices.
The Global Strategy was endorsed unanimously by WHO member states in 2002
and adopted by UNICEFs Executive Board in the same year.
To implement the Global Strategy, actions at international, national and local
level are needed to:
Strengthen policies and legislation to protect infant and young child
feeding;
Strengthen health system and health services to support optimal infant
and young child feeding;
Strengthen actions to promote and support optimal infant and young
child feeding practices within families and communities
____________________________________________________________________________
Other internationally recognized policy instruments to protect, support and

promote optimal infant and young child feeding:
United Nations Convention on the Rights of the Child (CRC) adopted by
UN member states almost universally in 1989. Article 24 addresses child
health and nutrition.
International Code of Marketing of Breast Milk Substitutes, and
subsequent relevant WHA resolutions adopted by WHO member states
in 1981. Health workers have important responsibilities to comply with the
provisions of the Code.
International Labour Organization (ILO) Maternity Protection Convention
No. 183, 2000 sets out basic requirements for maternity protection at
work (maternity leave, cash benefits during leave, access to medical care,
breastfeeding breaks, employment protection and non-discrimination).
The Philippines is not yet a signatory to the ILO Maternity Protection
Convention.
Elements of a comprehensive infant and young child feeding program
A primary obligation of governments is to formulate, implement, monitor and
evaluate a comprehensive national policy on infant and young child feeding to
ensure better use of resources and coordination of efforts.
____________________________________________________________________________
155
156
Figure 10.1 Elements of comprehensive infant and young feeding program
POLICY
National coordinator and coordinating
body for infant and young child feeding
Health system norms
Code of marketing of breast-milk
substitutes
Worksite laws and regulations
Information, education and
communication
HEALTH SERVICES
Pre-service curriculum reform
Baby-friendly hospital initiate
In-service training
Supportive supervision
COMMUNITY
Community participation
Training and supervision of
counselling network
Community education
Information, education and

communication
Referral and counter referral
Health information system
Monitoring, research and evaluation
2. National Policy: EO 51 (Milk Code)

In 1981, the World Health Assembly (WHA) adopted the International Code of
Marketing of Breast Milk Substitutes, which aims to regulate promotion and sale of
formula milk, and is a minimum requirement to protect breastfeeding.
In the Philippines, the National Code of Marketing of Breast milk Substitutes, Breast
Milk Supplements and Other Products was signed into law on October 20, 1986
under Executive Order No. 51.
E.O. 51, commonly referred to as, "The Milk Code", is a law that ensures safe and
adequate nutrition for infants through the promotion of breastfeeding and the
regulation of promotion, distribution, selling, advertising, product public relations.
The Milk Code covers the following products:
Breast milk substitutes, including infant formula and milk supplements
Foods, beverages, and other milk products (when marketed or represented to
be suitable, with or without modification, for use as partial or total
____________________________________________________________________________
replacement for breast milk)

Bottle-fed complementary foods
Feeding bottles and teats.
In 2006, the Revised Implementing Rules and Regulations (RIRR) of the Milk code
was promulgated to achieve the relevant constitutional mandates, implement
international commitments and provide solutions to problems identified on violations
committed against the law.
The RIRR is not meant to compel women to breastfeed or prohibit or restrict
commercial sales of formula milk. The RIRR of the Milk Code is meant to ensure that
women are provided with accurate and unbiased information to enable them to make
an informed choice.
Main Points of the Milk Code
Box 10.1 SUMMARY OF THE MAIN POINTS OF THE EO NO. 51 MILK CODE
Exclusive breastfeeding is for infants from zero (0) to six (6) months;
There is no substitute nor replacement for breast milk
Appropriate and safe complementary feeding should start from six months onwards
in addition to breastfeeding.
Breastfeeding is still appropriate for young children up to (twenty-four months) two
years of age and beyond;
Other related products such as, but not exclusive to, teats, feeding bottles, and
artificial feeding paraphernalia are prohibited in health facilities.
Government and all concerned stakeholders must continuously accomplish an
information, dissemination campaign/strategy, and do further research on the
advantages of breastfeeding and the hazards of breast milk substitutes or
replacements
Milk companies and their representatives should not form part of any policymaking
body or entity in relation to the advancement of breastfeeding
The latest survey of the Food and Nutrition Research Institute showed a rise in the
exclusive breastfeeding rate in the Philippines. In 2003, the rate was 29.7% but it
rose to 35.9% in 2008 and to 46.7% in 2011. The increase is encouraging but is
still far from the 90-95% target.
One explanation for this situation (as claimed by regulating bodies) is the
widespread violations of the Milk Code despite the revision of its rules and
regulations and improvement of the regulatory function of the inter-agency
committee (IAC) that was tasked to oversee the implementation.
____________________________________________________________________________
157
158
Box 10.2 PROHIBITIONS/VIOLATIONS OF THE EO NO. 51 MILK CODE

Advertising, promotion, and other marketing materials that are not approved by the
IAC.
Giving of samples and supplies of covered products to any member of the general
public, hospitals, health facilities, personnel within the healthcare system, and
members of their families.
Point-of-sale advertising, giving of samples, or any promotion devices to induce
sales directly to consumers at the retail level (ex. special displays, discount coupons,
premiums, rebates, special rates, bonus and tie-in sales, loss-leaders, prizes or
gifts).
Gifts, articles or utensils [that may promote the use of breast milk substitutes or
bottle feeding] given to pregnant women, mother of infants, the general public and all
mothers.
Direct or indirect promotion of covered products to pregnant women or mothers of
infants.
Gifts of any sort with or without company name, logo, or brand name, given by milk
companies, manufacturers, distributors, and representatives of products covered by
the Code, to any member of the general public, hospitals, and other health facilities,
including their personnel and members of their families.
Promotion of infant formula or other products covered by the Milk Code in the
healthcare system.
Undermining of breastfeeding (e.g. outright prescribing of infant formula without
medical or other legitimate reasons)
Display of products covered by the Milk Code or placards and posters concerning
such products in a healthcare facility.
Using of "professional service" representatives, "mother craft nurses", or similar
personnel provided or paid for by manufacturer or distributors of products covered by
the Milk Code in the healthcare system.
Assistance, logistics, or training, financial or material incentives, or gifts of any sort
from milk companies to health workers.
Information that implies or creates a belief that bottle feeding is equivalent or
superior to breastfeeding.
Accepting financial or material incentives or gifts of any sort, from milk companies, by
a health worker.
Providing samples of infant formula or other covered products, or of equipment and
utensils for their preparation or use to health workers.
Giving of samples of infant formula to pregnant women and mothers of infants or
their family members by a health worker.
Health and nutrition claims on labels and in advertisements.
False or misleading information or claims on labels and in advertisements.
Texts, pictures, illustrations, or information that discourage or seemingly undermine
the benefits or superiority of breastfeeding, or that idealize the use of breast milk
substitutes and milk supplements.
____________________________________________________________________________
These are the violations committed by manufacturers and distributors of milk

formula. As a response, in coordination with other agencies involved in the
implementation of Milk Code, the Department of Health (DOH) set forth guidelines
for monitoring compliance to EO No. 51 and AO No. 2006-0012. These guidelines
are embodied in Department Circular 2009-0228: Guidelines for the Monitoring of
Milk Code Activities.
This involved the creation of monitoring teams with representatives of various
government agencies at the national, regional and provincial levels.
A Milk Code Monitor
Being a milk code monitor is not only limited to the monitoring teams;
anyone who is committed to protecting and promoting breastfeeding can
be a Milk Code Monitor.
Individual health facilities and health workers can protect breastfeeding
by being aware of the violations committed against the milk code
commonly through advertisements, promotion and sponsorship of infant
formula or breast milk substitute by manufacturers and distributors. This
responsiveness is an important social responsibility.
For alleged violation against milk code, the report should be supported
by these items:
Date and place where the violation was found or seen
Specific location (health facility, store, TV ad, radio/TV channel)
For printed matter, get a sample or picture of the violation
For radio/TV ad or programs, clearly specify the airing time and
TV channel or radio frequency
For website-based violations, provide the web link
For violative (ex. mislabeled or misbranded) products, a sample
shall be purchased, and the receipt obtained and submitted as
part of the evidence
Reporting forms (See Appendix 3 MONITORING REPORT FORM E.O. 51
(MILK CODE) will be used by National and Regional Monitoring teams to
report to the respective Field Regulatory Operations Offices for proper action.
This reporting form is available in Food and Drug Administration (FDA) and
Department of Health (DOH) Regional Offices, and in the DOH and FDA
websites.
Reporting of alleged violations to the Milk Code can be done thru written
reports, via telephone hotlines and by means of the internet.
The report should be supported by all the items mentioned earlier for it
to be valid.
After due process, violators of the Milk Code are going to be given the
necessary sanctions and penalties as mandated by the law. These
include:
Imprisonment of two months to one year
A fine of not less than one thousand pesos and not more than
____________________________________________________________________________
159
160
thirty thousand pesos

Suspension or revocation of license
3. National Policy: Republic Act 10028

Working women should be provided with safe and healthful working conditions
without hampering their maternal functions.
RA 10028 or Expanded Breastfeeding Promotion Act of 2009 is a law designed to
promote and encourage breastfeeding and provide the specific measures that would
present opportunities for mothers to continue expressing their milk and/or
breastfeeding their infant or young child.
Box 10.3 SUMMARY OF THE MAIN POINTS OF RA 10028 BREASTFEEDING
PROMOTION ACT OF 2009
Breastfeeding in the workplace and public places
This applies to all establishments whether operating for profit or not which employ in
any workplace.
Every workplace shall develop a clear set of guidelines that protects, promotes and
supports breastfeeding program.
Lactation stations shall be accessible to the breastfeeding women. It shall be

adequately provided with the necessary equipment and facilities and other items.
The lactation station shall be clean, well ventilated, comfortable and free from
contaminants and hazardous substances, and shall ensure privacy for the women to
express their milk and/or in appropriate cases, breastfeed their child.
The workplace shall be in compliance with the milk code.
Duration and frequency of breaks may be agreed upon by employees and employers
with the minimum being 40 minutes. Usually, there could be2-3 breast milk
expressions lasting to l5-30 minutes each within a workday.
Employers shall ensure that staff and employees shall have access to breastfeeding
information such as this law.
Any health and non-health facility may apply with their respective LGUs for a
'working mother-baby friendly' certification.
Milk Storage and Milk Banking in Health Institutions
All health institutions adopting rooming-in and breastfeeding shall provide "milk
storage facilities".
Health institutions that are encouraged to put up milk banks include, but not limited
to, Medical Centers and Regional Hospitals. A human milk bank should only be used
as a temporary solution when the mother and baby are separated.
The importance of breastfeeding should at all opportunities be emphasized to all

mothers through counselling.
Human milk banks should be registered, licensed and monitored by the Department
of Health (Bureau of Health Facilities and Services).
____________________________________________________________________________
Donation of human milk must be made on a voluntary basis.
Pasteurized human milk should be dispensed only with a prescription from a

physician.
Breastfeeding Integration in the Curriculum
The DOH, DepEd, CHED, TESDA, PRC, academe, academic organizations,

professional and socio-civic organizations have their roles to play and responsibilities
to meet in integrating breastfeeding advocacy in the curriculum.
Continuing Education, Re-education and Training of Health Workers and Health

Institutions
The Department of Health with the assistance of other government agencies,

professional and non-governmental organizations shall conduct continuing
information, education, re-education and training programs for physicians, nurses,
midwives, nutritionist-dietitians, community health workers and traditional birth
attendants (TBAs) and other health and nutrition workers and allied professionals on
current and updated lactation management.
Public Education and Awareness program on breastfeeding promotion
The month of August in each and every year throughout the Philippines shall be
known as "Breastfeeding Awareness Month".
A comprehensive national public education and awareness program shall be

undertaken.
4. IYCF peer support and other community actions

Involvement of the health sector is necessary for community based approaches
to succeed. Health workers supporting roles include:
Helping with the training of lay or peer counselors
Providing feedback to peer counselors when they refer infants with
feeding difficulties
Initiating and participating in breastfeeding support group meetings to
provide information and discuss appropriate feeding practices
Encouraging existing womens groups to include support for optimal IYCF
in their activities
Participating in other community activities (health fairs, community
meetings, radio programs) where infant feeding can be promoted
Protecting, supporting and promoting appropriate infant feeding practices
whenever they are in contact with mothers, caregivers or families.
____________________________________________________________________________
161
162
Appropriate actions in the community that can be carried out in partnership with
the health sector include:
Behavior change communication
Training and support of community health workers
Training and support of lay peer counselors
Fostering breastfeeding support groups
Roles and responsibilities - IYCF community support group
All IYCF peer support activities have key players that sustain the implementation
of such programs. In knowing their roles and responsibilities, we will be able to
know their importance and what to expect from them.
Roles and responsibilities of IYCF community support group:
Identifies target mothers and children
Conducts home visits
Counsels mothers or caregivers
Records and reports activities between the counselors and the
mother
Refers mothers needing clinical management or treatment
Attends regular meetings
____________________________________________________________________________
References
Contents of this session are adapted from this module:
2009.
1. About Executive Order No. 51, Retrieved October 10, 2012, from
www.milkcodephilippines.org
2. FDA launches crackdown vs companies violating Milk Code, Philippine Star,
September 3, 2012, page 18, Retrieved October 10, 2012, from
http://www.doh.gov.ph/sites/default/files/090312-0007.pdf
3. Administrative Order 2006-0012: Revised Implementing Rules and Regulations
of Executive Order No. 51, Otherwise Known as the Milk Code, Relevant
International Agreements, Penalizing Violations Thereof, and for other Purposes,
Retrieved October 10, 2012, from
http://www.milkcodephilippines.org/milkcodereport/files/12852812375027fcb1def
08.pdf.
4. Department Circular 2009-0228: Guidelines for the Monitoring of Milk Code
Activities, Retrieved October 10, 2012 from
http://www.milkcodephilippines.org/milkcodereport/files/3663856975027ffdbc4c8
c.pdf
5. Department of Health. The implementing rules and regulation of Republic Act No.
10028. Retrieved October 25, 2012 from
http://www.nnc.gov.ph/index.php?option=com_docman&task=doc_download&gid
=230&Itemid=207.
6. Department of Health/National Nutrition Center. Guide on mobilizing community
support for Infant and Young Child Feeding (IYCF) Program; 2012.
7. Malacaan Palace. Executive Order No. 51: Adopting a National Code of
Marketing of Breast - Milk Substitutes, Breast milk Supplements and Related
Products, Penalizing Violations Thereof, and for Other Purposes. Manila: 1986.
8. RP-Congress of the Philippines (Republic of the Philippines-Congress of the
Philippines). Republic Act No. 10028: Expanded Breastfeeding Promotion Act of
2009. Manila: 2010.
9. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding: Geneva:
World Health Organization; 2003.
____________________________________________________________________________
163
164
Notes
____________________________________________________________________________
Appendices
Appendices
Appendix 1: Breastfeeding and Mothers Medication
Appendix 2: Micronutrient Supplementation Package for 0-11 Month Old Infants and 12
to 59 Month Old Infants
Appendix 3: Monitoring Report Form EO 51 (Milk Code)
____________________________________________________________________________
165
Appendices
166
Appendix 1: Breastfeeding and Mothers Medication
Medication
sedating psychotherapeutic drugs, antiepileptic drugs and opioids and their
combinations
Consideration
may cause side effects such as
drowsiness and respiratory depression
and are better avoided if a safer
alternative is available.
radioactive iodine-131
is better avoided given that safer

alternatives are available a mother can
resume breastfeeding about two months
after receiving this substance
excessive use of topical iodine or

iodophors (e.g., povidone-iodine),
especially on open wounds or mucous
membranes
can result in thyroid suppression or

electrolyte abnormalities in the breastfed
infant and should be avoided
cytotoxic chemotherapy
stops breastfeeding during therapy
____________________________________________________________________________
Appendices
167
Appendix 2: Micronutrient Supplementation Package for 0-11 Month Old Infants and
12 to 59 Month Old Infants
Table 1. Micronutrient Supplementation Package for 0-11 Month Old Infants
Target
Micronutrient
Preparation
Dosage/Frequency/Duration
Clients
A. Routine Supplementation
6-11 monthIron
Drops, 15 mg
Give 0.6 ml once a day for 3
old
Once the
elemental
months
micronutrient
iron/0.6 ml
Give 60 sachets to consume
powder (MNP) is MNP
in 6 months
locally available,
Single served
(This maybe provided during
iron requirement
sachet 15
the growth monitoring visits of
will be in the form micronutrient
children at the health center)
of MNP instead
formulation
of iron drops.
Vitamin A
B. Therapeutic Supplementation
Low Birth
Iron
Weight
Infants (<2.5
kg)
6-11 month
Continue with the
old clinically
iron supplement
diagnosed
but infants need
with iron
to be assessed
deficiency
for further
anemia
management
Capsule, 100,00
IU
Give 1 capsule once (single

dose)
Drops, 15 mg
elemental iron/
0.6ml
Give 0.3ml once a day

starting at 2 months up to 6
months
Drops, 15 mg
elemental iron/
0.6 ml
Give 3-6 mg/kg/d elemental

iron in 3 divided doses a day
for 3 months
Note: After completing 3
months therapeutic
supplementation, infants
should continue preventive
supplementation regimen.
OR
Give approximately 0.6 ml
two to three times a day for 3
months
6-11 months
clinically
diagnosed
with measles
(based on
IMCI protocol)
6-11 months
with
persistent
diarrhea
Vitamin A
Capsule,
100,000 IU
Give 1 capsule upon

diagnosis regardless when
the last dose of VAC was
given. Give another capsule
after 24 hours.
Vitamin A
Capsule,
100,000IU
6-11 month-
Vitamin A
Capsule,
Give 1 capsule upon

diagnosis except when the
child was given VAC less
than 4 weeks before
diagnosis.
Give capsule upon diagnosis
____________________________________________________________________________
Appendices
168
old with
severe
pneumonia
6-11 monthold severely
underweight
100,000 IU
except when child was given

VAC less than 4 weeks
before diagnosis
Give capsule upon diagnosis
except when child was given
VAC less than 4 weeks
before diagnosis
Give immediately 1 capsule
upon diagnosis, 1 capsule
the next day, and another
capsule 2 weeks after
Vitamin A
Capsule,
100,000 IU
6-11 monthold clinically

diagnosed
with
xerophthalmia
<6 month-old
with diarrhea
Vitamin A
Capsule,
100,000 IU
Zinc
Drops 27.5
mg/ml
(equivalent to
the elemental
zinc) 15 ml
drops
Tablet, 20 mg
elemental zinc
Give 1 ml once a day for not

less than 10 days;
OR
Give tablet once a day for
not less than 10 days
6-11 monthold with

diarrhea
Zinc
Give 20 mg once a day for

not less than 10 days;
OR
Give 1 tablet once a day for
12-59 monthold with

diarrhea
Zinc
Syrup, 55mg/ml
(equivalent to
20mg elemental
zinc) 60 ml
syrup
Tablet, 20 mg
elemental zinc
Syrup, 55mg/ml
(equivalent to
20mg elemental
zinc) 60 ml
syrup
Tablet, 20 mg
elemental zinc
Give 1 teaspoon once a day

for not less than 10 days
OR
Give 1 tablet once a day for
____________________________________________________________________________
Appendices
169
Appendix 3: Monitoring Report Form E.O. 51 (Milk Code)

Mon. No. ______
Date/Time: ________________________________________
Place/Location: _____________________________________
1) Type of Violation: _________________________________
2) Advertising Materials
Type of material: (get sample or picture)
_____ Booklet
_____ Leaflet
_____Advertisement
_____ Video Cassette
_____ Mail
_____ Audio
_____ Compact disc
_____ Display
_____ Web page
_____ Text Messages
_____ Visual
_____ Poster
_____ Bill Board
_____ Telephone calls_____ Electronic Media
_____ Theater
_____ Audio-visual _____ Others (specify)
3) Where was the material found/observed?
_____ General Hospital
_____ Clinic
_____ Pharmacy
_____ By the road side
_____ Local TV
_____ Cinema
_____ Scientific Journal
_____ Maternity
_____ Doctors office
_____ Supermarket
_____ Magazine
_____ Cable TV
_____ Newspaper
_____ Internet
_____ Pediatric Hospital

_____ Health Centre
_____ Shop
_____ Radio
_____ Junk Mail
_____ Video
_____ Others (write here)
4) Has any company given scholarship/fellowships/continuing education and other related

researchers or other services? _____ Yes _____ No
5) Where was the assistance for scholarship/fellowships/continuing education and other
related researches conducted?
_____ National events
_____ Regional events
_____ Local government events
_____ With certificate approval
_____ Without certificate approval
_____ Materials/activities observed

_____ Others (specify)
6) Who was the recipient of the donation?

_____ Orphange
_____ TV networks
_____ Government organizations
_____ Non-government organizations
_____ Public Officials
_____ Others (speficy)
____________________________________________________________________________
Appendices
170
7) What is the type of product donated?

_____ Infant formula
_____ Follow-up formula
_____ Special formula
_____ Cereal
_____ Fruit/vegetable/meat puree
_____ Sweetened condensed milk
_____ Bottle
_____ Teats
_____ Others (speficy)
8) What is the purpose of the donation? ________________________________________

9) Observations made in the hospital/health centers/ health facilities?
_____ Presence of medical representatives/visits/decking
_____ Health personnel receiving samples of milk products or gifts
_____ Distribution of companies detailing materials
_____ Product display in the hospital pharmacy
_____ Contact with mothers
_____ Speakers from milk companies during mothers class
conference/meetings
Other materials/activities observed
Described/remarks
________________________________________
________________________________________
________________________________________
________________________________________
10) Has any company sent promoters to advise consumers on infant feeding or on particular
products?
_____ Yes
_____ No
If yes, give details:
___________________________________
11) Is any of the following promotion techniques used to promote sales of infant
foods/bottles/teats in this shop? If yes, give details in the box below.
_____ Discounts to customers
_____ Special Displays
_____ Coupons
_____ Samples
_____ Gifts with purchase
_____ Posters on display
_____ Product Information

_____ Special Sales
_____ Tie-in-sales (buy one, get two,etc.)
_____ Product Launch
_____ Shelf-talkers
_____ Other
12) Does the labels of feeding bottles and teats

a. Carry a photo, drawing or other representation of an
infant or young child, or a parent feeding a baby? _____ Yes _____ No
(If yes, please attach photo of offending bottle)
b. Contain any other drawing, image, or text which
Idealizes the use of the product?
_____ Yes _____ No
If yes, describe:
______________________________________________________________
c. Promote breast milk subsitutes?
_____ Yes _____ No
____________________________________________________________________________
Appendices
171
If yes, describe:
______________________________________________________________
d. Have text which suggest similarity
of the product to the breast or nipple?
_____ Yes _____ No
If yes, describe:
______________________________________________________________
13) Does the label indicate the recommended age of user/s?_____ Yes
_____ No
If YES, what is it? ______________ Months OR, (other wording)

______________________
14) Labels of follow-on formula/infant formula
Does the label?
a. Suggest that a bottle be used for the product?
b. Carry a photo, drawing or other representation
of an infant?
(If YES, please attach photo of offending lable)
c. resemble the companys infant formula labels?
d. Indicate or suggest in any way that this product
could be for babies under six months?
_____ Yes
_____ No
_____ Yes
_____ No
_____ Yes
_____ No
_____ Yes
_____ No
Details and comments:

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Remarks/Findings/Proposed Action/Action Taken:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Monitored by:
_____________________________________
(Signature over Printed Name)
_____________________________________
Designation
____________________________________________________________________________
172
Glossary of Terms
Glossary of Terms
AIDS: Acquired immune deficiency syndrome, which means that the HIV-positive person
has progressed to active disease.
Amenorrhea: Absence of menstruation.
Anemia: Lack of red cells or lack of haemoglobin in the blood.
Antibodies: Proteins in the blood and in breast milk which fight infection.
Artificial feeding: Feeding an infant on a breast-milk substitute.
Artificial feeds: Any kind of milk or other liquid given instead of breastfeeding.
Artificially fed: Receiving artificial feeds only, and no breast milk.
Asthma: Wheezing illness.
Baby-friendly Hospital Initiative (BFHI): An approach to transforming maternity practices
as recommended in the joint WHO/UNICEF statement on Protecting, promoting and
supporting breastfeeding: the special role of maternity services (1989).
Bonding: Mother and baby developing a close loving relationship.
Bottle-feeding: Feeding an infant from a bottle, whatever is in the bottle, including
expressed
breast milk, water, formula, etc.
Breastfeeding support: A group of mothers who help each other to breastfeed.
Breast-milk substitute: Any food being marketed or otherwise represented as a partial or
total replacement for breast milk, whether or not it is suitable for that purpose.
Calories: Kilo calories or Calories measure the energy available in food.
Cessation of breastfeeding: Completely stopping breastfeeding, including suckling.
Closed questions: Questions which can be answered with `yes' or `no'.
Colostrum: The special breast milk that women produce in the first few days after delivery;
it is yellowish or clear in colour.
Confidence: Believing in yourself and your ability to do things.
Contaminated: Containing harmful bacteria or other harmful substances.
Commercial infant formula: A breast-milk substitute formulated industrially in accordance
with applicable Codex Alimentarius standards to satisfy the nutritional requirements of
infants during the first months of life up to the introduction of complementary foods.
Complementary feeding: The child receives both breast milk or a breast-milk substitute
and solid (or semi-solid) food.
Complementary food: Any food, whether manufactured or locally prepared, used as a
complement to breast milk or to a breast-milk substitute.
Counselling: A way of working with people so that you understand their feelings and help
them to develop confidence and decide what to do.
Cup-feeding: Feeding from an open cup without a lid, whatever is in the cup.
Deficiency: Shortage of a nutrient that the body needs.
____________________________________________________________________________
Glossary of Terms
173
Dehydration: Lack of water in the body.

Demand feeding (Feeding on demand): Feeding a baby whenever he shows that he is
ready, both day and night. This is also called `unrestricted' or `baby-led' feeding.
Distraction (during feeding): A baby's attention easily taken from the breast by
something else, such as a noise.
Early contact: A mother holding her baby during the first hour or two after delivery.
Exclusive breastfeeding: An infant receives only breast milk and no other liquids or
solids, not even water, with the exception of drops or syrups consisting of vitamins, mineral
supplements or medicines.
Expressed breast milk (EBM): Milk that has been removed from the breasts manually or
by using a pump.
Express: To squeeze or press out.
Family foods: Foods that are part of the family meals.
Fortified foods: These are foods that have certain nutrients added to improve their
nutritional quality.
Growth factors: Substances in breast milk which promote growth and development of the
intestine, and which probably help the intestine to recover after an attack of diarrhea.
HIV: Human immunodeficiency virus, which causes AIDS (acquired immune deficiency
syndrome).
HIV-infected: Refers to a person infected with HIV, but who may not know that he/she is
infected.
HIV-negative: Refers to people who have taken a test with a negative result and who know
their result.
HIV-positive: Refers to persons who have taken an HIV test, whose results have been
confirmed and who know and/or their parents know that they tested positive.
HIV-status unknown: Refers to people who have not taken an HIV test or who do not
know the result of their test.
HIV testing and counselling: Testing for HIV status, preceded and followed by
counselling. Testing should be voluntary and confidential, with fully informed consent. The
expression means the same as the terms: counselling and voluntary testing, voluntary
counselling and testing, and voluntary and confidential counselling and testing. Counselling
is a process, not a one-off event: for the HIV-positive client it should include life planning,
and, if the client is pregnant or has recently given birth, it should include infant-feeding
considerations.
Hormones: Chemical messengers in the body.
Infant: A child from birth up to 11 months.
Infant feeding counselling: Counselling on breastfeeding, on complementary feeding,
and, for HIV-positive women, on HIV and infant feeding.
Immune system: Those parts of the body and blood, including lymph glands and white
blood cells, which fight infection.
Immunity: A defense system that the body has to fight diseases.
____________________________________________________________________________
174
Glossary of Terms
Judging words: Words which suggest that something is right or wrong, good or bad.
Lactation: The process of producing breast milk.
Lactation Amenorrhoea Method (LAM): Using the period of amenorrhoea after childbirth
as a family planning method.
Low-birth-weight (LBW): Weighing less than 2.5 kg at birth.
Micronutrients: Essential nutrients required by the body in small quantities (like vitamins
and some minerals).
Micronutrient supplements: Preparations of vitamins and minerals.
Milk expression: Removing milk from the breasts manually or by using a pump.
Mixed feeding: Feeding both breast milk and other foods or liquids.
Non-verbal communication: Showing your attitude through your posture and expression.
Nutrients: Substances the body needs that come from the diet. These are carbohydrates,
proteins, fats, minerals and vitamins.
Nutritional needs: The amounts of nutrients needed by the body for normal function,
growth and health.
Mother-to-child transmission: Transmission of HIV to a child from an HIV-infected
woman during pregnancy, delivery or breastfeeding.
Mother-support group: A community-based group of women providing support for optimal
breastfeeding and complementary feeding.
Open questions: Questions which can only be answered by giving information, and not
with just a `yes' or a `no'.
Oxytocin: The hormone which makes the milk flow from the breast.
Pacifier: Artificial nipple made of plastic for a baby to suck, a dummy.
Paladai: A paladai is a small bowl with a long pointed tip traditionally used for feeding LBW
infants in some cultures.
Partially breastfed: Breastfed and given some artificial feeds.
Pneumonia: Infection of the lungs.
Porridge: Is made by cooking cereal flour with water until it is smooth and soft. Grated
cassava or other root, or grated starchy fruit can also be used to make porridge.
Postnatal check: Routine visit to a health facility after a baby is born.
Premature, preterm: Born before 37 weeks gestation.
Protein: Nutrient necessary for growth and repair of the body tissues.
Psychological: Mental and emotional.
Puree: Food that has been made smooth by passing through a sieve or mashing with a
fork, pestle or other utensil.
Replacement feeding: The process of feeding a child who is not receiving any breast milk
with a diet that provides all the nutrients the child needs until the child is fully fed on family
foods. During the first six months this should be with a suitable breast-milk substitute. After
six months it should be with a suitable breast-milk substitute, as well as complementary
____________________________________________________________________________
Glossary of Terms
175
foods made from appropriately prepared and nutrient-enriched family foods.

Responsive feeding: Feeding infants directly and assisting older children when they feed
themselves, being sensitive to their hunger and satiety cues.
Skin-to-skin contact: A mother holding her naked baby against her own skin.
Sucking: Using negative pressure to take something into the mouth.
Sucking reflex: The baby automatically sucks something that touches his palate.
Suckling: The action by which a baby removes milk from the breast.
Supplements: Drinks or artificial feeds given in addition to breast milk
Support: Help.
Sustaining: Continuing to breastfeed up to 2 years or beyond; helping breastfeeding
mothers to continue to breastfeed.
Sympathize: Show that you are sorry for a person, from your point of view.
`Teat': Stretched out breast tissue from which a baby suckles.
Warm compress: Cloths soaked in warm water to put on the breast.
Young child: A child from 12 months up to 3 years of age (36 months).
____________________________________________________________________________

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Participant Handbook

Maternal and Young Child Nutrition for

3-Day Training Schedule

Session 1: Introductions, Expectations, Objectives

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Session 3: Importance of Infant and Young Child Feeding and

Session 4: The Physiological Basis of Breastfeeding

Session 5: Complementary Feeding

Session 6: Management and Support of Infant Feeding in Maternity

Session 7: Continuing Support for Infant and Young Child Feeding

Session 8: Appropriate Feeding for Exceptionally Difficult Circumstances

Session 9: Management of Breast Conditions and Other Breastfeeding

Session 10: Policy, Health System, Community Actions (With Emphasis

Session 6: 120 minutes

8D: Infants of HIV-positive mothers 75 minutes

8F: Severe Malnutrition - 15 minutes

Session 7 contd: 30 minutes

Session 5: 105 minutes

Session 8: Appropriate feeding in

Session 10 contd: 15 minutes

8A: Low Birth Weight- 60 minutes

Session 11: 60 minutes

Session 1: Introductions, expectations and objectives

Specific Objectives of Training of Peer Counselors and Community Volunteers

Session 1: Introductions, expectations and objectives

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Recommended maternal nutrition during pregnancy and lactation

Practicing Good Nutrition

No special food is required to produce breast milk.

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Effects of mothers illness, intake of medications and drugs to breastfeeding

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Selected psychiatric drugs and anticonvulsants (see

Monitor baby for

Use alternative drug.

Chloramphenicol, tetracyclines, metronidazole, quinolone

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

(may inhibit lactation)

Family planning for a breastfeeding woman

It could prevent as many as one in every three maternal deaths, allowing to

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Recommended Time Spacing for Children

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Other family planning methods

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

Session 2: Mothers Health and Nutrition During Pregnancy and Lactation

12. UNICEF/World Health organization. Breastfeeding and Maternal Medication:

Session 3: The importance of IYCF and recommended practices

The Global Strategy for IYCF

Session 3: The importance of IYCF and recommended practices

WHO and UNICEFs recommendations for optimal infant feeding are:

Session 3: The importance of IYCF and recommended practices

Session 3: The importance of IYCF and recommended practices

Session 3: The importance of IYCF and recommended practices