Care of Low Birth Weight Babies through Kangaroo Mother Care
Learner’s Handbook July 2015
Government of Nepal Ministry of Health and Population National Health Training Center
Care of Low Birth Weight Babies through Kangaroo Mother Care
Learner’s Handbook July 2015
Government of Nepal Ministry of Health and Population National Health Training Center
TABLE OF CONTENT
Acknowledgement
Abbreviations
Introduction 1
Course Syllabus 3
Training Schedule 5
Knowledge Assessment Pre-course and Post-course Questionnaire 7
Chapter one: Identification of Low Birth Weight Babies and its Complications 15
Chapter two: Feeding of Low Birth Weight Babies 19
Chapter three: Danger Sings and Common Problems of LBW Babies with their 31 Management
Chapter four: Hypothermia in newborn and its management 35
Chapter five: Kangaroo Mother Care 39
Chapter six: Recording and Reporting 55
References 57
Annexes 59
Annex I KMC Register 61
Annex II Case Scenario 65
Annex III Course Evaluation 67
Annex IV Participants Registration Form 69
ABBREVIATIONS
GV Gentian Violet
IUGR Intra Uterine Growth Retardation
KMC Kangaroo Mother Care
LBW Low Birth Weight
LDHF Low Dose High Frequency
OSCE Objective Structured Clinical Examination
SGA Small for Gestational Age
INTRODUCTION
Low birth weight (LBW) as defined by the World Health Organization is weight at birth less than 2,500 grams. LBW can be a consequence of preterm birth or due to small size for gestational age or both. It is estimated that more than one million babies die on the day they are born with the main causes of death being prematurity/LBW, birth asphyxia and neonatal infection.
Infant mortality rates can be substantially reduced by improving the quality of care for LBW infants.
Kangaroo Mother Care (KMC) is a low cost, high impact evidence based intervention and standardized care for LBW infants. A Cochrane review from 2014 suggests that continuous KMC leads to a reduction in mortality, reduces nosocomial infection/sepsis, severe illness, and lower respiratory tract disease, and increase in weight gain in the newborn.
This training package is focused on care of LBW babies through Low Dose and High Frequency (LDHF) approach.
This LDHF training package is driven by findings from a recent review of the evidence of effective elements of in- service training programs which suggests that learning outcomes and retention of knowledge and skills are superior when training interventions are repetitive, when simulations are used and when training is realized in settings similar to the workplace.
The training package comprises of a Facilitator‟s Notebook, Learner‟s Handbook and Information Education and Communication materials. The package provides information about the needs and essential health care of LBW babies (i.e. preterm and small for gestational age) from birth up to the time of discharge from KMC. The essential care of LBW babies starts from the health facility and continues to the community and at home.
The Learners Handbook uses a competency based approach and is designed to teach the health workers regarding care of LBW babies. They are used for in-service training of health workers who already have the basic knowledge and skills in maternal and newborn care. It contains all the technical contents, checklists, case scenarios and the schedule for two days training.
The Facilitator‟s Notebook comprises of technical content and course outline, including knowledge assessment questionnaire with answer key, skills assessment checklists and case scenarios.
There are five checklists with which the facilitator and learner would use during the course of training. A facilitator can use the checklists in the following ways:
To assess competency on key skills before training. To monitor learners‟ progress during training. To assess skills at the end of the training. To assess and coach skill retention later as part of LDHF training.
This training course is designed to improve capacity of health workers for improving the quality of services provided to stable LBW babies in settings with scarce resources. The package describes about identification of LBW babies, danger signs and common problems of LBWs, hypothermia, KMC as a method for care, feeding of LBW babies and recording and reporting of KMC services.
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Contents of this training package are incorporated in SBA national training package.
Humanistic: This training uses humanistic training approach which reduces learner stress and protects the safety and dignity of the learners and clients involved in the learning process. It involves practicing and mastering clinical services in simulation before working with clients to reduce the risk of client harm or discomfort and increasing learner confidence by having learners practice in a safe environment.
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COURSE SYLLABUS
COURSE DESCRIPTION This is 2-day training to help health workers to gain knowledge, skills and attitude on caring LBW babies at health facilities.
FACILITATOR SELECTION CRITERIA Doctor and Staff Nurse who have completed Clinical Training Skills course and attended training related to care of LBW babies through KMC.
LEARNER SELECTION CRITERIA Health professionals (doctors and nurses) working and managing LBW babies.
TRAINING SITE Accredited new born care training/skilled birth attendant training site by the National Health Training Center.
COURSE GOAL The purpose of this training is to enable dedicated health workers to acquire the knowledge, skills, and professionalism needed to care LBW babies through KMC at health facilities and communities.
LEARNING OBJECTIVES Chapter One: Identification of LBW babies and its complications
1. Define LBW babies and describe its types. 2. Describe the global and country situation of LBW babies. 3. Describe the risk factors of LBW babies. 4. Describe the complications of LBW babies.
Chapter Two: Feeding of LBW babies
1. Describe the importance of optimal feeding for LBW babies and challenges of feeding LBW babies. 2. Describe how to decide the initial feeding method. 3. Describe the benefits of breast feeding for LBW babies and breast feeding situation in Nepal. 4. Describe signs of correct positioning, good attachment and good suckling during breast feeding. 5. Describe the benefits of cup feeding. 6. Calculate the amount of milk to be fed by cup feeding for LBW babies. 7. Demonstrate how to feed babies (breast feeding and expressed breast milk and cup feeding). 8. Describe the problems in breast feeding and its management.
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Chapter Three: Danger signs and common problems of LBW babies with their management
1. Describe danger signs of LBW babies. 2. Identify and manage common problems of LBW babies in the health facility.
Chapter Four –Hypothermia in newborn and its management
1. Describe hypothermia and mechanism of heat loss among newborns. 2. Describe ways to prevent hypothermia among newborns. 3. Describe about management of hypothermia among newborns.
Chapter Five-Kangaroo Mother Care
1. Describe KMC. 2. Describe about components and prerequisites of KMC. 3. Describe eligibility criteria for KMC. 4. Describe the importance of counseling on KMC. 5. Perform counseling on KMC. 6. Excel skills on the steps of KMC. 7. Describe the discharge criteria of babies from KMC unit.
Chapter Six: Recording and Reporting
1. Fill KMC register correctly 2. Calculate the indicators of data summary sheet.
CERTIFICATION Health worker after receiving two days training on “Care of Low Birth Weight Babies through Kangaroo Mother Care” should maintain the log book for recording the information on KMC service provided. National Health Training Center will provide certificate to the service provider who have completed five cases and maintained in their log book.
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TRAINING SCHEDULE
DAY 1 DAY 2 AM AM
Registration Review of Previous Day
Introduction Chapter Three: Danger signs and common problems of LBW babies with their Objectives and introduction of the course management.
Knowledge Assessment Chapter Four: Hypothermia in newborn and its management OSCE KMC counseling, Chapter Five: KMC demonstration and KMC wraps and procedure, practice (KMC counseling, use of traditional Breast feeding, and Care Plus wrap) Express breast milk and cup feeding Chapter Six: Recording and Reporting Tea break
Chapter One: Identification of LBW babies and its complications LUNCH LUNCH PM PM
Review of knowledge/skill assessment and Knowledge assessment discussion OSCE Chapter Two: Feeding of LBW babies KMC counseling, KMC wraps and procedure, Demonstration and practice (Breast Feeding Breast feeding, and Expressed Breast Milk and Cup Express breast milk and cup feeding Feeding) Review of knowledge/skill assessment and discussion Summarization and wrap up Course evaluation
Closing Reading assignment: Chapter 3,4,5 and 6
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KNOWLEDGE ASSESSMENT : PRE-COURSE AND POST-COURSE QUESTIONNAIRE
Facilitator’s note:
Pretest questionnaires scores and results should be evaluated as early as possible so that the content and teaching learning can be adapted as per their results and decide the requirements of their learning needs. Any questions that are found to be difficult and invalid should be revised or deleted. After the post test result, questionnaire should be reviewed and adapted as per the learner‟s feedback.
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Knowledge Assessment: Pre and Post Course Questionnaire
Instructions for the participants Time: 30 minutes Tick the letter of the single best answer to each question.
Tick the letter of the single best answer 1. Baby Sharada weighs 2000 grams at birth. Baby Sharada is a. Normal weight for a term newborn b. Low birth weight c. Very low birth weight d. Above normal weight for the female baby
2. What is baby Sharada‟s chances of survival? a. About the same as other newborns in her community b. Lower than the 2500 grams newborn c. Better than average female newborn d. Lower than the very low birth weight babies
3. According to Nepal Demographic Health Survey 2011, Neonatal mortality is a. 46 per 1000 live births b. 54 per 1000 live births c. 33 per 1000 live births d. 27 per 1000 live births
4. Prevalence of LBW babies in Nepal according to NDHS 2011 is a. 16 percent b. 12 percent c. 9 percent d. 4 percent
5. Preterm babies are those newborns a. Born at 38 weeks of gestation b. Born before 37 weeks of gestation c. Born at 40 weeks with 2500 grams d. Born after 37 weeks with 2500 grams
6. Preterm baby can be identified by a. May be floppy with extended arms b. Breast tissue very few or absent c. Sole creases absent or in anterior part d. All of the above Learners’ Handbook 8
7. Which of the following is a danger sign for a 2 days old newborn weighing 2000 grams? a. Axillary temperature of less than 35.5 degree C b. Poor feeding or not sucking c. Convulsion d. All of the above
8. Danger signs in LBW babies are a. Same as in newborn babies regardless of a baby‟s weight b. Different than for normal weight babies c. Not as common as they are in normal weight babies d. None of the above
9. Which of the following is not the common problem of LBW babies? a. Bulging fontanel b. Oral thrush c. Conjunctivitis d. Skin pustules less than 10 in number
10. Babies can lose heat when a. Baby remains in KMC for 24 hours b. The bath is delayed for more than 24 hours c. Both a and b d. None of the above
11. Low birth weight babies are likely to have problems a. Low blood sugar b. Hypothermia c. Infections d. All of the above
12. Severe hypothermia in LBW is defined as an axillary temperature of a. Less than 35.5 degree C b. 35.5 – 36.5 degree C c. 36.5 -38.5 degree C d. None of the above
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13. Typical low birth weight babies will benefit from a. Giving bath within 24 hours b. Avoiding breast milk c. Providing skin to skin contact continuously d. Feeding honey water orally
14. Kangaroo Mother Care (KMC) is a method that a. Is natural for caring low birth weight babies b. Should only take place in hospitals c. Should only be practiced by mother d. Both b and c
15. KMC can be given to a. Stable term newborn weighing 2200 grams b. Stable preterm newborn weighing 2200 grams c. Both a and b d. Sick unstable newborn weighing 2200 grams
16. Baby for KMC should be dressed in a. A cap b. Pair of socks c. Nappy to collect stool and urine d. All of the above
17. Which of the following is not required for starting KMC? a. Willingness of the mother b. Mother should be free from serious disease c. Supportive family d. Mother should be well educated
18. Kangaroo Positioning includes all except a. Baby placed in an upright position between the breast b. The head turned to one side in a slightly extended position c. The hips and arms flexed in a frog like position d. The chest and abdomen very tight with the mother
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19. Advantages of KMC includes a. Easy to give oil massage b. Family members can replace her whenever mother is busy c. Both a and b d. Cannot be practiced at the community
20. The duration of KMC does not depends upon a. Condition of the baby b. Age of the baby c. Family planning method the mother decides to adopt d. How the baby tolerates KMC
21. Which of the following are the benefits of KMC? a. Encourages to have exclusive breastfeeding b. Stabilizes baby‟s body temperature c. Early discharge from the hospital d. All of the above
22. A father wants to take care of baby Sharada through KMC. He can safely do which of the following activities while practicing KMC? a. Take a shower b. Go swimming in a shallow water c. Can sleep comfortably with the baby d. Go for running
23. When is it most appropriate to initiate breastfeeding after birth? a. Within the 30 minutes of birth b. After one hour of birth c. One to two hours after birth, d. More than 12 hours after birth
24. Baby Sharada was born at home and is now being cared with the KMC method. Her sucking reflex is present but not very strong. To ensure sufficient nutrition for the baby, the nurse advises mother to a. Give infant formula by cup b. Bottle feed expressed breast milk c. Give sugar water between feeds by spoon d. Give expressed breast milk by cup
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25. Which of the following is wrong about cup feeding? a. Breathing is easier than in bottle feeding b. It takes less energy than in bottle feeding c. Prepares baby to ease breastfeeding later d. Cup with half-filled milk poured into the baby‟s mouth
26. Position of the baby while breastfeeding should be a. Baby‟s head and neck in line with the body b. Whole body well supported c. Baby‟s nose just opposite to the nipple d. All above
27. Signs of good attachment during breastfeeding is a. Baby‟s lower lip turned inwards b. More areola is visible below the baby‟s mouth than above it c. Baby‟s mouth is wide open d. Baby‟s upper and lower lips holding only the nipple
28. Stable LBW babies with strong sucking reflex should be encouraged for a. Breast feeding b. Cup feeding c. Bottle Feeding d. None of the above
29. Expressed breast milk should be stored correctly as below a. Stored in clean, covered container b. Kept in a coolest place possible for up to six hours c. Discarded after six hours unless refrigerated for 24 hours d. All of the above
30. A baby in KMC unit becomes sick and needs to be referred. During referral, the nurse should encourage the mother to a. Keep the baby in skin-to-skin contact during transport b. Refrain from feeding the sick infant to avoid breathing problems c. Work with health staff to ensure that the baby is periodically given oxygen d. Keep the baby in a cot to avoid cross infection
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CHAPTERS
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CHAPTER 1: IDENTIFICATION OF LOW BIRTH WEIGHT BABIES AND ITS COMPLICATIONS
1.1 INTRODUCTION Low birth weight has been defined as weight at birth of less than 2,500 grams irrespective of gestational age. LBW can result from preterm birth, intra uterine growth restriction (IUGR) or a combination of both.
LBW babies need special care to survive and thrive. In some countries 40-80% of deaths occur among LBW babies. LBW babies are at much greater risk of dying in the neonatal period as well as during infancy period (29-365days). Those babies who survive are at greater risk of frequent illness and poor growth during infancy and childhood. They also may have compromised cognitive, motor and behavioral development.
1.2 TYPES OF LOW BIRTH WEIGHT LBW babies can be classified according to their gestation and birth weight. According to Gestation: Preterm: born before 37 completed weeks (LBW infants may be born at term) Very preterm: born before 32 completed weeks Small for Gestational Age (SGA): birth weight lower than expected for gestational age (may be term or preterm)
According to Birth Weight: Table 1 Classification of LBW babies LBW babies are classified as very Classification Birth Weight low birth weight if their birth weight Low birth weight Less than 2500 grams Very Low birth weight Less than 1500 grams is less than 1.5 kg and as extremely low birth weight if their birth weight Extremely low birth weight Less than 1000 grams is less than 1 kg as outlined in Table 1.
1.3 SCENARIO OF LBW BABIES Global An estimated 20 million infants are born LBW every year accounting 15.5% of all live births and majority (96.5%) of them occurring in developing countries.
In 2010, an estimated 43.3 million infants (36% of live births) were born either too small (SGA) or too soon (preterm), or both in low or middle income countries. The highest rates and number of babies born SGA were in South Asia, where more than half of SGA babies are born.
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National Prevalence of LBW in Nepal was reported as 12% according to Nepal 18 16 15 Demographic Health Survey 2011. 16 14
There is significant variation in 14 12 12 11 prevalence of LBW across nation, 9 with highest prevalence in eastern 10 8 development region (16%) and the 6 lowest in central development 4 region (9%) as shown in figure 1. 2
Percentage of LBWof Percentage 0 The prevalence of LBW in Nepal National Eastern Central Western Mid Far decreased very slowly (2 %) from Western Western 2006 to 2011. Development regions In developing countries like Nepal, due to lack of skilled staff Figure 1 Trend of LBW across development regions and modern technology, lots of resources are required to take care of LBW babies. LBW babies requiring minimal medical care can be met by instituting KMC as an alternative method to incubator care. It is still not widely practiced for caring LBW babies in Nepal.
1.4 RISK FACTOR OF LOW BIRTH WEIGHT BABIES The cause for LBW is multifaceted. There is no evidence on single factor leading to LBW and also there is no direct cause but it happens more frequently to certain mothers, or in certain fetal or placental conditions. Most common factors are as follows:
Maternal factors 1. History of LBW baby 2. Maternal smoking and passive smoking 3. Maternal weight and height 4. Pregnancy induced hypertension 5. Shorter inter pregnancy interval (less than 3 years gap in-between pregnancies) 6. Maternal age less than 20 years and greater than 35 years 7. Anemia in pregnancy 8. Bleeding in third trimester 9. Pre-eclampsia and eclampsia 10. Premature rupture of membrane 11. Infections during pregnancy
Fetal Factors 1. Chromosomal disorder or certain congenital anomalies 2. Chronic fetal conditions like Congenital Rubella Syndrome 3. Multiple gestations
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Placental Factors 1. Placental insufficiency (leading to IUGR) 2. Placenta Previa 3. Preterm placental separation (placenta abruption)
Socioeconomic factor 1. Low socioeconomic status 2. Poor sanitary condition 3. Poor antenatal visit 4. Maternal nutrition 5. Maternal education
1.5 PHYSICAL FEATURES OF PRETERM / SGA BABIES Physical features of preterm babies Thin with visible veins and less fat under the skin, may be covered with thin Skin whitish cheesy oil like material (vernix) and also may be covered by soft thin hair (lanugo). Relatively large compared with the size of the body, sutures and fontanels Head are wide and soft, ear cartilage absent before 25 weeks and does not become normal immediately after making the ear fold. Suck reflex May be weak or absent Chest Breast tissue might be absent Arms/Legs May be floppy, legs and arms may be extended or semi flexed Feet Sole creases in anterior of the foot Small in size Genitals Female – labia minora is not covered by labia majora, Male – testis absent in the scrotum, absent or few creases in the scrotal sac
Physical features of SGA babies Activity Active and alert Skin Absence of fat under the skin, dry and cracked Large compared with the small size of the body, ear cartilage present and the Head ear fold immediately turns to normal Suck reflex Usually vigorous Chest Breast tissue present Arms/Legs Thin usually flexed Feet Sole creases in all over foot
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1.6 COMPLICATIONS OF LBW BABIES 1. Hypoglycemia LBW babies are more prone to develop hypoglycemia as their glycogen storage capacity is less than normal weighed newborns.
2. Hypothermia LBW babies are more prone to develop hypothermia as their brown fat deposition in different parts of body is less than normal weighed newborns.
3. Infection LBW babies are more prone to get infection as they have low immunity level than normal weighed newborns.
4. Hypocalcaemia LBW babies are more likely to develop hypocalcaemia due to imbalance in hormonal regulation of calcium homeostasis.
5. Apnea LBW babies are more prone to develop apnea due to lack of maturity of respiratory centers in brain.
6. Birth Asphyxia LBW babies are likely to develop birth asphyxia due to various risk factors e.g. hypotonia, anemia, and placental insufficiency.
7. Hyperbilirubinemia LBW babies are more prone to develop neonatal hyperbilirubinemia due to immature liver enzymes, immature conjugation capacity of unconjugated bilirubin.
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CHAPTER 2: FEEDING OF LOW BIRTH WEIGHT BABIES
2.1 INTRODUCTION Optimal feeding of LBW influences immediate survival as well as subsequent growth and development. Even simple interventions such as early initiation of breastfeeding and avoidance of pre-lacteal feeding have been shown to improve their survival in resource restricted settings.
2.2 FEEDING OF LBW BABIES: HOW IS IT DIFFERENT A term normal newborn requires minimal assistance to start breastfeeding but in contrast the LBW newborns require close attention and monitoring because of the following limitations:
1. Premature newborns have inadequate skills on breastfeeding. They might not be able to breastfeed and would require other methods of feeding like cup feeding or nasogastric tube feeding. 2. These newborns are prone to significant illnesses which make them necessary to use other methods of feeding because of unsuccessful breastfeeding. 3. Preterm very low birth weight newborns have higher fluid requirements in the first few days of life due to insensible excessive water loss. 4. Since intrauterine nutrition gradually builds up in the later part of the 3rd trimester, very low birth weight newborns (especially born before 32 weeks) have low body stores at birth; hence they require supplementation of various nutrients and even LBW newborns who are likely to be growth restricted needs more calories for “catch up” growth. 5. They are more likely to experience feed intolerance due to gut immaturity necessitating adequate monitoring and treatment.
2.3 HOW TO DECIDE THE INITIAL FEEDING METHOD It is important to remember that not all newborns born at a particular gestation would have same feeding skills. Hence the ideal way in a given newborn would be to evaluate if the feeding skills expected for his/her gestation are present. It is done by classifying the newborns on the basis of birth weight:
1. Birth weight : more than 1800 grams – breast feeding 2. Birth weight : 1200- 1799 grams Breast feeding if possible Cup feeding 3. Less than 1200 grams refer to higher center for feeding purpose
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2.4. BREASTFEEDING All stable LBW newborns, irrespective of their initial feeding method should be put on their mother‟s breast. The immature sucking observed in LBW newborns born before 34 weeks might not meet their daily fluid and nutritional requirements but helps in rapid maturation of their feeding skills and also improves the milk secretion in their mothers („Non –nutritive sucking‟)
2.4.1 Benefits of breast feeding on LBW babies 1. Protects against illnesses and enhances the baby‟s immune system (antibodies). 2. Results in superior rates of weight gain. 3. Reduces incidence of hypoglycemia. 4. Reduces incidence of diarrhea and vomiting. 5. Hastens gastric emptying.
2.4.2 Breastfeeding Situation in Nepal 1. 98% of mothers breastfeed their babies. 2. 70% newborns are exclusively breastfeed. 3. 45% of newborns receive breastfeeding within 1 hour of birth. 4. 85% of newborns receive breastfeeding in one day. 5. 28% of newborns fed pre-lacteal feed.
2.4.3 Breast feeding: Ensuring a good start Getting to know right way of breastfeeding while the mother is in the hospital, will help her succeed in maintaining exclusive breastfeeding for the first six months. So the health professional has a very important role in helping mothers establish good breastfeeding practices from the time of birth. Correct positioning and attachment are important to effective breastfeeding which can occur between comfortable mother and baby situation. a) Good positioning should have the following signs: 1. Baby‟s head and body in straight line. 2. Baby‟s face opposite the nipple and breast. 3. Baby‟s nose opposite the mother‟s nipple. 4. Baby held close to the mother. 5. Baby‟s whole body supported not only the head and shoulder.
Figure 2: Proper positioning and attachment of breast feeding Source: Breastfeeding Campaign in Philippines retrieved from http://pinoykidsmd.com/tag/breastfeeding-campaign-in-philippines
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b) Good Attachment should have the following signs: 1. Baby‟s mouth is widely open. 2. The tongue is forward in the mouth, and may be seen over the bottom gum. 3. The lower lip is turned outwards. 4. The chin is touching the breast. 5. More areola is visible above the baby‟s mouth than below it. c) Good suckling will have following signs: 1. Slow, deep sucks with pauses, 2. Baby releases breast when finished, 3. Mother notices signs of oxytocin reflex (milk dripping from nipples), 4. Breast appears softer after feeds,
Always observe a mother breastfeeding before you try to help her, so that you understand her situation clearly. Do not rush to solve her problem, but find out if she really wants her baby to take larger mouthful of breast. If she agrees then you can start to help her by explaining first about position and attachment, then let the mother position and attach the newborn himself/herself.
Look for the signs of good attachment and effective suckling again, if not then ask mother to remove the newborn from her breast to try again. To remove newborn from the breast, mother should slip her little finger into the corner of the newborn‟s mouth to break the suction between the breast and mouth, and then gently take the newborn away from the breast.
When the newborn is suckling well, explain mother that it is important to breastfeed about 30 minutes on each breast.
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CHECKLIST 1: CHECKLIST FOR BREASTFEEDING
Place “√” if step is performed satisfactorily and “X” if step is not performed satisfactorily or N/O if not observed Satisfactory: Performs the step or task according to the standard procedure or guidelines. Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines. Not Observed: Step or task or skill not performed by participant during evaluation by facilitator.
Id no: CHECKLIST FOR BREASTFEEDING
STEP/TASK Pre Post test test 1. Greets the mother and make her comfortable. 2. Explains what she is going to do. 3. Encourages the mother to ask questions and address her questions. 4. Washes his/her hands and let the mother wash her hands also. 5. Asks the mother to put the baby to her breast and observe the feeding. 6. If the baby is in KMC position, helps the mother loosen the wrap around her and the baby as needed, while maintaining skin to skin contact. 7. Checks the position of the baby: Baby‟s head and body in straight line. Baby‟s face is placed opposite to the nipple and breast. Baby‟s nose is placed opposite to the mother‟s nipple and is not covered by the mother‟s breast. Baby is held close to the mother. Baby‟s whole body is supported properly (not only the head and shoulder). 8. Checks for good attachment: Baby‟s mouth is widely open. The lower lip is turned outwards. The chin is touching the breast. More areola is visible above the baby‟s mouth than below it. 9. Checks the effective suckling: Slow, deep sucks. Occasional short pauses. Mother reports that breast feels softer after the feeding. 10. Documents findings.
Facilitator’s Signature: ______Date: ______
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2.5 ALTERNATIVE METHODS OF FEEDING
2.5.1 Expressed breast milk by cup feeding Majority of the newborns have no difficulty in breastfeeding after birth. A small percentage of newborns (LBW and sick) may not be able to breastfeed at this time. They may need to be fed their mother‟s milk using an alternative method of feeding (expressed breast milk) through cup feeding or nasogastric tube feeding.
2.5.2. Importance of cup feeding a) Better than bottle feeding 1. It is easier for low birth or premature baby. 2. It prepares a baby to breast feed later; the mouth action is more like the action of breastfeeding. 3. The baby can control the feed (how fast, how much, and when to rest). 4. It does not need special equipment. 5. Easy to prepare and clean. b) Better than a palladi and spoon 1. The feeding is faster. 2. Not as much milk is spilled. 3. It prevents to get milk into the lungs. 4. Spoon can cause damage to a baby‟s mouth.
2.5.3 Helping mother to express her milk A mother‟s own breast milk is the ideal milk for her baby. If breastfeeding cannot begin soon after birth, encourage the mother to express her milk, so that it can be given by an alternative method of feeding. The mother should learn to do this by herself. She should be aware about the colostrum which is thicker than the later milk after 2-3 days. Colostrum is vital to the baby‟s health due to its protective and special growth factors which has long term effect on baby‟s health.
Expressed breast milk can be fed by using a clean open cup. The cup should be as small as possible even if the milk was expressed into a larger cup. Pour a little at a time into the small cup to feed the baby.
Avoid using bottles and nipples, which are difficult to clean and baby can become sick. Furthermore it can confuse the baby and discourage on taking the breast feed.
Always wash hands with clean running water and soap before and after expressing breast milk. Expressed breast milk can be stored up to 6 hours at room temperature and to 3 days in the refrigerator. Baby may drink breast milk cool, at room temperature or warmed. Used utensils used to feed baby should be cleaned with water and soap and keep them covered. Anyone in the family can feed the baby by using a clean open cup. Newborn baby learns quickly how to drink from a cup.
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2.5.4 Expression of breast milk To feed the baby using hand expression, the mother should 1. Wash her hands. 2. Hold her baby skin to skin, with the mouth close to her nipple. 3. Express some drops of milk from the nipple. 4. Wait until the baby is alert and opens his/her mouth widely. 5. Stimulate the baby if s/he appears sleepy. 6. Let the baby smell and lick the nipple and attempt to suck. 7. Let some breast milk fall into baby‟s mouth. 8. Wait until the baby swallows before expressing more drops of milk. 9. When the baby has had enough s/he will close its mouth and will take no more milk. 10. Ask the mother to repeat this every 1-2 hours if the baby is very small or every 2-3 hours if the baby is bigger.
2.5.5 How to do cup feed Cup feeding is a safe and useful method of feeding breast milk to a newborn baby. The mother is the best person to cup feed her baby; she has the time and patience and can be involved with her baby by having good eye contact between them.
1. Position of the baby – Awake the baby and hold partly sitting in your lap; support the baby‟s shoulder and neck with your hand, so you have control over the head.
2. Hold a small cup of milk, half filled, to the baby‟s lips: Tip the cup so the milk just reaches to the lips. The cup should rest lightly on the baby‟s lower lip. The cup edges should touch the baby‟s outer parts of the lip. 3. The baby will become alert and open his/her mouth and eyes.
A LBW newborn will start to take up the milk with tongue. A full term or older baby will suck or sip the milk, spilling some of it. 4. Do not pour the milk into the baby‟s mouth; keep the cup at the baby‟s lips, letting the baby take the milk.
5. When the baby has had enough, the baby will close its mouth and refuse to take more: A baby who has not taken enough may take more next time or, You may increase the frequency of feedings. 6. Advise the mother to hold her baby to her shoulder and rub the baby‟s back to help him/her burp.
7. Measure the baby‟s intake over 24 hours rather than at each feeding.
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2.5.6 Calculate amount of milk by cup feeding 1. Feeding volume is determined by the age and size of a baby; begins at low volume and increased gradually.
2. Determine the amount by weight and age of the baby and give it every 3 hourly
1.75 – 2.5 kg (start 15 ml per feed and increase 5 ml per feed daily to 40+ml) 1.5 – 1.75 Kg ( start at 12 ml per feed and increase by 4 ml per feed daily to 32+ml) 3. As a whole it can be given 160 ml per kg per day by 7 days if tolerating well.
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Checklist 2: CHECKLIST FOR EXPRSSING BREAST MILK AND CUP FEEDING
Place “√” if step is performed satisfactorily and “X” if step is not performed satisfactorily or N/O if not observed Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step or task or skill not performed by participant during evaluation by facilitator.
Id no: CHECKLIST FOR EXPRESSNG BREAST MILK AND CUP FEEDING Pre Post S.N STEP/TASK test test 1. Greets the mother and make her comfortable. 2. Explains what she is going to do. 3. Encourages the mother to ask questions and address her questions. 4. Washes his/her hands and let the mother wash her hands also. 5. Obtains a clean cup or bowl. 6. Asks the mother to do the following steps: Put clean warm wet clothes on the breast for 5 minutes if engorged. Massage the breast from outer side towards the nipple to help the milk come out down. Hold the breast with the thumb on top and other fingers below pointing away from the areola. Place a clean container below breast to collect milk. Lean slightly forward so that the milk will go into the cup or bowl. Squeeze thumb and other fingers together, and move them towards areola so the milk comes out. 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. Avoid rubbing or sliding her fingers along the skin, the movement of the fingers should be more like rolling. Press and release repeatedly and move hands around the breast so milk is expressed from all areas of the breast Express one breast until breast softens ( usually at least 3-5 minutes) Follow the same process to express milk from the other breast
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CHECKLIST FOR EXPRESSNG BREAST MILK AND CUP FEEDING
Pre Post S.N STEP/TASK test test For Cup Feeding
7. Position of the baby Ask the mother to hold the baby in semi upright sitting position on her lap. Tell the mother to support the baby‟s shoulder and neck with her hands, so that she has control over the head. 8. Feeding the baby: Ask the mother to hold the small cup half filled with the mother‟s milk, towards the baby‟s lips. Place the cup near the baby‟s lips so the milk just reaches to the lips. The cup should rest lightly on the baby‟s lower lip. The cup edges should touch the baby‟s outer parts of the lip. 9. Ensures that the baby is alert and his/her mouth and eyes are open.
10. Feed the baby slowly, making sure that the milk has been swallowed properly before feeding the baby with more milk. 11. When the baby has had enough, s/he will close his/her mouth and will not take any more. Do not force-feed the baby. 12. Document findings including the amount fed by the baby.
Facilitator’s Signature: ______Date: ______
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2.6. Problems in Breast Feeding a. Inverted nipple Management should begin after birth. Manually stretch and roll the nipple between the thumb and finger several times a day. Teach the mother to grasp the breast tissue so that areola forms a teat, and allows the baby to feed. Use syringe suction method to draw nipple out.
Figure 3 Inverted nipple
Treatment of inverted nipple by syringe method
Cut along this STEP 1 line with blade
Use 5cc or 10cc syringe
STEP 2 Insert the plunger from cut end
STEP 3 Mother gently pulls the plunger
Before the feeds 5-8 times a day
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b. Sore nipple Causes Incorrect attachment : Nipple suckling Frequent use of soap and water Pulling the baby off the breast while s/he is still sucking Candida (fungal) infection Management Continue breastfeeding and correct the position & attachment Apply hind milk to the nipple after a breastfeed Expose the nipple to air between feeds Figure 4 Sore Nipple
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c. Breast engorgement Causes Delayed and infrequent breastfeeds Incorrect latching of the baby leading to accumulation of milk in alveoli leading to painful, hard, tender breast.
Management Give analgesics to relieve pain Apply warm packs locally Gently express milk prior to feed Put the baby frequently to the breast Figure 5: Breast Engorgement d. Breast Abscess Causes Untreated engorged breast, infected cracked nipple, blocked duct and mastitis
Management Give analgesics and antibiotics. Manually express out the milk frequently. Refer for incision & drainage. Start breastfeeding as soon as possible. Avoid massaging the breast with oil. Figure 6: Breast Abscess e. Not enough milk Causes Infrequent breastfeeding. Too short or hurried breastfeeding. Night feeds stopped early. Poor suckling position / attachment. Breast engorgement or mastitis. Stressful conditions to mother. Poor oxytocin reflex.
Management Put baby to breast frequently in a correct position. Ensure correct positioning. – Build mother‟s confidence. – Gentle message at the back of mother. – Galactogogues e.g. Metoclopramide (Tab Perinorm 10 mg xTDS x 5 days) may help in increasing milk production by increasing prolactin secretion – Provide other milk to the baby (formula feed, other mother‟s milk) till sufficient milk secretion.
Note: Adequate weight gain and urine frequency 5-6 times a day are reliable signs of enough milk intake
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CHAPTER 3: DANGER SIGNS AND COMMON PROBLEMS OF LBW BABIES WITH MANAGEMENT
3.1 DANGER SIGNS OF LBW BABIES The danger signs in LBW newborn are same as in normal weight newborn except baby‟s weight. Danger signs pose a serious problem in the LBW babies. Many babies die due to illness that presents with these danger signs. Health workers need to know and recognize danger signs in the newborn babies to be able to manage and /or refer the baby appropriately.
Followings are the danger signs that a LBW baby may present
1. Poor feeding or not sucking: For preterm babies, especially less than 34 weeks of gestation, poor sucking may be normal. But for term babies poor feeding is as danger sign. 2. Hypothermia (36.5°C or less) in spite of efforts to re-warm 3. Fever (>37.5°C) 4. Convulsion: Sudden involuntary stiffness of the body, tonic and colonic movement or upward rolling of eye ball. 5. Breathing problems e.g. Apnea, chest retraction, grunting, flaring of nose, cyanosis 6. Lethargy (excessive sleepiness, reduced activity): Preterm babies sleep more and less active than term babies. Notable decrease in activity or increase sleepiness than previous days should be worrisome for the baby. 7. Jaundice: There are two types of jaundice in newborns. a. Physiological jaundice appears usually after 24 hours of birth and disappears within 2 weeks of life without any active intervention. b. Pathological jaundice appears within 24 hours of life with ABO or Rh incompatibility, persists more than 2 weeks. It requires intervention like phototherapy, exchange transfusion and drugs. 8. Prone to sepsis
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Signs of Sepsis
1. Unable to breast feed
2. Lethargic or unconscious
3. Fast breathing
4. Severe chest in drawing
5. Grunting
6. Fever
7. Hypothermia
8. Umbilical discharge with redness extending up to surrounding skin
9. Ten or more than ten pustules over skin of baby or one big abscess
10. Weak or absent cry
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3.2 COMMON PROBLEMS OF LBW BABIES AND MANAGEMENT The LBW babies can have the following common problems:
S.N. Problems Management
a. Treat mouth ulcers with Gentian Violet(GV) (0.25%) twice daily Procedure a. Wash hands. 1 Oral thrush b. Wash the child‟s mouth with a clean soft cloth wrapped around the finger and wet with salt water. c. Paint the mouth with 1/2 strength GV (0.25% dilution). d. Wash hands again. e. Continue using GV for 48 hours after the ulcers have been cured. a. Treat eye infection with Tetracycline or Ciprofloxacin eye ointment. Procedure a. Wash hands. b. Clean both eyes 3 times daily. c. Use clean cloth and boiled and cooled water to gently wipe Conjunctivitis or 2 away pus. swollen eyes d. Then apply Tetracycline or Ciprofloxacin eye ointment in both eyes 3 times daily. e. Squirt a small amount of ointment on the inside of the lower lid. f. Wash hands again. g. Treat until there is no pus discharge. h. Do not put anything else in the eye. Skin pustules less than a. Treat with 0.5% GV application every 6 hours for 5 days. 10 in number b. Start syrup amoxicillin (2.5ml) per oral two times a day for five days. 3 a. Observe for signs of sepsis and if more than 10 Skin pustules more pustules, needs antibiotic treatment at health facility. than 10 in number b. Start syrup amoxicillin (2.5ml) per oral two times a day for five days and give Gentamycin 10 mg IM once daily for 7 days. Redness of the umbilical cord ** (Local or mild cord infection) a. Start syrup amoxicillin (2.5ml) per oral two times a day 4 No pus or foul for five days smelling b. Apply 0.5% GV application every 6 hours for 5 days Redness does not extend beyond 1 cm No signs of sepsis
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S.N. Problems Management Discharges from umbilical cord (severe cord infection) a. Start syrup amoxicillin (2.5ml) per oral two times a Pus discharge, day for five days and give Gentamycin 10 mg IM 5 Delayed cord separation once daily for 7 days. plus b. Apply 0.5% GV application every 6 hours for 5 days. Redness and swelling extending beyond 1 cm May have signs of sepsis or other danger signs
** These conditions may spread to the blood stream and lead to sepsis. Sepsis is an infection affecting the whole body. The infection may be in the blood (septicemia) or in one or more organs of the body. Organisms that cause sepsis may enter the body during pregnancy, labor and delivery or after birth. They may spread in the body from an infection of the skin, cord or other organs. Sepsis is a serious illness and can quickly cause death in the newborn. Therefore prompt treatment with antibiotics is necessary.
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CHAPTER 4: HYPOTHERMIA IN NEWBORN AND ITS MANAGEMENT
4.1 HYPOTHERMIA Hypothermia is defined as axillary temperature of newborn less than 36.5 0C (97.7 0F).Normal axillary temperatures for newborn is 36.5 – 37.50C.
Hypothermia is often caused by a lack of knowledge rather than lack of equipment. It is important that all health workers involved in the process of delivery and newborn care be trained on the principles of thermal protection for the newborn. On the job training and supervised practice should be provided to ensure that the warm chain becomes part of routine care of the newborn. Family and community should be educated about the risks of hypothermia.
Newborn babies regulate their body temperature much less efficiently than adult does and lose heat easily. The smaller and more premature the baby, the greater the risk and hence LBW babies are most vulnerable to hypothermia. Newborns are not able to maintain their temperature due to their:
1. Large body surface area relative to their body weight. 2. Small amount of fat insulating in the body. 3. Immature brain center which controls temperature. 4. Thin layer of skin (which allows more evaporation) especially in first week of life.
4.2 TYPES OF HYPOTHERMIA 1. Hypothermia (cold stress)
Axillary temperature: 35.5 – 36.5 0 C Abdomen warm Extremities cold 2. Severe hypothermia
Axillary Temp < 35.5 0C. Abdomen cold Extremities cold
4.3. SIGNS OF HYPOTHERMIA 3. Hypothermia (Cold Stress): The baby is:
Less active. Does not breastfeed well. Has a weak cry. Has respiratory distress.
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Has cold extremities (feet and hands) and may also have a cold body.
4. Severe Hypothermia
The baby‟s face, hands and feet may develop a bright red color in skin. The skin over the baby‟s back and limbs or over the whole body may become hard together with reddening and oedema (scleremma). The baby becomes lethargic and develops slow, shallow and irregular breathing and a slow heartbeat. The baby will have a low blood sugar (hypoglycemia) and metabolic acidosis with possible internal bleeding. It is important to note that these above signs are danger signs and they should be urgently referred.
4.4. WAYS OF LOSING HEAT BY NEWBORN /LBW BABIES 1. Conduction: Heat loss can occur by conduction, when a neonate comes in direct contact (naked) with an object cooler than their skin. E.g. Tray, cloth or cold hands etc.
2. Evaporation: Evaporation occurs, when wet surfaces are exposed to the air. This happens particularly soon after birth as the amniotic fluid evaporates from the neonatal skin surface by losing heat.
3. Convection: Convection occurs by a process of heat being transferred to the surrounding air. This occurs by cold air currents from open windows/ doors replacing warm air around the baby.
4. Radiation: Radiation occurs due to transfer of heat to cooler objects that are not in direct contact with the newborn. For e.g.: Babies uncovered head exposed to the cold surface.
Source: WHO 1997: Thermal Protection of the Newborn. WHO/RHT/MSM/97.2 Geneva Figure 7 Four ways a newborn may lose heat to the environment
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4.5. METHOD OF PREVENTING HEAT LOSS AT DIFFERENT SITUATION The key action for prevention of heat loss is maintaining warm chain as explained below:
1. Maintenance of warm chain Warmth during the delivery. Delivery room temperature of 250 C– 26oC. Warm resuscitation corner: pre warmed baby warmer. 2. Immediate drying and skin to skin contact Immediately dry the newborn baby after birth with a warm towel while newborn baby is in mother‟s abdomen. Cover the newborn with warm clothes. Maintain skin to skin contact between mother and newborn baby. 3. Feeding Initiate breast feeding within half hours of birth. Continue breast feeding, cup feeding or nasogastric feeding. Regardless of feeding, encourage the mother to maintain skin to skin contact during feed. 4. Delay bathing Delay bathing for more than 24hours. When newborn baby is in sponge bath, it should be done quickly with warm water in warm room. Then newborn baby should be dried quickly and thoroughly, dressed in cap, nappies and socks and placed in skin to skin contact. 5. Warmth during caring or transportation Warm the objects (hands, tray) that will touch the newborn. Keep the newborn baby out of drafts. Newborn baby should be placed away from the walls and windows. KMC is a safe and simple method to transport a stable newborn baby. 6. Management in postnatal ward Initiate KMC if not initiated in delivery ward. Encourage breast feeding. Remove soiled clothes immediately. Keep doors and windows closed. Encourage 24 hours KMC. 7. Training/Awareness Training to health workers. Awareness raising to parents.
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4.6 MANAGEMENT OF HYPOTHERMIA 1. Rapid re-warming is advised for hypothermic babies.
2. Remove cold clothes. 3. Cover the newborn baby properly with warm cloths. 4. Practice KMC for rewarming. 5. Continue breast feeding. 6. Monitor temperature frequently, watch for apnea and hypoglycemia. 7. Refer to higher center for further management in case of severe hypothermia by keeping newborn baby in KMC position.
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CHAPTER 5: KANGAROO MOTHER CARE
5.1 OVERVIEW OF KMC Kangaroo Mother Care is a natural method for caring of stable low birth weight babies carried through skin to skin contact with the mother/guardian like that of an incubator care as the incubator care is costly and not feasible for the resource poor countries. KMC method is a cost effective way to meet baby‟s needs for warmth, breastfeeding, protection from infection, stimulation, safety and love for LBW infants. In KMC, the baby is continuously kept in skin-to-skin contact by the mother/guardian and breastfed exclusively to the utmost extent. KMC is initiated in the hospital and community as well. KMC is a early, prolonged and continuous skin-to-skin contact between a mother/guardian and her newborn LBW baby both in hospital and after early discharge, until the baby reaches at least the 40th week of postnatal gestational age or 2,500 grams in weight.
KMC was initiated in 1979 by Professor Edger Rey in Bogota in Colombia. It has since been introduced into the medical establishment of both the developed and developing world as an alternate and complement to the incubator care for LBW babies. The evidence says that KMC is feasible everywhere because it is not based on equipment and it will be successful if the health services are provided with:
Appropriate health facility Appropriate supporting staff and professionals Good quality follow up and Institutional, social and community support 5.2 BENEFITS OF KMC 1. Breastfeeding: Studies have revealed that KMC results in increased breastfeeding rates as well as increased duration of breastfeeding and promotes exclusive breastfeeding. Even when initiated late and for a limited time during day and night, KMC has been shown to exert a beneficial effect on breastfeeding. 2. Thermal control: Prolonged skin-to-skin contact between the mother and her LBW infant provides effective thermal control with a reduced risk of hypothermia. For stable babies, KMC is at least equivalent to conventional care with incubators in terms of safety and thermal protection. 3. Early discharge: Studies have shown that KMC cared LBW infants could be discharged from the hospital earlier than the conventionally managed babies. The babies gained more weight on KMC than on conventional care. 4. Less morbidity: Babies receiving KMC have more regular breathing and fewer predispositions to apnea due to mother‟s respiratory movements (physical stimulation). KMC protects against nosocomial infections. Even after discharge from the hospital, the morbidity amongst babies managed by KMC is less. KMC is associated with reduced incidence of severe illness leading to reduce risk of mortality. 5. Other effects: KMC helps both infants and parents. Mothers are less stressed during Kangaroo Mother Care as compared with a baby kept in incubator. Mothers prefer skin- to-skin contact to conventional care. They report a stronger bonding with the baby,
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increased confidence, and a deep satisfaction that they were able to do. Fathers also felt more relaxed, comfortable and better bonded while providing Kangaroo Mother Care. 5.3 TYPES OF KMC 1. Continuous KMC In continuous KMC, the newborn is kept in the position constantly (> 20 hours per day) except for short periods for bathing or diaper changing or when the mother is attending personal needs... Family members should assist the mother with continuous KMC by keeping the baby in skin to skin care when mother has to bathe or attend personal needs. This is an ideal type of KMC for stable LBW babies. 2. Intermittent KMC Intermittent KMC is done for certain periods of a day only within the hospital (or from home); the mother comes to the neonatal unit for KMC for certain specific hours only. The newborns are kept in incubator or warmer or well wrapped for remainder of the time. Intermittent KMC is done mostly for very small and sick babies, and /or for mothers who do not want or are not yet ready for continuous KMC. 5.4 THE COMPONENTS OF KMC 1. Skin-to-skin contact Components of KMC Early, continuous and prolonged skin-to-skin contact between the mother and her baby is the 1. Skin to skin contact basic component of KMC. The newborn is placed 2. Exclusive breast feeding on her mother's chest between the breasts and 3. KMC discharge and follow up kept for day and night or close to 24 hours as a continuous care. When continuous care is not possible, kangaroo position can be used intermittently, ensuring emotional and breast feeding promotion benefits remains intact. 2. Exclusive breastfeeding The baby on KMC is breastfed exclusively. Skin to skin contact promotes lactation and facilitates the feeding interaction. 3. KMC discharge and follow up Early home discharge in the KMC position from the health facility is one of the benefits of the KMC intervention. Mothers at home require adequate support and follow up. Hence a follow-up program and access to newborn care services must be ensured.
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5.5 THE PRE-REQUISITES OF KMC 1. Support to the mother in hospital and at home A mother cannot successfully provide KMC all Pre-requisites of KMC alone. She would require counseling along with supervision from care-providers, and Support to the mother in hospital and at home assistance and cooperation from her family Post –discharge follow up members. 2. Post-discharge follow up KMC is continued at home after early discharge from the hospital. A regular follow up and access to health care providers for solving problem are crucial to ensure safe and successful KMC at home. 5.6 ELIGIBILITY CRITERIA 1. Baby All stable1 LBW babies are eligible for KMC. However, sick and very small babies (<1200 gram) needing special care should be cared under radiant warmer initially. KMC should be started after the baby is hemodynamically stable. Short KMC sessions can be initiated during recovery with ongoing medical treatment (IV fluids, oxygen therapy). KMC can be provided while the baby is being fed via nasogastric tube or on oxygen therapy. Figure 8 shows the timing of KMC initiation for different birth weight categories.
a. Birth weight >1800 gram: These babies are generally stable at birth. Therefore, in most of them KMC can be initiated soon after birth.
b. Birth weight 1200-1799 gram: Many babies of this group have significant problems in neonatal period. It might take a few days before KMC can be initiated. If such a baby is born in a place where neonatal care services are inadequate, s/he should be transferred to a proper facility immediately after birth, along with the mother/ family member. S/he should be transferred to a referral hospital after initial stabilization and appropriate management. One of the best ways of transporting small babies is by keeping them in continuous skin-to- skin contact with the mother/family member during transport.
c. Birth weight <1200 gram: Frequently, these babies develop serious prematurity related morbidity, often starting soon after birth. They benefit the most from in utero transfer to the institutions with neonatal intensive care facilities. It may take days to weeks before baby's condition allows initiation of KMC.
2. Mother All mothers can provide KMC, irrespective of age, parity, education; culture and religion. The following points must be taken into consideration when counseling on KMC:
1 Stable preterm or low-birth-weight infant: a newborn infant whose vital functions (breathing and circulation) do not require continuous medical support and monitoring, and are not subject to rapid and unexpected deterioration, regardless of intercurrent disease.
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a. Willingness: The mother must be willing to provide KMC. Health workers should counsel and motivate her. Once the mother realizes the benefits of KMC for her baby, she will learn and undertake KMC.
b. General health and nutrition: The mother should be free from serious illness to be able to provide KMC. She should receive adequate diet and supplements recommended by her physician.
c. Hygiene: The mother should maintain good hygiene: daily bath/sponge, change of clothes, hand washing, short and clean finger nails. d. Supportive family: Apart from supporting the mother, family members should also be encouraged to provide KMC when mother wishes to take rest or attend personal needs.
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KMC is recommended for the routine care of newborns weighing 2000 gram or less at birth, and should be initiated in health-care facilities as soon as the newborns are clinically stable.
Birth Weight
< 1200 grams 1200 – 1800 grams >1800 grams
Most infants suffer from Many infants suffer from
serious morbidities; serious morbidities therefore birth should take place in the specialized Transfer to a specialized Generally stable at neonatal centers center, if possible birth
Best transported in skin to skin contact with mother / family member
May take days to May take days KMC can be initiated weeks before before KMC can be immediately after KMC can be initiated birth initiated
Figure: 8 Timing of KMC initiation for different birth weight categories
Adapted from Operational Guidelines for Programme Managers on KMC and optimal feeding of LBW infants (Government of India, 2014)
5.7 COUNSELING ON KMC Counseling is a person to person interaction in which the counselor provides adequate information to enable the client to make an informed choice about the course of action that is best for her or him. Providing information is the process of helping an individual or a group of individuals to reach their own decision by providing appropriate, accurate and unbiased information and emotional support. In case of KMC, counseling is an ongoing process that is initiated at the time of admission, continues in the ward and upon discharge, and continues at home and in the community. It involves giving health advice or guidance to the mothers and families to solve health related problems to those who are practicing or are about to start practicing KMC. Skills such as
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positioning and breastfeeding of the baby, expressing breast milk and feeding by cup should not only be explained but demonstrated as well.
Basic counseling principles: 1. Receptive atmosphere: The counselor should greet the mother and speak politely to make her feel comfortable. 2. Informed decision: The counselor should provide clear and adequate information regarding KMC. The counselor should be unbiased and explain all the benefits, risk, process of doing KMC correctly by using wraps and any side effects, advantages and disadvantages. 3. Confidentiality: The counselor protects the mother‟s privacy by keeping information confidential. 4. Nonjudgmental: The mother‟s attitude and behavior should be assessed objectively without preconceived ideas. 5. Freedom of expression: Mother must be allowed to speak her mind even if it means not agreeing with the counselor. Mother should be encouraged to ask questions and express her concerns. 6. Communication without emotional involvement: The counselor should be responsive and empathetic to the mother‟s feelings without getting emotionally involved. 7. Privacy: The place for counseling to mother must be free from noise and disturbances. No one else should be able to see or hear what is being said or done between counselor and mother. 8. Recognize limitations: The counselor must recognize his/her limitation and should be honest regarding the unavailability of information or answer to mother‟s question.
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Checklist 3: CHECKLIST FOR COUNSELING FOR KANGAROO MOTHER CARE
Place a “√” if step is performed satisfactorily; “X” if step is not performed satisfactorily and “NO” if not observed
Satisfactory: Performs the step or task according to the standard procedure or guidelines. Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines. Not Observed: Step or task or skill not performed by participant during evaluation by facilitator.
Id no:
CHECKLIST FOR COUNSELING KANGAROO MOTHER CARE (KMC) Pre STEP/TASK Post test test PREPARATION FOR COUNSELING 1. Greets the mother/guardian with respect and kindness, introduces herself. 2. Ensures privacy. 3. Confirms mother's name, address and baby‟s weight. 4. Ensures that the mother/guardian is ready to listen. 5. Asks the mother/guardian whether s/he knows about her newborn baby‟s weight. 6. Explains mother/guardian about the condition of the baby What is normal weight and LBW baby? Her baby's weight at birth. Risk of LBW babies (hypothermia, feeding problems, infection) 7. Prepares KMC wraps to show mother/guardian. 8. Encourages the mother/guardian to ask questions during the procedure and address his/her questions. GENERAL COUNSELING 9. Discusses about the benefits of KMC with the mother/guardian, Helps to stabilize baby‟s temperature. Keeps the baby near to the mother‟s breasts for feeding on demand. Promotes mother‟s milk let-down reflex and helps breastfeeding succeed. Promotes faster weight gain. Protects the baby from injury and infections. 10. Explains that it is easy to perform KMC by mother as frequent breast feeding is convenient for mother and baby. 11. Informs the mother/guardian that she will teach him/her, how to give KMC, so that she can do it herself/himself. 12. Uses simple language that the mother/guardian can understand. 13. Explains mother/guardian about the components of KMC: Skin-to-skin contact Exclusively breast feeding KMC discharge and follow up Explains the mother/guardian about pre-requisite of KMC Support from family members to do KMC to give mother periodic 14. breaks. Continue KMC at home even after discharge from the hospital. 15. Ensures that the mother/guardian has understood the discussion. 16. Shows KMC wraps to the mother/guardian and asks him/her to feel them. 17. Ask mother/guardian whether s/he is interested to do KMC.
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CHECKLIST FOR COUNSELING KANGAROO MOTHER CARE (KMC) Pre STEP/TASK Post test test If the mother/guardian is interested, demonstrates the steps on how to do 18. KMC using the checklists. 19. Document findings.
Facilitator’s Signature: ______Date: ______
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5.8. KANGAROO POSITIONING
The baby should be placed between the mother's breasts in an upright position, chest to chest (as shown in Figure 9). The head should be turned to one side and in as lightly extended position. This slightly extended head position keeps the airway open and allows eye to eye contact between the mother and her baby. The hips should be flexed and abducted in a "frog” position; the arms should also be flexed. Baby's abdomen should be at the level of the mother's epigastrium. Mother's breathing stimulates the baby, thus reducing the occurrence of apnea.
Figure: 9 Position of baby in Kangaroo Mother Care
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Checklist 4: CHECKLIST FOR USING TRADITIONAL WRAP FOR KMC
Place a “√” if step is performed satisfactorily and “X” if step is not performed satisfactorily or N/O if not observed Satisfactory: Performs the step or task according to the standard procedure or guidelines. Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines. Not Observed: Step or task or skill not performed by participant during evaluation by facilitator.
Id no:
CHECKLIST FOR USING TRANDITIONAL WRAP FOR KMC Pre STEP/TASK Post test test PREPARATION 1. Greets the mother/guardian and make him/her comfortable. Explains what she is going to do. Encourages the mother/guardian to ask questions and address his/her questions. 2. Washes hands with soap and water and air dries it. Dress the baby in cap, socks and nappy/diapers. Explains that the person who will be doing KMC should wear loose dress that has opening in front. Make traditional wrap ready (Unfolds 3 meters long wrap and hold it by dividing half in the middle). STEPS FOR KMC 3. Opens the front part of blouse or upper half part of the dress. 4. Positioning the baby in KMC position Places baby on mothers/guardian chest between her breasts in an upright position. The head should be turned to one side and in a slightly extended position. This slightly extended head position keeps the airway open and allows eye to eye contact between the mother/guardian and her baby. The back and buttocks of the baby should be supported by one hand during this time Baby‟s hands are placed above the mother‟s/guardian‟s chest. Baby‟s feet are placed below the mother‟s/guardian‟s breast i.e. frog like position 5. Puts the center of the wrap over the baby on the mother‟s/ guardian‟s chest. 6. Wraps both ends of the cloth around the mother/guardian under his/her arms to her back and tie knot securely. *NB: Baby should not slip out when the mother stands up or moves around. 7. Supports the baby‟s head by pulling the wrap just up to the ear of the baby. 8. Cover mother/guardian and baby with a shawl. 9. Documents findings.
Facilitator’s Signature: ______Date: ______
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CHECKLIST 5: CHECKLIST FOR USING CARE PLUS WRAP FOR KMC
Place a “√” if step is performed satisfactorily and “X” if step is not performed satisfactorily or N/O if not observed Satisfactory: Performs the step or task according to the standard procedure or guidelines Unsatisfactory: Unable to perform the step or task according to the standard procedure or guidelines Not Observed: Step or task or skill not performed by participant during evaluation by facilitator Id no:
CHECKLIST FOR USING CARE PLUS WRAP FOR KMC STEP/TASK Pre Post test test PREPARATIONS 1. Greets the mother/guardian and make him/her comfortable. Explains what she is going to do. Encourages the mother/guardian to ask questions and address his/her questions. 2. Wash‟s hands with soap and water and air dries. Dress the baby in cap, socks and nappy/diapers. Explains that the person who will be doing KMC should wear loose dress that has opening in front. Makes Care Plus wrap ready. STEPS FOR KMC 3. Opens the front part of blouse or upper part of the dress. 4. Puts both straps of the wrap over the shoulder, so that the front part of the wrap is attached with mother‟s/guardians‟ chest. 5. Ties the lower part straps (light blue color) of the wrap once at the back of the waist Adjustment for smaller babies Fold the lower end strap round the waist to prevent smaller babies to sliding down 6. Brings the remaining part of the same straps in front around the waist and ties securely once again. 7. Takes out the upper strap (light blue) from both shoulders to place the baby. 8. Positioning the baby in KMC position Places baby on mother‟s/guardian‟s chest between his/her breasts in an upright position. The head should be turned to one side in a slightly extended position. This slightly extended head position keeps the airway open and allows eye to eye contact between the mother and baby. The back and buttocks of the baby should be supported by one hand during this time. Baby‟s hands are placed above the mother‟s/guardian‟s chest. Baby‟s feet are placed below the mother‟s//guardian‟s breast i.e. frog like position.
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CHECKLIST FOR USING CARE PLUS WRAP FOR KMC STEP/TASK Pre Post test test 9. Puts one strap over the mother‟s/guardian‟s shoulder supporting the baby with another hand. 10. Puts the next strap over the mother‟s/guardian‟s shoulder while supporting baby with the other hand. 11. While supporting the baby with the left hand brings the strap which is at the left side from the back to the front using the right hand and holds the strap and the baby with the same hand. 12. Again supporting the baby with the right hand brings the strap which is at the right side from the back to the front using the left hand and tie knot securely at the waist. (strap at the back should be cross) 13. Support the baby‟s head by pulling the wrap just up to the ear of the baby. 14. Covers the mother/guardian and baby with a shawl.
15. Document findings.
Facilitator’s Signature: ______Date: ______
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5.9 DISCHARGE CRITERIA FOR KMC The mother and baby can go home once the baby is feeding well, maintaining stable body temperature in KMC position and gaining weight. Consider discharge of the baby from the facility if 1. The kangaroo position is well tolerated by the baby and mother. 2. The condition of the baby is stable (vital signs normal). Respirations are normal without any difficulty in breathing. Temperature is within the normal range in the KMC position for at least 3 consecutive days (axillary temperature of 36.5 to 37.5o C). 3. There are no signs of infection, illness or danger signs. 4. The baby feeds well (with coordinated sucking and swallowing) and is exclusively or nearly exclusively breast feeding. 5. Gaining weight at the rate of at least 15-20 gram/kg/day for at least three consecutive days. 6. The mother and family members are confident to take care of the baby.
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CHAPTER 6: RECORDING AND REPORTING
6.1 INTRODUCTION The chapter provides a brief overview of recording and reporting system for caring of LBW babies through KMC at health facilities. Appropriate recording and reporting of the KMC unit is necessary to ensure appropriate data are collected to measure the outcome and impact of the program.
6.2 RECORDING AND REPORTING SYSTEM Details of service provided to stable LBW babies should be recorded in KMC register attached in Annex I. The KMC register should be filled by health worker involved in caring LBW babies through KMC. The KMC register contains information about 24 variables as outlined below:
IP no Sex of Baby Mothers name Birth Weight of Baby Caste and Ethnicity Code Date of KMC admission Mothers Address Time of KMC admission Contact Number Type of KMC practiced Age Date of Discharge from Health Facility Parity Weight at Discharge Last Menstrual Period Status at Discharge Expected Date of Delivery If dead, cause of death Gestational Age Status at Discharge Type of Delivery If dead, cause of death Date of Delivery Weight at 4th week
6.3 USE OF DATA FOR CONTINUOUS KMC Data from KMC register should be collected and analyzed monthly using the data summary sheet outlined in table 2. The information should be shared with health workers involved in providing KMC so as to promote discussions on findings and use of data for continued KMC. The information can also be shared with relevant stakeholders involved in decision making.
Table 2: Data Summary Sheet
S.N. INDICATOR FREQUENCY a) Number of deliveries b) Number of LBW babies c) Number of stable LBW babies d) Number of LBW referred to NICU from this ward. e) Number of LBW received KMC f) Continuous KMC g) Intermittent KMC h) Number of neonatal deaths at health facility i) Number of deaths among LBW babies
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REFERENCES
1. World Health Orgnatization. Kangaroo Mother Care. WHO. 2003. 914 p.
2. Katz J. Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries : a pooled country analysis. 2013;382(9890):417–25.
3. Access. USAID. Kangaroo Mother Care, Facilitator‟s Guide. The ACCESS Program, Jhpiego. The ACCESS Program, Jhpiego; 2009. 248-250 p.
4. World Health Orgnatization. Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. [Internet]. Maternal and …. 2011. Available from: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Guidelines+on+Optimal+fe eding+of+low+birth-+weight+infants+in+low-and+middle-income+countries#0
5. United Nations Children‟s Fund and World Health Organisation. Low Birthweight: Country, regional and global estimates. UNICEF, New York. Last accessed from http://www. …. 2004. 1-31 p.
6. Lee ACC, Katz J, Blencowe H, Cousens S, Kozuki N, Vogel JP, et al. National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010. Lancet Glob Heal. 2013;1(1).
7. Population Division. Ministry of Health and Population. New Era. Macro International Inc. Nepal Demographic and Health Survey 2011. 2011.
8. Population Division. Ministry of Health and Population. New Era. Macro International Inc. Nepal Demographic And Health Survey 2006 [Internet]. Health (San Francisco). 2007. Available from: http://www.measuredhs.com/pubs/pdf/FR191/FR191.pdf
9. Hirve SS, Ganatra BR. Determinants of low birth weight: a community based prospective cohort study. Indian Pediatr. 1994;31(10):1221–5.
10. Metgud CS, Naik VA, Mallapur MD. Factors affecting birth weight of a newborn--a community based study in rural Karnataka, India. PLoS One [Internet]. 2012;7(7):e40040. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3390317&tool=pmcentrez&render type=abstract
11. Vega J, Sáez G, Smith M, Agurto M, Morris NM. [Risk factors for low birth weight and intrauterine growth retardation in Santiago, Chile]. Rev Med Chil [Internet]. 1993;121(10):1210–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8191127
12. Lunze K, Hamer DH. Thermal protection of the newborn in resource-limited environments. Journal of Perinatology. 2012. p. 317–24.
13. Ghai,OP. Gupta P. Newborn infants. Newborn infants. 7th ed. New Delhi (India): CBS publications; 2010. p. 121.
14. Ministry of Health and Population. Government of Nepal. Integrated Management of Neonatal and Childhood Illness. 2071.
15. World Health Organization. Protecting promoting and supporting breast feedding: the special role of maternity services. A Joint WHO/UNICEF Statement. 1989.
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16. AIMS. Kangaroo Mother Care AIMS Protocol 2014.
17. Save the Children. Kangaroo Mother Care Clinical Practice Guidelines. 2004;
18. Division of Neonatology. Department of Pediatrics. All India Institute of Medical Sciences. feeding of Low Birth Weight Infants. AIMS-NICU protocols 2008. 2008. p. 401–4.
19. World Health Organization. Essential newborn care course: Director‟s guide. 2010; Available from: http://www.who.int/maternal_child_adolescent/documents/newborncare_course/en/
20. Ministry of Health and Population. Government of Nepal. FCHV classification card. 2006.
21. Bergh A-M. Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants (last revised: 1 September 2011).The WHO Reproductive Health Library; Geneva: World Health Organization.
22. Kangaroo mother care to reduce morbidity and mortality and improve growth in low-birth-weight infants http://www.who.int/elena/titles/kangaroo_care_infants/en/
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ANNEXES
Annex I
Kangaroo Mother Care Register
Mothers address Date of Caste/ LMP EDD Gestational Type of IP Contact 2 delivery S.N. Mother’s Name Ethnicity Name of Ward no. Age Parity (day/mth/y (day/mth/y age delivery no number (day/mth/ code1 VDC/ r) r) (wk) municipality yr) 1.
2.
3.
4.
1 Use caste and ethnicity classification of MoHP attached
2 Spontaneous Vaginal-1, Forcep-2, Vacuum-3
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Weight Date of Sex of KMC admission Type of Status gained Birth discharge Weight at Status at th KMC 4 If dead, at 4 If dead, since birth baby wt Date Time form HF discharge discharge Remarks Male-M practiced3 cause of death week5 cause of death at PNC (gms) (day/mth/y (AM/P (day/mth/ (gms) Female-F checkup r) M) yr) (gms)
3 Cotinuous-1, Inermittent-2
4 Alive-1, Referred-2, Dead-3
5 Alive-1, Dead-3
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Code Group Caste/Ethnicity 1. Biswokarma (Kami, Sunar, Od, Chunara, Parki, Tamata), 2. Pariyar (Damai, Darjee, Suchikar, Nagarchi, Hudrake), 3. Hill Sarki (Mijar, Charmakar, Bhul), 4. Gandharwa (Gaine), 5. Badi 1 Dalit 6. Kalar, 7. Kakaihiya, 8. Kori, 9. Khatik, 10. Khatwe (Mandal, Khadga), 11. Chamar (Ram, Mochi, Harijan, Rabidas), 12. Chidimar, 13. Dom (Marik), 14. Tatma (Tati, Das), 15. Dushad (Paswan, Hajara), 16. Dhobi (Rajak) Hindu, 17. Terai Pattharkatta, 18. Pasi, 19. Batar, 20. Mushahar, 21. Mestar (Halkhor), 22. Sarbhanga (Sarbariya) 23. Sonar, 24. Lohar, 25. Natuwa 1. Sherpa, 2. Bhote (Bhutia), 3. Thakali, 4. Byansi, 5. Wallung, 6. Chhairotan, 7. Dolpo, 8. Tangbe, 9. Tin Gaule Thakali, 10. Topkegola (Dhokpya) 11. Bara Gaunle Thakali, 12. Marphali Thakali, 13. Mugali, 14. Lhopa, 15. Lhomi (Shingsawa), 16. Siyar (Chumba), 17. Thudam, 18. Magar, 19. Tamang, 20. Newar 21. Rai, 22. Gurung, 23. Limbu 24. Bhujel, 25. 2 Janajati Hill Sunuwar, 26. Chepang, 27. Thami, 28. Yakkha, 29. Pahari, 30. Chhantyal, 31. Jirel, 32. Dura, 33. Lepcha, 34. Hayu, 35. Yehlmo, 36. Kushbadia, 37. Kusunda, 38. Phree (Free), 39. Bankaria,40. Baramo/ Baramu, 41. Larke, 42. Surel, 43. Kumal, 44. Majhi, 45. Danuwar, 46. Darai, 47. Bote, 48. Raji, 49. Raute 50. Tharu, 51. Dhanuk (Rajbanshi), 52. Rajbansi (Koch), 53. Satar/Santhal, 54. Jhagar/Jhangar, 55. Gangai, 56. Dhimal, Terai 57. Tajpuriya, 58. Meche (Bodo), 59. Kisan 1. Yadav, 2. Teli, 3.Kalwar, 4. Sudhi, 5. Koiri, 6. Kurmi, 7. Kanu, 8. Haluwai, 9. Hajam/Thakur, 10. Badhae, 11. Rajbhar, 12. Kewat, 13. Mallah, 14. Nuniya, 15. Kumhar, 16. Kahar, 17. Lodha, 18. Binna (Bing/Binda), 19. Gaderi/Bhediyar, 20. 3 Madhesi Mali, 21. Kamar, 22. Dhunia, 23. Barae, 24. Munda, 25. Badai, 26. Panjabi, 27. Bangali, 28. Marwadi, 29. Nurang, 30. Kayastha, 31. Rajput, 32. Jaine, 33. Brahman (Terai) 34. Baniya, 35. Amat, 36. Kathawaniya, 37. Rajdhob, 38. Kushbaha 4 Muslim 1. Muslim, 2. Churaute 5 Brahman/Chhetri 1. Brahman (Hill), 2. Chhetri (Hill) 6 Others 1. Thakuri, 2. Sanyasi/Dasnami, etc.,
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Annex II Case Scenario
Case Scenario: 1 Sumitra Devi has given birth to a male baby with birth weight of 1800 gram at 32 weeks of gestation. Initial normal newborn care along with cord care and eye care is done. On examination baby respiration is 40 breaths/min; heart rate is 120 beats/min, Temp is 360C in axillary region. Baby is active and well alert. Counsel the mother for Kangaroo Mother Care.
Case Scenario: 2 Ram Maya has given birth to a female baby with birth weight 1900 gram with 35 weeks gestational age. Initial normal newborn care along with cord care and eye care is done. On examination baby respiration is 46 breaths/min; heart rate is 140 beats/min, Temp is 360C in axillary region. Baby is active and well alert. Counsel the mother for Kangaroo Mother Care using Care Plus Wrap.
Case Scenario: 3 Dhana Maya has given birth to a male baby with birth weight 2000 grams with 38 weeks gestational age. Initial normal newborn care along with cord care and eye care is done. On examination baby respiration is 50 breaths/min; heart rate is 150 beats/min, Temp is 360C in axillary region. Baby is active and well alert. Counsel the mother for Kangaroo Mother Care using Traditional Wrap.
Case Scenario: 4 Mrs Yamuna devi has given birth to a male baby with birth weight 2300 grams with 38weeks gestational age. Initial normal newborn care along with cord care and eye care is done. On examination baby respiration is 50 breaths/min; heart rate is 150 beats/min, Temp is 36.70C in axillary region. Baby is active and well alert. Mother would like to start breast feeding for her baby. Help the mother to start breast feeding in this baby.
Case Scenario: 5 Mrs Ramadevi has given birth to a male baby with birth weight 2300 grams with 36 weeks gestational age. Initial normal newborn care along with cord care and eye care is done. On examination baby respiration is 52 breaths/min; heart rate is 140 beats/min, Temp is 36.70C in axillary region. Baby is active and well alert. As the baby is not able to breast feed properly. How will you fed this baby? Teach the mother to express breast milk and fed the baby through cup.
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Annex III Course Evaluation Please indicate your opinion of the course components using the following rate scale: 4-Strongly Agree 3-Agree 2-Disagree 1-Strongly Disagree
COURSE COMPONENT RATING
1. The trainers clearly stated their learning objectives.
2. The trainers communicated clearly and effectively.
3. The information presented in the course was new to me.
4. The trainer used a variety of audiovisual materials.
5. The trainers were interested in the subjects they taught. 6. The course content (or the content of the sessions) had sufficient theoretical knowledge.
7. The sessions were well organized.
8. The trainers asked questions and involved me in the sessions.
9. The content of the course was useful to my work. 10. The training has made me competent or skillful in providing counseling about Kangaroo Mother Care. 11. The training has made me competent or skillful in demonstrating how to do KMC. 12. The training has made me competent or skillful in demonstrating how to do breastfeeding. 13. The training has made me competent or skillful in demonstrating how to do expressed breast milk and cup feeding.
ADDITIONAL COMMENTS (use reverse side if needed)
1. What topics if any should be added (and why) to improve the course?
2. What topics (if any) should be deleted (and why) to improve the course?
3. The course length (2days) was: (circle one) Too long Too short Just right
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Government of Nepal Ministry of Health and Population Photo National Health Training Center
2069/12/22 TRAINING REGISTRATION FORM
Training Name :- ………………………………………………………………… Participant Trainer / Co-Trainer/co-ordinator
Training Site :- ………………………………………………………………… Region :- …………………………………………………………………
Starting Date :-………………..…..……………… Ending Date:-…………………...……………. Fiscal Year:-…..……………………………
PERSONAL INFORMATION
Name (in Block Letter) :- ……..………………………………………………………….………………………………………………………………… g]kfnLdf M ……………………………………………………………………….…………………………………………………………………......
Sex :- Male Female Other
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CURRENT HOME ADDRESS CASTE:-
District :- ………………………………………………………………………………………… Dalit Disadvantaged Janjati VDC/Municipality :-………………………………………… Ward No. :-…………... Disadvantaged Non Dalit Terai Caste Group Phone No.:- ……………………………………………………………………………………. Religious Minorities Relatively advantaged Janjatis Email:- …………………………………………………………………………………………….. Upper Caste Groups
Cadre Sponsore:-
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WORKING PLACE
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District :- ………………………………………………… VDC/Municipality :-……………………………………………………….… Ward No. :-…………...
Phone No.:- ………………………… ….…Fax:-………………………………Post :- ………………………………….……………Level:- …………………………
Civil S. Reg No(l;6/f]n g+=).:- ……………… HuRIC No.:-……………. Citizenship No.:-……………….. Council Reg. No:- …………………………
……………………………. Trainer Name & Sign. …………………………………………………………………………………………. Participant Sign.