lnTeGraTeD MaNaGeMenT of ChildHooD Illness

September 2002

Ministry of Health I Health Service unicef Republic of Ghana I I I I I I I I I I The Production of these Materials was Sponsored by I I 1414'1•) I BASICS II I Cttt#ttl ~ .• ,•. ,. I I I I I I I I I I I I Integrated Management of Childhood Illness was prepared by the World Health I Organization's Division for Control of Diarrhoeal and Respiratory Infections I (CDR), now the Division of Child and Adolescent Health (CAH), and UNICEF through a contract with ACT International, Atlanta, Georgia, USA, and adapted I by the Ministry of Health, Ghana. I I I I Contents I . I Introduction ...... I Feeding Recommendations ...... 2 I Exercise A ...... l l I I 1.0 Assess the Child's Feeding...... 13 I 2.0 Identify Feeding Problems ...... 15 I Exercise B ...... 17

I 3.0 Counsel the Mother about Feeding Problems ...... 18 3.1 Give Relevant Advice ...... 18

Exercise C ...... 22

3.2 Use Good Communication Skills ...... 27

3.3 Use the Mother's Card ...... 30

Exercise D ...... , ...... 33

4.0 Advise the l\lother to Increase Fluid During Illness ...... 36

5.0 Advise the Mother When to Return to a Health Worker ...... 37

Exercise E ...... 43

6.0 Counsel the Mother About her own Health ...... 47

Exercise F ...... 48

Annex:Mother's Card ...... 49

Answers to Short Answer Exercises ...... 55 • INTRODUCTION • • You have learned how to treat the sick child and how to teach the mother to continue • treatment at home. For many sick children, you will also need to assess feeding and counsel the mother about feeding. • For all sick children going home, you will also advise the mother when to return for • follow-up visits and teach her signs that mean to return immediately for further care. Recommendations on FOOD, FLUID, and WHEN TO RETURN are given on the • chart titled "Counsel the Mother" (called the COUNSEL chart in this module). • • LEARNING OBJECTIVES • This module will describe and allow you to practice the following tasks: * assessing the child's feeding • * identifying feeding problems • * counselling the mother about feeding problems • * advising the mother to increase fluid during illness • * advising the mother: • - when to return for follow-up visits, - when to return immediately for further care, • - when to return for immunisations. • * Counsel the mother about her own health • In practicing these tasks, you will focus on: • * giving relevant advice to each mother I * using good communication skills I * using a Mother's Card as a communications tool I Even though you may feel hurried, it is important to take time to counsel the mother carefully and completely. You have been learning communication skills throughout I this course. When counselling a mother, you will use some of the same communication skills that you have already practiced when assessing and treating the I child. I For example, you will ask the mother questions to detern1ine how she is feeding her I child. You will then listen carefully to the mother's answers so that you can make vour advice relevant to her. I I I I I I

I You will praise the mother for appropriate practices and advise her about any I practices that need to be changed. You will use simple language that the mother can understand. Finally, you will ask checking questions to ensure that the mother I knows how to care for her child at home. I I I I I I I I I I I I I FEEDING RECOMMENDATIONS

This section of the module will explain the feeding recommendations on the COUNSEL chart and any local adaptations. The recommendations are listed in columns for 5 age groups. You need to understand all of the feeding recommendations, but you will not need to explain them all to each mother. You will first ask questions to find out how her child is already being fed. Then you will give only the advice that is needed for the child's age and situation.

These feeding recommendations are appropriate both when the child is sick and when the child is healthy. During illness, children may not want to eat much. However, they should be offered the types of food recommended for their age, as often as recommended, even though they may not take much at each feeding. After illness, good feeding helps make up for weight loss and helps prevent malnutrition. When the child is well, good feeding helps prevent future illness.

Sick child visits are a good opportunity to counsel the mother on how to feed the child both during illness and when the child is well. • Recon1mendations: from Birth up to 6 months • • Birth up to The best way to feed a child from birth to • 6 Months of Age at least 6 months of age is to breastfeed • exclusively. Exclusive breastfeeding I means that the child takes only breastmilk and no additional food, water, or other I fluids (with the exception of medicines and vitamins, if needed). I I • Start breastfeeding within half an Breastfeed children at this age as often as hour after birth. they want day and night. This will be at I • Give only breastmilk as often as least l 0 times in 24 hours. the child wants, at least 10 times I during the day and night. Note: {/"other.fluids andfoods are • Breastfeed long enough to empty the breast at each already being given, counselling is I feeding. needed as described in section 3.1 of"this • Do not give water, sugar water, module. I gripe water, juice, pito, herbal preparations, koko, milk, or other I liquids or foods. I The advantages of breastmilk are described below. I Breastmilk contains all the nutrients needed by an infant. I It contains: ,.. Protein I ,.. Fat Lactose (a special milk sugar) I Vitamins A and C Iron I I These nutrients are more easily absorbed from breastmilk than from other milk. Breastmilk also contains essential fatty acids needed for the infant's growing brain, I eyes, and blood vessels. These fatty acids are not available in other milks. I Breastmilk provides all the water an infant needs, even in a hot, dry climate. The infant should not be given anything else. I Breastmilk protects an infant against infection. An infant cannot fight infection as I well as an older child or an adult. Through breastmilk, an infant can share his mother's ability to fight infection. Exclusively breastfed infants are less likely to get I diarrhoea, and less likely to die from diarrhoea or other infections. Breastfed infants are less likely to develop pneumonia, meningitis. and ear infections than non­ I breastfed infants. I I I I I

I Breastfeeding helps a mother and her baby to develop a close, loving relationship.

I Breastfeeding protects a mother's health. After delivery, breastfeeding helps the I uterus return to its previous size. This helps reduce bleeding and prevent anaemia. Breastfeeding also reduces the mother's risk of ovarian cancer and breast cancer. I It is best not to give an infant below the age of 6 months any milk or food other I than breastmilk. For example, do not give cow's milk, goat's milk, fonnula, cereal, or I extra drinks such as teas, juices, or water. Reasons: I Giving other food or fluid reduces the amount of breastmilk taken. Other food or fluid may contain germs from water or on feeding bottles or I utensils. These germs can cause infection. Other food or fluid may be too dilute, so that the infant becomes I malnourished. I Other food or fluid may not contain enough Vitamin A. Iron is poorly absorbed from cow's and goat's milk. I The infant may develop allergies, such as rashes. The infant may have difficulty digesting animal milk, so that the milk causes I diarrhoea, or other symptoms. Diarrhoea may become persistent.

I Exclusive breastfeeding will give an infant the best chance to grow and stay healthy.

Most babies do not need complementary foods before 6 months of age. Breastmilk remains the child's most important food, but at some time between the ages of 5 and 6 months, some children begin to need foods in addition to breastmilk. These foods are often called complementary or weaning foods because they complement breastmilk.

The mother should only begin to offer complementary foods if the child shows interest in semisolid foods, appears hungry after breastfeeding, or is not gaining weight adequately. The child may show interest by reaching for the mother's food, or by opening her mouth eagerly when food is offered.

It is important to continue to breastfeed as often as the child wants, day and night. The mother should give the complementary foods 1-2 times daily after breastfeeding to avoid replacing breastmilk.

4 • Recommendations for ages 6 months up to 9 months • • The mother should continue to breastfeed 6 Months up as often as the child wants, day and night. to 9 Months • However, after 6 months of age, • breastinilk cannot meet all the child's I energy needs. Therefore, from 6 months of age, all children should receive a thick, I nutritious complementary food. I • Breastfeed as often as the child The mother should gradually increase the I wants, at least 8 times during the day and night. amount of complementary foods given. • Give 3 times per day an I adequate* serving of a variety of The child should receive 3 times* daily foods without pepper. I (Give 4 times if not breastfed) 3/4 - l cup ( 150-200 ml) of a variety of • Give fruit every day. foods such as listed on the mother's card I Wash the fruit, mash or squeeze in addition to breast milk. as juice. •Feed new foods patiently, allowing I the child to get used to them. New foods should be fed patiently • Do not give water just before allowing the child to get used to them. I breastfeeding or other feeds. • Give breastmilk, not water after I naps. Fruits and solid foods such as yam, • The child should receive 3 times , plantain, rice and fish should be I daily 3/4-1 cup (150-200ml) of a mashed before serving the child. variety of foods I I The child should not be offered water just before breastfeeding or other feeds. The child should be given breast milk, not water after naps (sleep). I

It is important to actively feed the child. Active feeding means encouraging the child I to eat. The child should not have to compete with older brothers and sisters for food I from a common plate. He should have his own serving. The mother or another caretaker (such as an older sibling, father, or grandmother) should sit with the child I during meals and help get the spoon into his mouth. I An adequate serving means that the child does not want any more food after active feeding. I I Children at this age cannot take spicy foods. Complementary foods should therefore be prepared separately without pepper or the child's portion should be taken out I before adding pepper. I *!(the child is not hrcastfed. give complemc11tarvfiJ0ds 4 times daily.!fpossihlc. include.feedings o( formula milk by ctlp. However breastmilk substitutes are not as good for babies as breastmilk. I I I I I I Recommendations for ages 9 months up to 12 months I The mother should continue to breastfeed 9 Months up as often as the child wants, day and night. I to 12 Months Complementary foods should be I increased to 4 times* daily in addition to I breast milk. The child should be given 1- 1 114 cup I (200-250ml) of a variety of family foods I such as listed on the mother's card. It is important to wash the hands of the I • Breastfeed as often as the child wants. child and the caretaker before eating. • Give 4 times per day an I adequate* serving of a variety of The child's food should be served foods without pepper. separately in a clean bowl. I (Give 5 times if not breastfed) • Give fruit every day. Give fruit everyday in a form that the I Wash the fruit, mash, cut-up, or child can take (mashed, cut-up or squeeze as juice. squeezed as juice). I • Serve the child in a separate bowl and feed or supervise the child Some children will attempt to feed I during feeding. •Wash both adult's and child's themselves at this age. It is important to hands with soap and water before feed or supervise the child when eating. I feeding. • Do not give water just before An "adequate serving"** means that the I breastfeeding or other feeds. child does not want any more food after • The child should be given 1-1 114 active feeding. I (200-250ml) of a variety of foods. Do not offer the child a lot of water before I breastfeeding or meals. I

I Good complementary foods: 6-12 months I Good complementary foods are energy-rich, nutrient-rich, and locally affordable. I Examples are thick koko with added oil or groundnut paste and mashed solid foods such as fish. vegetables, beans, meat, eggs, and mashed fruits. If the child receives I formula milk, these and any other drinks should be given by cup, not by bottle.

I * !/"the child is 11or breastfed. give compfe111e11ta1yfoods 5 times daily.Ifpossible, include feedings ojfomwla milk by cup. However breastmilk substitutes are not as good for babies as breastmilk. I **A good daily diet should be adequate in quantity and include an energy-rich food (/"or example. thick cereal 1vi1h added oil): meal, fish, eggs, or pulses; andfi·uils and vegetables. I I I I I I > Porridge Give Fruit every day

Adequate quantities of thick (explain) koko made of Such as: pawpaw, banana, avo­ (akasa), millet, sorghum, cado pear, orange, pineapple, guinea corn or rice; ekwegbemi or other thick porridge like mango or watermelon tombrown and weanimix ~ ~ with sugar and enriched with one or more of the following: ~~lg palmoil or other vegetable oil, groundnut paste, shea butter, ;VI")~~ ;) ;),, 'I soya flour, bean flower, egg, milk or fish powder. ~ ~~·

Give Snacks in between main meals

E.g. bofrot, koose, maasa, bread, kulikuli, biscuit, For children 12 months and older, porridge should be served doughnuts, egg, roasted or fried plantain or yam

Family foods

Adequate quantities of waakye, rice, , banku, , aboloo, gari, yam, cocoyam, plantain, cassava, sweet potato, kdl:­ onte, , or tuozafi, served with at least one ladle of stew such as: kontomire, beans, garden egg, okra, tomato, agushi, A aleefu, bra, ayoyo, pumpkin,bokoboko all cooked with palm oil or other vegetable oil and mashed fish or meat ~ or with at least one ladle of such as: groundnut, palmnut, neri, okra, vegetable soup with dawadawa or green leafy vegetab~ssoup. All prepared with mashed fish, meat, egg or beans

Other family foods: Mpotompoto, gari-foto, with palmoil or other vegetable oil and mashed fish ¢r ------...... I I Recommendations for ages 12 months up to 2 years I I During this period the mother shou Id I 12 Months continue to breastfeed as often as the child up to wants. I 2 Years I By the age of 12 months, complementary foods are the main source of energy and I the variety and quantity of food should be I increased. I • Breastfeed as often as the child Family foods should become an important wants. part of the child's diet and be mashed or • Feed 3 times per day a variety of I family foods with no or little chopped so that they are easy for the child pepper. to eat. I • Give also, twice daily, snacks in between main meals. The child should receive 3 times daily I • Give fruit every day. • Serve the child in a separate I Y2 cups (250-300mls) of a variety of I bowl and supervise the child family foods such as listed on the when eating. mother's card. •Wash both adult's and child's ( 1 Y2 cups= 2 slices yam. 2 cocoyams, I I hands with soap and water before eating. adult fist kenkey with l-2 ladles of soup I • Do not offer child a lot of water or stew). just before eating. I In addition the child should be offered I twice daily a snack, in between main meals. I It continues to be important to serve the I child in a separate bowl and supervise the I child when eating. I I

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8 I Recommendations for ages 2 years and older I I I I 2 Years and Older At this age the child should be taking a variety of family foods in 3 meals per day. I I The child should also be given 2 extra I feedings per day. These may be family foods or other nutritious foods which are I convenient to give between meals. I • Feed 3 times per day a variety of family foods. Examples are listed on the mother's card. I • Give also. twice daily, snacks in between main meals. At this age it is still important to serve the • Give fruit every day. I Wash fruit before eating child separately in a clean bowl and • Serve child separately in a clean supervise the child when eating. I bowl and supervise eating. •Wash child's hands with soap Before the child starts eating, the child's I and water before eating. hands should be washed with water and I soap. I

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9 I I I Feeding recommendations for persistent diarrhoea I I I Children with persistent diarrhoea may have difficulty digesting milk other than breastmilk. They need to temporarily reduce the amount of other milk in their diet. I They must take more breastmilk or other foods to make up for this reduction. I I I ~Feeding Recommendations for PERSISTENT DIARRHOEA

I > If still breastfeeding, give more frequent, longer breastfeeds, day and night. I > If taking other milk: - replace with increased breastfeeding OR I - replace half the milk with thick porridge (see feeding recommendations). I > For other foods. follow feeding recommendations for the child's age. I I I Continue other foods appropriate for the child's age. I The mother should also give the child multivitamin I mineral supplement each day for 14 days. I The child with persistent diarrhoea should be seen again in 5 days for follow-up. I Further feeding instructions will be described in the module Follow-Up. I I I I I I

EXERCISE A I I

In this exercise you will answer questions about the feeding recommendations. I I I. Write a "T" by the statements that are True. Write an "F" by the statements I that are False. I a. __ Children should be given fewer feedings during illness. I b. __ A 3-month-old child should be exclusively breastfed. c. __ A very thin cereal gruel is a nutritious complementary food. I d. __ A 3-year-old child needs 5 feedings each day of family foods or I other nutritious foods. I e. __ A 5-month-old child should be breastfed as often as he wants, day I and night. I 2. When should complementary foods be added to the child's diet? (Your answer should include an age range plus three signs that the child needs to start I complementary foods.) I I I I I I 3. List 2 locally available, nutritious complementary foods: I I I I I I I I I 4. Kuukua is 9 months old. She is classified as NO ANAEMIA AND NOT I VERY LOW WEIGHT. She is still breastfed. Her diet also includes fruit juice, water, and a thick cereal gruel mixed with oil or mashed banana. How I many times per day should Kuukua be given these foods? I I 5. Samuel is 15 months old. He is classified as NO ANAEMIA AND NOT I VERY LOW WEIGHT. He still breastfeeds. but he also takes a variety of foods, including rice and bits of meat, vegetables, fruits, and yoghurt. How I can the mother judge whether she is giving an adequate serving to Samuel? I I I I I I 6. Ramon is 15 months old. He has PERSISTENT DIARRHOEA and NO DEHYDRATION. He is classified as NO ANAEMIA AND NOT VERY I LOW WEIGHT. He stopped breastfeeding 3 months ago and has been taking cow's milk since then. He also eats a variety of family foods about 5 times a I day. What recommendations should the health worker make for feeding I Ramon during persistent diarrhoea? I

I I

When should Ramon return for a follow-up visit?

When you have completed this exercise, please discuss your answers with a facilitator. I 1.0 ASSESS THE CHILD'S FEEDING I I You will assess feeding of children who: I

* are classified as having ANAEMIA OR VERY LOW WEIGHT, or I * are less than 2 years old. I However, if the mother has already received many treatment instructions and is I overwhelmed, you may delay assessing feeding and counselling the mother about feeding until a later visit. I

To assess feeding, ask the mother the following questions. These questions are at the I top of the COUNSEL chart and also at the bottom of the Sick Child Recording Form. I These questions will help you find out about the child's usual feeding and feeding during this illness: I I I ~Assess the Child's Feeding I Ask questions about the child's usual feeding and feeding during this illness. Compare the mother's answers to the Feeding Recommendations for the child's age in the box below. I ASK- >- Do you breastfeed your child? - How many times during the day? I - Do you also breastfeed during the night? I >- Does the child take any other food or fluids? - What food or fluids? I - How many times per day? - What do you use to feed the child? I - If very low weight for age: How large are servings? Does the child receive his own serving? Who feeds the child and how? I >- During this illness, has the child's feeding changed? If yes, how? I I I Note that certain questions are asked only if the child is very low weight for age. For these children, it is important to take the extra time to ask about serving size and I a·ctive feeding. I Listen for correct feeding practices as well as those that need to be changed. You may I look at the feeding recommendations for the child's age on the COUNSEL chart as yJu lis'.en to tl:e mother. If an answer is unclear. ask another question. For example, I ifthe motlier of a very-low-weight child says that servings are "large enough," you could ask, "When the child has eaten. does he still want more?" I I I I I I

I ...1·~i...... /l...... l ____ sH_O_R_T_A_N_sw_E_R_E_x_E_Rc_1_sE ____ I> I I I. Which sick children need a feeding assessment? I I I I I I I .....') Which of the questions in the box titled "Assess the Child's Feeding" are intended to find out about active feeding? I I I I I I

3. Which of the questions is intended to find out whether a feeding bottle is being used?

Check your own answers to this exercise by comparing them to the answers given at the end of this module. I I 2.0 IDENTIFY FEEDING PROBLEMS I It is impo11ant to complete the assessment of feeding and identify all the feeding I problems hefore giving advice. I Based on the mother's answers to the feeding questions, identify any differences between the child's actual feeding and the recommendations. These differences are I problems. Some examples of feeding problems are listed below. I Examples of feeding problems I I CHILD'S ACTUAL FEEDING RECOMMENDED FEEDING I A 3-month-old is given sugar A 3-month-old should be given only water as well as breastmilk. breastmilk and no other food or fluid. I A 2-year-old is fed only 3 times A 2-year-old should receive 2 extra feedings I each day. between meals, as well as 3 meals a day. I An 8-month-old is still A breastfed 8-month-old should also be exclusively breastfed. given adequate servings of a nutritious I complementarv food 3 times a day. I An 18-month-old child eats with Serve child in a separate bowl. other siblings from the same bowl. I I A 12-month-old child is not given A 12-month-old child should receive fruits any fruit. everyday. I I In addition to differences from the feeding recommendations, some other problems I may become apparent from the mother's answers. Examples of such problems are: I * Difficulty breastfeeding The mother may mention that breastfeeding is uncomfortable for her, or that I her child seems to have difficulty breastfeeding. If so, you will need to assess breastfeeding as described on the YOUNG INFANT chart. You may find that I the infant's positioning and attachment could be improved. I * Use of feeding bottle Feeding bottles should not be used. They are often dirty, and germs easily I grow in them. Fluids tend to be left in them and soon become spoiled or sour. The child may drink the spoiled fluid and become ill. Also, sucking on a I bottle may interfere with the child's desire to breastfeed. I I I I I I * Lack of active feeding I Young children often need to be encouraged and assisted to eat. This is I especially true if a child has very low weight. If a young child is left to feed himself, or if he has to compete with siblings for food, he may not get enough I to eat. By asking, "Who feeds the child and how?" you should be able to find out if the child is actively being encouraged to eat. I * Not feeding well during illness I The child may be eating much less, or eating different foods during illness. I Children often lose their appetite during illness. However, they should still be encouraged to eat the types of food recommended for their age, as often as I recommended, even if they do not eat much. They should be offered their favourite nutritious foods, if possible, to encourage eating. I * Feeding of hot/spicy foods I The young child cannot eat enough food with hot pepper in it. It makes him I drink a lot of water during feeds. He does not get satisfied and will not grow well. I * Not feeding soft/mashed foods I Young children should be fed soft/mashed foods because they do not have I enough teeth to chew. If a young child is given hard/unmashed foods he/she will find it difficult to eat, he will not eat enough. I * Feeding thin porridge I Dilute food fills the baby's stomach but does not give him enough energy to grow better. Thick porridge like akasa. tom brown and ekuegbemmi satisfy the I child better and for a longer period. I On the Sick Child Recording Form, next to the feeding questions, there is a box labelled "Feeding Problems." Use that space to record any feeding problem found. You will counsel the mother about these feeding problems. Example: Here is part of the Sick Child Recording Form for a 4-month-old child with the classification NO ANAEMIA AND NOT VERY LOW WEIGHT.

ASSESS CHILD'S FEEDING If child~ ANAEMIA OR VERY LOW WEIGHT or is less than 2 years FEEDING PRCELEMS • Do you breastfeed your child? Yes_V_ N:l _ . / If Yes, now rrany brres in 24 hours?::£. lirres. Do you breastleed during the night? Yes_ No_V No-f brea.si{tlJ • Does the child take any other food or fluids? Yes.Y!_ No oflen evt0L!:]l-1 If Yes. v.ha! food or fluids ? -form ld.-LQ ro Tfi.<., u{c 1-bw rrnny tirros por day?_ tirres. What do you use to feed the child? .f4€-dlna :boff'2. G7 vi vr_J (onn II very tw ~ght tor age: H::Jw large are sen.ings? ______-:::1"=--- I'()' I k. Does tr.a child recei'.-6 his ov.n sarl.ing? __ Who feeds tt1e child and how? • Di.iring Ille illness, has the child's feeding changed? Yes_ NJ i/'.. ----- If Yes, hew/? ______~~1+feedl~

16 I I I I EXERCISE B I In this exercise, there will be a role play of a feeding assessment. I Role Play Situation I

The child's name is Zenabu and she is 5 months old. Zenabu has no general danger I signs. She has: I NO PNEUMONJA: COUGH OR COLD I NO ANAEMIA AND NOT VERY LOW WEIGHT no other classifications I

The health worker has already told the mother about a soothing remedy for cough. I

Health worker: Use the questions at the bottom of the Sick Child Recording Form I (reprinted below) to assess feeding. Record the mother's answers and any feeding I problems. Below the form, also record correct feeding practices. I Mother: You will be given a card that describes your attitude and situation. I Observers: Listen carefully and record the mother's answers on the form below. Also record feeding problems and correct feeding practices. I Record any correct feeding practices below: I I I I ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years FEEDING PRCBLEl'vlS • Do you breastfeed your child? Yes_ No_ I If Yes, how many times in 24 hours?_ times. Do you breastfeed during the night? Yes_ No_ • Does the child take any other food or fluids? Yes_ No_ If Yes. Vvtiat food or fluids? ______I

How many ti mes per day?_ ti mes. What do you use to feed the child? ______If very low v.eight for age: How large are servings?------I Does the child recei\19 his own serving? __ Who feeds the child and how?______• During the illness, has the child's feeding changed? Yes_ No_ I If Yes, how? ______I I I I I

17 I I I I 3.0 COUNSEL THE MOTHER ABOUT FEEDING I PROBLEMS I This section of the module covers the third section of the COUNSEL chart. Since you I have identified feeding problems. you will be able to limit your advice to what is most I relevant to the mother. I 3.1 GIVE RELEVANT ADVICE I I If the feeding recommendations are being followed and there are no problems, praise the mother for her good feeding practices. Encourage her to keep feeding the I child the same way during illness and health! If the child is about to enter a new age group with different feeding recommendations. explain these new recommendations I to her. For example, ifthe child is almost 6 months old. explain about good complementary foods and when to start them. I If the feeding recommendations for the child's age are not being followed, explain I those recommendations. I In addition, if you have found any of the problems listed on the chart in the section I "Counsel the Mother About Feeding Problems." give the mother the recommended advice: I I I > If the mother reports difficulty with breastfeeding, I assess breastfeeding (see YOUNG INFANT chart) - As needed. show the mother correct positioning and I attachment for breastfeeding I I

I You will learn to check and improve positioning and attachment in the module Management ofthe Sick Young Infant. If the mother has a breast problem. such as I engorgement, sore nipples, or a breast infection, then she may need referral to a I specially trained breastfeeding counsellor (such as a health worker who has taken Breastjeeding Counselling: A Training Course) or to someone experienced in I managing breastfeeding problems. I I I I I I > If the child is less than 6 months old and is taking other milk or foods: I - Build mother's confidence that she can produce all the I breastmilk that the child needs. - Suggest giving more frequent, longer breastfeeds day and I night, and gradually reducing other milk or foods. I If other milk needs to be continued, counsel the mother to: I - Breastfeed as much as possible, including at night. - Make sure other milk is correctly and hygienically I prepared and given in adequate amounts. - Finish prepared milk within an hour. I I If a chi Id under 6 months old is receiving food or fluids other than breastmilk. the goal is to gradually change back to more or exclusive breastfeeding. Suggest giving I more frequent. longer breastfeeds, day and night. As breastfeeding increases, the I mother should gradually reduce other milk or food. Since this is an important change in the child's feeding, be sure to ask the mother to return for follow-up in 5 days. I

In some cases, changing to more or exclusive breastfeeding may be impossible (for I example, if the mother never breastfed, if she must be away from her child for long periods, or if she will not breastfeed for personal reasons). In such cases, the mother I should be taught how to correctly prepare cow's milk or other breastmilk substitutes I and use them within an hour to avoid spoilage. It is important to use the correct amount of clean, boiled water for dilution. I I I > If the. mother is using a bottle to feed the child I - Recommend substituting a cup for the bottle. - Show the mother how to feed the child with a cup. I I I I A cup is better than a bottle. A cup is easier to keep clean and I does not interfere with breastfeeding. To feed a baby by cup: I * Hold the baby sitting upright or semi-upright on your lap. I * Hold a small cup to the baby's lips. Tip the cup so the liquid just reaches the baby's lips. I I I I I I * The baby becomes alert and opens his mouth and eyes. I - A low-birthweight baby takes the milk I into his mouth with the tongue. A full-term or older baby sucks the I milk, spilling some of it. I * Do not pour the milk into the baby's I mouth. Just hold the cup to his lips and let him take it himself. I * When the baby has had enough, he I closes his mouth and will not take more. I I I > If the child is not being fed actively, counsel the I mother to:

I - Sit with the child and encourage eating. - Give the child an adequate serving in a I separate plate or bowl. I I I I I I I

I This mother is actively This child must compete with siblings I feeding her child. and may not get enough to eat. • > If the child is not feeding well during illness, counsel • the mother to: • - Breastfeed more frequently and for longer if possible. - Use soft. varied. appetizing. favourite foods to • encourage the child to eat as much as possible, and offer frequent small feedings. • - Clear a blocked nose if it interferes with feeding. - Expect that appetite will improve as child gets better. • • Even though children often lose their appetites during illness, they should be • encouraged to eat the types of food recommended for their age, as often as • recommended. Offer the child's favourite nutritious foods to encourage eating. Offer small feedings frequently. After illness, good feeding helps make up for any weight • loss and prevents malnutrition. Offer 1 or 2 extra feeds per day for 2 weeks after the child gets better. •I I I I I I I I I I I I I I I I I I I I I I I I I EXERCISE C I

I In this exercise you will identify feeding problems and relevant advice for written I cases. I None of these cases needs referral. The health worker has asked the questions to assess feeding. Read the information about feeding on the recording form. Then I describe the correct feeding practices, feeding problem(s) and relevant feeding advice.

I I. The child is 2 months old and is classified as NO ANAEMIA AND NOT I VERY LOW WEIGHT. The mother has started giving formula milk and is thinking of stopping breastfeeding soon. She thinks that her child may gain I more weight on formula milk than breastmilk.

I Briefly describe the feeding problems in the box on the right of the form.

I What is this mother doing correctly to feed her child? I A.5SESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years FEEDING PRCBLEMS • Do you breastfeed your child? Yes~ f\b _ I If Yes. hoo rrany tirres in 24 hours? 2_ tirres. Do you txeastfeed durirg the night? Yes v1 No_ • Does the child take any other food or fluids? Y~_L_ No I If Yes. v.hat food or fluids? -fOrrrtl.{J.p, m itlZ H:Jw rrony tirres per day? 2:00 tirres. What do you use to feed the child?feed/19 bvHt: If \€fY low \'.eight for age: H:Jw large are ser'.1ngs? ______Does the child recei-.e his o'Ml ser'.1ng? _Who feeds the child ard how?____ _ • Durirg the illness, has the child"s feeding changed? Yes_ l'-b ~ If Yes, h:Nf! .

What feeding advice is needed? I

2. The child is 15 months old and has VERY LOW WEIGHT. The child shares I a plate with 3 brothers and sisters and sometimes does not get much food. I Briefly describe the feeding problems in the box on the right of the form. I I

FEEDING PRC8LEM3 I I I I I I What is this mother doing correctly to feed her child? I I I What feeding advice is needed? I I I I I I I I I I I I I I I I I I

I 3. The child is 2 years old and has ANAEMIA. He has some palrnar pallor but is not very low weight for age. The child has PERSISTENT DIARRHOEA. NO I DEHYDRATION. and MALARIA. I Briefly describe the feeding problems in the box on the right of the form. I What is this mother doing correctly to feed her child? I

I A.5SESS CHILD'S FEEDING If child has NON'. MIA OR VERY LOO WEIGHT or is less thM 2 years FEEDING PRC8LEMS • Do you b-eas:leed yOJr ctlld? Yes_ I'()~ I If Yes, hew rrany (mas in 24 h::lurs? _ti rres. Do yoo b'easlfeed d.Jring the night? Yes_ f\b_ • Does the child take any other f~ a fluids? Yes V f\b ['_..., · ~ I If Yes, vJiat food er fuids? j(,9\c_ \) ~ :;1.-fMRi\.S ~ \ ~ ~ . 1-bw rrany tirres per clay?_ tirres. What do you use to feed the child? -l-l..l.IC.Uol4-1'-K.>1-..llUU""­ I lf Vl?f'/ low v.eighl fa age: 1-bw large are senirgs?-:------Does the child recei-.e his OW'l ser\oing? __ Wh::l feeds the cnld ~ row? _____ • wring the illness, has lhe cnld's feeding changed? Yes_ I'()~ I ~Yes,OOW? ______I I What feeding advice is needed? I I I

I 4. A11 I I-month-old is classified as NO ANAEMIA AND NOT VERY LOW WEIGHT. He is primarily breastfed but normally also takes other fluids and I thin koko twice a day. He does not use a feeding bottle. During the illness, I his mother has stopped giving koko and given more breastmilk. His mother believes that, before I year of age. children do not really need food in addition I to breastmilk. Foods available to the family are koko. bread, rice, cooking oil, vegetables, fruits. and occasionally fish and eggs. I The Sick Child Recording Form for this child is on the opposite page. Briefly I describe his feeding proh/em(s) in the appropriate hox on theform. I Thenf(J/d the edge ofthe form hack and write the relevant advice on the I rei•ersc side. I When you have finished this exercise, discuss your answers with a facilitator. I I I I I I I I Name: _MANAGEMENT OF THE SICK ~~~~o,tG~Ji~ONvJe~g~t:UP T~ 5 v;:RT~mperature ?, i ·c I ASK: Whal are the chile's problems? For pre cl.em Initial visit? - Follow-up Visit? -

CHECK FOR GENERAL DANGER SIGNS lGeneral danger sign pre,sent? I •NOT ABLE TO DRINK OR BREASTFEED • LETHARGIC OR UNCONSCIOUS I Yes No/ •VOMITS EVERYTHING • CONVULSING NOW . Remember to use danger sign •HISTORY OF CONVU_SIONS I when selecting classlflcallons I DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes_No_L I I • For how long? __ Days • Count the brealhs in one minute. I breaths per minute. Fast breal.,ing? I • Look chest 1ndrawing. I • look and listen for slridor. I -- DOES THE CHILP HAVE DIARRHOEA? Yes - NoL I •For how long? __ Days • Look at the child's general condition. ls lhe chLd: • Is there blood in the s:ools? Lethargic or unconscious? Restless or irritable? I • Look for sunken eyes. • Offer the child fluid. Is the cnild: Not able to drink or drinking poorly? I Drinking eagerly, thirsty? • Pinch the skin of the abdomen. Does it go back: I Very slowly (longer than 2 seconds)?

Slowly? i ~DOES THE CHILD HAVE FEVER? (by history/feels ho~~{~~re 37.5°C or above)) YesL No_ i I • For how long? __ Days • Lock or feel for stiff neck. • If more than 7 days. nas fever been I present every day? Look for signs of MEASLES· I tv1ala '( 1'c1 • Has child had measles within • Generalized rash and the last three months? • One of these: cough, runny nose, or red eyes. I -· ...... ·-~-----.-.-. ------,-~- --··~------·-··-----··- .. J__ .. _, .. , .. -· --·--·····- .. -. ,_ .. ·- ···---· -· -·-----·--- -·--· ------If the child has measles now • Loo« for mouth ulcers. I or within the last 3 months: If Yes. are they deep and extensive? I I I • Look for pus draining from the eye ! • Look for clouding of the cornea - I DOES THE CHILD HAVE AN EAR PROBLEM? ~/ -Ac1ftc .=tciy- • Is lhere(ear pain?\ • Look for~~s draining fro~ the ear) I • Is th er( ear disch~e~ • Feel for tender swellirlgoehlnd the ear. .- ....+·. If Yes. for how 1ong? Days Jnt:f-u' C·r; ' I THEN CHECK FOR MALNUTRITION ANO ANAEMIA No -Ancu1Y1•cl • Look for visible severe wasting. 1 • Look for palmar pallor. and !Jot '/2r(. I Severe palmar pallor? Some palmar pallor? LcL:.., • Look for oedema of both feel. l0~~ OP~ ~110:-v f:~v-;-y (Da:e) I -ASSESS CHILD'S FEEDING If child has ANAEMIA OR VERY LOW WEIGHT or Is less than 2 years FEEDING PROBLEMS • Do you breastfeed your child? YesJL'.:' N\) __ _,. I !fYes, how many times in 24 hours? b times. Qo you breastfeed during the night? Yes J No_ • Does the child take any other food or fl~ds? Yes~ No~ I If Yes. what food or fluids ? 0JCl ( \'., j Ll f CE ; Ii t'l Kr-,ko How many times oer day?_ times. What do pu use to feed the -child? <:::.~::cc p thc;Jx\fl l-t I If very low weight for age: How large are servings? -- Does t~e child receive how. own serving? __ Who feegs the child and how? I

ASSESS OTHER PROBLEMS: I I I I I I TREAT Remembu to refer any child who has a danger sign and no other I severe ctasslflcation. I I I I I I I I I I I I I I I I I I

I Actvise mother when 10 return immediately Give any immunisations and/or vitamin A needed today: 117P!CJ.S,/eEf I and UPJ/ow fb1/Clr Feeding advice: J - · I .....__..... '--' I I I I I I I I I 3.2 USE GOOD COMMUNICATION SKILLS I I When counselling mothers, it is important to use the following skills: I I ASK and LISTEN: You have already learned the impo11ance of asking questions to assess the child's feeding. Listen carefully I to find out what the mother is already doing for her child. Then you will know what she is doing well, and I what practices need to be changed. I PRAISE: It is likely that the mother is doing something helpful I for the child, for example. breastfeeding. Praise the mother for something helpful she has done. Be sure I that the praise is genuine, and only praise actions that are indeed helpful to the child. I I ADVISE: Limit your advice to what is relevant to the mother at this time. Use language that the mother will I understand. If possible, use pictures or real objects to help explain. For example, show amounts of fluid in a I cup or container. I Advise against any harmful practices that the mother I may have used. When correcting a harmful practice, be clear, but also be careful not to make the mother feel I guilty or incompetent. Explain why the practice is harmful. I I CHECK UNDERSTANDING: Ask questions to find out what the mother understands I and what needs further explanation. A void asking leading questions (that is, questions which suggest the I right answer) and questions that can be answered with a simple yes or no. I I Examples of good checking questions are: "What foods will you give your child?" "How often will you give I them?" If you get an unclear response, ask another checking question. Praise the mother for correct I understanding or clarify your advice as necessary. I I I I ,,·, I I I I I ~~~~~j~'~~~S-HO_R_T_A_Ns_w_E_R_E_XE_R_C_ISE~~~_._I~ I I. How could you restate the following advice in simpler words? I I Givefoods that are high in energy and nutrient content in relation to volume. I I I

I 2. The mother of an 8-month-old girl says that her child usually takes infant I formula by cup about 5 times a day and plain koko 3 times per day. The mother stopped breastfeeding about I month ago when she had to return to I work. which requires that she be away from the child for I 0 hours each work day. The child has taken the same amount of food during the illness. Which I of the following comments are appropriate when counselling this mother'? I (Tick appropriate comments.) I a. You should still be breastfeeding this child.

I --b. It is good that your child is still eating as usual during the illness. I I C. It is good that you are using a cup instead of a feeding bottle. I d. Your child needs food more often. Try to increase the number of times you give the koko to 5 times a day. I e. The cereal is good for your child. Add a little oil and some I powdered fish or groundnut paste to the koko. I Then it will be even better for your child. I I I I I I I I I I 3. You are talking with the mother of a 15-month-old child who is no longer I breastfed. The child has PERSISTENT DIARRHOEA. He normally takes 2 feedings of infant formula and I meal of family foods each day. His diet has I not changed during the diarrhoea. Which of the following are appropriate to say when counselling this mother? (Tick appropriate comments.) I I a. You were right to keep feeding your chi Id during the diarrhoea. He needs food to stay strong. I

b. Your child needs more food each day. Try to give him 3 family I meals plus 2 feedings between meals. I c. Infant formula is very bad for your child. I d. Your child may be having trouble digesting the infant formula, I and that may be the reason that the diarrhoea has lasted so long. I e. Give only half the usual milk and increase the amount of family foods to make up for this. I I 4. A health worker has just counselled the mother of a 5-month-old about starting I complementary foods. The first and second columns below show the health worker's first checking questions and the mother's responses. In the third I column, write another checking question to clarify that the mother knows how to feed the child correctly. I I First Checking Question Mother's Response Second Checking Question I

What are some good Thick. nutritious foods I foods to give when your baby is ready? I I When will you begin When he is ready I giving these foods? I I

Check your own answers to this exercise I by comparing them to the answers given at the end of the module. I I I I I

?Cl I I I 3.3 USE A MOTHER'S CARD I I A Mother's Card can be shown to each mother to help her remember appropriate food and fluids, and when to return to the health worker. The Mother's Card has words and I pictures that illustrate the main points of advice.

I An example of a Mother's Card was given to you with your course materials. This I card is reprinted in the Annex of this module. I Take a moment to study the Mother's Card given in this course. The card shows advice about foods. fluid, and signs to return immediately to the health worker. I There is also a place to tick appropriate fluids for diarrhoea and record when to return I for the next immunization. I There are many reasons a Mother's Card can be helpful: I It will remind you or your staff of important points to cover when counselling mothers about foods, fluid, and when to return. I I It will remind the mother what to do when she gets home. I The mother may show the card to other family members or neighbours, so more people will learn the messages it contains. I The mother will appreciate being given something during the visit. I I Multivisit cards can be used as a record of treatments and immunizations given. I I When reviewing a Mother's Card with a mother:

I 1. Hold the card so the mother can easily see the pictures, or allow her to hold it I herself. I 2. Explain each picture. Point to the pictures as you talk. This will help the mother remember what the pictures represent. I 3. Circle or record information that is relevant to the mother. For example, circle I the feeding advice for the child's age. Circle the signs to return immediately. I If the child has diarrhoea, tick the appropriate fluid(s) to give. Record the date of the next immunization needed. I I I I I I I 4. Watch to see ifthe mother seems worried or puzzled. If so, encourage questions. I 5. Ask the mother to tell you in her own words what she should do at home. I Encourage her to use the card to help her remember. I 6. Give her the card to take home. Suggest that she show it to others in her I family. - I If you cannot obtain a large enough supply of cards to give to every mother, keep several in the clinic to show to mothers. I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I EXAMPLE I Demonstration Role Play I In this example, your facilitator will counsel a mother about feeding. He will demonstrate communication skills and use of a Mother's Card. The child in this I example is named Akonor. He is 8 months old, has no general danger signs, and has: I NO PNEUMONIA: COUGH OR COLD MALARIA I NO ANAEMIA AND NOT VERY LOW WEIGHT I Tell the facilitator when you are ready for the demonstration to begin. During the demonstration, record infonnation on the fom1 below. Record any feeding problems I that the "health worker" uncovers. Below the form, record feeding advice given. I Notice use of the following communication skills as your facilitator points them out: I ASK and LISTEN I PRAISE, when appropriate ADVISE, using simple language and giving only relevant advice I I ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years FEEDING PRCBLEMS • Do you breastfeed your child? Yes_ l'b _ If Yes, how mmy tirres in 24 hours?_ tirres. Do you breastfeed during the night? Yes_ No_ I • Does the child take any other food or fluids? Yes No If Yes, 'Ahat food or fluids? --

I 1-bw rrany tirres per day?_ tirres. What do you use to feed the child? ______If very low v.eight for age: 1-bw large are servings? ______I Does the child receive his OVITT serving? __ Who feeds the child and how?____ _ • During the illness, has the child's feeding changed? Yes_ l'b _ If Yes, how? ______I I CHECK UNDERSTANDING

I Feeding Advice Given: I I I I I I I I I I I I EXERCISE D I In this exercise, there will be two role plays of feeding assessment and counselling. I Health worker: Ask the questions on the recording form to assess feeding. Identify I and record feeding problems. Record the feeding advice to be given. Then counsel the mother about feeding, using good communication skills. Use the FOOD section I of the Mother's Card. Feel free to refer to the COUNSEL chart as necessary. I Mother: Try to behave as a real mother might behave. For example, you may be I confused, timid, worried, or anxious to leave the clinic. You will be given a card with details about your child's feeding and age and suggestions about your attitude. I

Observers: Watch the role play and record information on the form given. Be I prepared to answer the questions in the module. I Role Play 1 I Tawia is a 7-rnonth-old boy with a cough and runny nose. He has no general danger I signs and has been classified as NO PNEUMONIA: COUGH OR COLD and NO ANAEMIA AND NOT VERY LOW WEIGHT. He has no other classifications. The I mother has been taught to soothe the throat and relieve the cough. In the role play the health worker will assess feeding and counsel the mother about feeding. I I I ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years FEEDING PRCELEMS • Do you breastfeed your child? Yes_ N:> _ I If Yes, h'"1w n'0ny tirres in 24 hours?_ tirres. Do you breastfeed during the night? Yes_ No_ • Does the child take any otner food or fluids? Yes_ No_ I If Y~. v.hat food or fluids? ______

·j"b.w rrany tirres per day?_ tii'.TllJS. What do you use to feed the child? ______I If very low 'height for age: f-bwlarge are servings? ______,0oe5 the child receive his 01M1 serving? __ Who feeds the child and how?____ _ • During the illness. has the child's feeding changed? Yes_ N:> _ I If Yes, rON? ______I I Feeding advice: ------I I I I I I I After the role play you will discuss the following questions: a. Did the health worker ask all of the necessary questions to assess Tawia's I feeding'? Did the health worker finish the feeding assessment before identifying the I feeding problems and giving advice'? I I b. What feeding problems did the health worker find? I I I c. Did the health worker give appropriate praise for something the mother had done? I I d. Did the health worker give advice relevant to this child's situation? I

I Was any advice given that \Vas not relevant? If so, what? I I e. Was the advice correct and complete for the child's age and any problems identified? I I f Did the health worker use clear, simple language'? I

I g. What checking questions were asked? Were they good checking questions? If they were answered incompletely or incorrectly, did the health worker clarify the advice? I I I I Role Plav 2

I Nii is a I 5-month-old boy with no general danger signs, diarrhoea with NO I DEHYDRA TJON, PERSISTENT DIARRHOEA, and VERY LOW WEIGHT (no pallor). Nii has no other classifications. His mother has been taught how to give I fluids on Plan A for diarrhoea. In the role play the health worker will assess feeding and counsel the mother about feeding. I I I I

I 14 ------··· I ASSESS CHILD'S FEEDING if child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years FEEDING PROOLEMS I • Do you breastfeed your child? Yes_ NJ_ If Yes, howrrany tirres in 24 hours?_timls. Do you breastfeed during the night? Yes_ No_ • Does the child take any other food or fluids? Yes_ No_ I If Yes, Wiat food or fluids? ______I 1-bw rrnny ti rres per day?_ ti ITTlS. What do you use to feed the child? ______If very low v.eight for age: 1-bw large are servings? ______Does the child recei1.e his O\Ml serving? __ Who feeds the child and how?____ _ I • During the illness, has the child's feeding changed? Yes_ NJ_ If Yes. h:NI? ______I Feeding advice:------· I I I I

After the role play you will discuss the following questions: I a. Did the health worker ask all the necessary questions to assess Nii's feeding? Did the I health worker finish the feeding assessment before identifying the feeding problems and giving advice? I I b. What feeding problems did the health worker find? I I c. Did the health worker give appropriate praise for something the mother had done? I I d. Did the health worker give advice relevant to this child's situation? I

Was any advice given that was not relevant? If so, what? I I I e. Was the advice correct and complete for the child's age and any problems identified? I f. Did the health worker use clear, simple language? I I g. What checking questions were asked? Were they good checking questions? If they I were answered incompletely or incorrectly, did the health worker clarify the advice? I I I I I I I I 4.0 ADVISE THE MOTHER TO INCREASE I FLUID AND CONTINUE FEEDING DURING I ILLNESS I During illness a child loses fluid due to fever, fast breathing, vomiting or diarrhoea. I The child will feel better and stay stronger if he drinks extra fluid to prevent dehydration. Extra fluid is especially important for children with diarrhoea: I these children should be given fluid according to Plan A or B as described on the I TREAT chart. Mothers of breastfeeding children should offer the breast frequently. I Also encourage the mother to continue feeding the child during illness. This will help to maintain the nutritional status of the child during the illness. After recovering, I advise the mother to give one or two extra feeds per day for 2 weeks to make up for the weight lost during the illness. Most children do not receive all the nutrients they I need to maintain their nutritional status during an illness. I Advice about food and fluid is summarized in the chart section below. Give this I advice to every mother who is taking her child home UNLESS she has already received many instructions and may be overwhelmed by more advice, or has already I been taught Plan A. I I I FOOD & FLUID I

I ~ Advise the Mother to Increase Fluid and Continue Feeding I during Illness I FOR ANY SICK CHILD: >- Breastfeed more frequently and for longer at each feed. I )> Increase fluid. For example, give soup, rice water. coconut water. fruit juice or clean water. >- Continue feeding I FOR CHILD WITH DIARRHOEA: I )> Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan B I on TREAT THE CHILD charl.

I ~ Advise the Mother to give 1 or 2 extra feeds per day for I 2 weeks after the child gets better I I I I I 5.0 ADVISE THE MOTHER WHEN TO RETURN I TO A HEAL TH WORKER I I EVERY mother who is taking her child home needs to be advised when to return to the health worker. She may need to return: I

for a FOLLOW-UP VISIT in a specific number of days (for example, when it I is necessary to check progress on an antibiotic), I IM MEDIATELY, if signs appear that suggest the illness is worsening, or I

for the child's next immunization (the next WELL-CHILD VISIT). I

It is especially important to teach the mother the signs to return immediately. You I learned these signs in the module Identify Treatment, and they are repeated in this I section of this module. These signs mean that additional care is needed for serious illness. I I I FOLLOW-UP VISITS I

In the module Identify Treatment, you learned that certain problems require follow-up I in a specific number of days. For example, pneumonia, dysentery, and acute ear infection require follow-up to ensure that an antibiotic is working. Persistent I diarrhoea requires follow-up to ensure that feeding changes are working. Some other I problems, such as fever or pus draining from the eye, require follow-up only if the problem persists. I

At the end of the sick child visit, tell the mother when to return for follow-up. I Sometimes a child may need follow-up for more than one problem. In such cases, I tell the mother the earliest definite time to return. Also tell her about any earlier follow-up that may be needed if a problem such as fever persists. I

The COUNSEL chart has a summary of follow-up times for different problems. I I I I I I I I I FOLLOW-UP VISIT I Advise the mother to come for follow-up at the earliest time I listed for the child's problems. If the child has: Return for I follow-up in: I PNEUMONIA DYSENTERY I 2 days MALARIA, if fever persists I MEASLES WITH EYE OR MOUTH COMPLICATIONS I PERSISTENT DIARRHOEA ACUTE EAR INFECTION I CHRONIC EAR INFECTION 5 days FEEDING PROBLEM I ANY OTHER ILLNESS, if not improving

I PALLOR 14 days I VERY LOW WEIGHT FOR AGE 30 days I I Notice that there are several different follow-up times related to nutrition: I If a child has a feeding problem and you have recommended changes in feeding, follow-up in 5 days to see ifthe mother has made the changes. You I will give more counselling if needed.

I If a child has pallor. follow-up in 14 days to give more iron. I If the child has VERY LOW WEIGHT. additional follow-up is needed in 30 I days. This follow-up would involve weighing the child. re-assessing feeding practices. and giving any further advice needed from the COUNSEL chart. I

I If your clinic has a regular session reserved for counselling about feeding, schedule I follow-up visits for that time. If such sessions are not offered. schedule an individual visit for feeding counselling at a time when a health worker will be available to I discuss feeding with the mother. This health worker will need to know about the child's feeding problems, changes recommended. and the child's weight. This I information can be recorded in the patient chart, or in a special follow-up note. I I I I I I I 38 I \VHEN TO RETURN IMMEDIATELY I I Remember that this is an extremely important section of WHEN TO RETURN. I I I I I I I I WHEN TO RETURN IMMEDIATELY I - Advise mother to return immediately if the child has any of these signs: I Any sick child • Not able to drink or breastfeed • Becomes sicker I • Develops a fever I If child has NO PNEUMONIA: • Fast breathing COUGH OR COLD, also return if: • Difficult breathing I If child has Diarrhoea, also return if: • Blood in stool I • Drinking poorly I Use the Mother's Card when teaching the signs to return immediately. Use local I terms that the mother can understand. The Mother's Card presents the signs in both words and drawings. Circle the signs that the mother must remember. Be sure to I check the mother's understanding. I I NEXT WELL-CHILD VISIT I Remind the mother of the next visit her child needs for immunization unless the I mother already has a lot to remember and will return soon anyway. For example, if a mother must remember a schedule for giving an antibiotic, home care instrnctions for I another problem. and a follow-up visit in 2 days. do not describe a well-child visit needed one month from now. However, do record the date of the next immunization I on the Muther's Card. I I I I

39 I I I I .....1~=·~:""'1~:1L.11 ____sH_O_R_T_A_N_sw_E_R_E_X_E_Rc_1_sE ___ __._I> I I I. A 3-year-nld is being treated with an antibiotic for PNEUMONIA. The child has no I other problems that require follow-up. She has no fever.

I When should you ask the mother to return for follow-up? I I What are the signs that this child should return immediately? I I I I I 2. A 6-munth-old child is being treated for DYSENTERY and an ACUTE EAR I INFECTION. He has a fever. I When should you ask the mother to return for follow-up? I

I What are the signs that this child should return immediately? I I I I I I After the first follow-up visit, what additional follow-up will be needed? I I I I I I I I

3. A 3-month-old child has a feeding problem. She is taking infant fomula milk in I addition to breastmilk. You have advised the mother to increase breastfeeding and I gradually decrease the infant formula milk. The child also has NO PNEUMONIA: COUGH OR COLD. She has no fever. I

When should you ask the mother to retlKn for follow-up? I I What are the signs that this child should return immediately? I I I I I 4. A 5-month-old child has diarrhoea with NO DEHYDRATION and ANAEMIA OR I VERY LOW WEIGHT. She has no fever. She has some palmar pallor as well as very low weight. You have found a feeding problem. The child's main food is a I breastmilk substitute which is made with too much water and given in a feeding bottle. You have counselled the mother on how to prepare breastmilk substitute I correctly and give it with a cup. You have also counselled the mother about I complementary feeding. I When should you ask the mother to return for follow-up? I

What are the signs that this child should return immediately? I I I I I I After the first follow-up visit. what additional follow-up will be needed? I I I I Check your own answers to this exercise by comparing them to the answers given at the end of this module. I I I I I I I I I I EXAMPLE I Demonstration Role Play I In this example, your facilitator will continue the demonstration of communication I skills begun earlier in this module. He or she will continue to advise the mother of I Akonor, the 8-month-old child who has: I NO PNEUMONIA: COUGH OR COLD MALARIA I NO ANAEMIA AND NOT VERY LOW WEIGHT

I The health worker has already counselled the mother about feeding. This I demonstration will include advice on increasing fluid and when to return. I Tell the facilitator when you are ready for the demonstration to begin. I I I I I I I I I I I I I I I I I I I I I EXERCISE E I I In this exercise, there will be a role play of the entire process covered by the I COUNSEL chart: assessing feeding, identifying feeding problems, c9unselling about feeding, advising about fluid, and advising about. when to return. I

Health worker: Assess feeding, identify feeding problems, and counsel the mother I on feeding, fluid, and when to return. Use good communication skills. Use the Sick I Child Recording Form given in this exercise. Also use the Mother's Card. I Mother: Try to behave as a real mother might behave. For example, you may be worried, timid, confused, or anxious to leave the clinic. You will be given a card with I details about your child's illness, age, and diet and other inforn1ation. I Observers: Listen and watch carefully. On the recording form given in this exercise, I write the answers to the feeding questions and any feeding problems. Notice whether the feeding questions are used, advice is correct and complete, and good I communication skills are used. Be prepared to discuss the questions given on the next page. I

Role Play: I I Rejoice is 2 yea,·s and 2 months old. Her Sick Child Recording Form follows. She has VERY LOW WEIGHT (but no palmar pallor) and an ACUTE EAR INFECTION. I I The health worker has already given the mother instructions on wicking the ear and giving an antibiotic for the ear infection. Now the health worker will assess feeding I and counsel the mother about FOOD, FLUID, and WHEN TO RETURN. I I I I I I I I I I I Questions for Discussion after Role Play: I I. Were all the necessary questions asked about the child's feeding? Did the I health worker finish the feeding assessment before identifying the feeding I problems and giving advice? I

I 2. What feeding problems were identified. if any'? I I

I 3. Was the mother praised for something she has been doing correctly? I I I 4. Was counselling about FOOD complete and correct for the child's age and feeding problems? I I I 5. Was advice on FLUID complete and correct? I

I 6. Was advice on WHEN TO RETURN complete and correct? Did it include signs to return immediately? I I I 7. Did the health worker ask appropriate checking questions? I I I 8. If no to any of the above, what could have been done better? Be prepared to make suggestions. I I I I I I I I I

f? . MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO~ YEARS '::7 Name: nf:':::JO lffi _ Age: 2{;otfh S Weight: ~ kg Temperature ~·c3 I ASK: What are the child's problems? E'qr Initial visit? V Follow-up Visit? _ I CHECK FOR GENERAL DANGER SIGNS IGeneral danger sign~ent? • NOT ABLE TO DRINK OR BREASTFEED • LETHARGIC OR UNCONSCIOUS Yes_ No • VOMITS EVERYTHING • CONVULSING NOW Remember to use danger sign I • HISTORY OF CONVULSIONS I when selecting classifications I DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes_No~ I • For how long? __ Days • Count the breaths in one minute. ___ breaths per minute. Fast breathing? • Look for chest indrawing. I • Look and listen for strider -· DOES THE CHILD HAVE DIARRHOEA? -Y~No~ I • For how long? __ Days • Look at the child's general condition. Is the child· • Is there blood in the stools? Lethargic or unconscious? Restless or irritable? I • Look for sunken eyes. • Offer the child fluid. Is the child: I Not able to drink or drinking poorly? i I Drinking eageny. thirsty? I • Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? I SloWly? --·--- -- DOES THE CHILD HAVE FEVER? (by history/feels hoVternperature 37.5°C or above) Yes NoL I • For how long? __ Days • Look or feel for stiff neck. • If more than 7 days. has fever been I present every day? Look tor signs of MEASLES: • Has child had measles within • Generalized rash and the last three months? • One of these: cough, runny nose, or red eyes. .. - ~ ·-- .. I If the child has measles now • Look for mouth ulcers. or within the last 3 months: If Yes, are they deep and extensive? • Look for pus draining from the eye. I • Look for douding of the cornea. DOES THE CHILD HAVE AN EAR PROBLEM? Yesy No - Aec-tte -G:rr I • Is there(iia;-;;;;;;'?> • Look for~ from the ear. • Is therf'lear d1scharae.P • Feel for tender swelling behind the ear. lvi(€ct-Fov, If Yes, for how long?_}_ Days I -· THEN CHECK FOR MALNUTRITION ANO ANAEMIA I • Look for visible severe wasting. A rae.rn'.1q_ • Look for palmar pallor. Severe palmar pallor? Some palmar pallor' Or Ver::] I • Look for oedema of both feet. • Determine w~ for age i-Ow llVeJsfrt Very Low · Not Very Low_ I ---- CHECK THE CHILD'S IMMUNISATION AND VITAMINA STATUS . Tick immunisation(s) received •Circle immunisation(s) and/or vitamin A needed today Return for next immunisation I v / ..,,,..... or vitamin A on- BCG DTP/Hep~b 1 DPT/HepB/Hib 2 DPT~BIH1b3 Measles Vitamin A I \../'.'.'.' I oWo OP~ OP~ 01¥( Yellow Fever (Date) I .. __ .. ASSESS CHILD'S FEEDING If child has ANAEMIA OR VERY LOW WEIGHT or is less than 2 years I FEEDING PROBLEMS I • Do you breastfeed your child? Yes-__ No __ If Yes, how many times in 24 hours? times. Do you breastfeed during the night? Yes_ No- • Does the child take any other food or fiuids? Yes_ No_ I If Yes. what food or nuids 7 ·-·---· How many times per day?_ times. Whal do you use to feed lhe child? I if very low weight for age: How large are servings? Does the child receive how own serving? __ Who feeds the child and how? • During the illness. has the child's feeding changed? Yes -- No -- I If Yes, how? _.. ASSESS OTHER PROBLEMS: I I I I I I I

I TREAT Remember to refer.any.child who has a danger sign and no other I severe classlflcatlon. I I I I I I I I I I I I I I I I Advise mother when lo retum immediately. I Give any immunisations and/or vitamin A needed today: _____ Feeding advice: I I

I I I I I I I 6.0 COUNSEL THE MOTHER ABOUT HER OWN I HEALTH I I During a sick child visit, listen for any problems that the mother herself may be having. The mother may need treatment or referral for her own health problems. I I I I · / ~ Counsel the Mother About Her Own Health I I ,, If the mother is sick, provide care for her. or refer her for help.

,, If she has a breast problem (such as engorgement, sore nipples, breast infection}, provide care for her or I refer her for help. I ,, Advise her to eat well to keep up her own strength and health.

,, Check the mother's immunisation status and give her tetanus toxoid if needed. I

,, Make sure she has access to: I - Family planning I - Counselling on STD and AIDS prevention

I. I ,, Give the pregnant mother Chloroquine prophylaxis I ! I I I I I I I I I I I I I I I

47 I I I I I I

I EXERCISE F I Your course facilitator will lead a group discussion of common local feeding I problems observed during the previous clinical session.

I You will discuss the following questions: I Have the major local feeding problems been described in this module? If not I what are additional or different problems that you have observed? I I I I I Is the recommended advice for local feeding problems practical? Are mothers I likely to follow the advice? If not, can you think of alternative suggestions I that would improve feeding, be practical, and be followed by mothers? I I I I I I I I I I I I ANNEX: I I Mother's Card I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I ,,. " ~ Feeding Recommendations During Sickness and Health

O up to 6 Months 9 Months 12 Months 2 Years 6 Months up to up to up to and Older of Age 9 Months 12 Months 2 Years 1'2!1,@.

~~\. I

• Start breastfeeding within half an •Breastfeed as often as the child • Breastfeed as often as the child • Breastfeed as often as the child • Feed 3 times per day a variety of hour after birth. wants, at least 8 times during the wants. wants. family foods'. • Give only breastmilk as often as day and night. • Give 4 times per day an • Feed 3 times per day a variety of • Give also. twice daily. snacks' in the child wants, at least 10 times • Give 3 times per day an adequate' serving of a variety of family foods' with no or little between main meals. during the day and night. adequate' serving of a variety of foods without pepper. pepper. • Give fruit' every day. • Breastfeed long enough to foods without pepper. (Give 5 times if not breastfed) •Give also, twice daily, snacks' in Wash fruit before eating .fl empty the breast at each (Give 4 times if not breastfed) • Give fruit' every day. between main meals. • Serve child separately in a clean feeding. •Give fruit'. Wash the fruit, mash, cut-up, or • Give fruit' every day bowl and supervise eating. • Do not give water, sugar water, Wash the fruit, mash or squeeze squeeze as juice. • Serve the child in a separate •Wash child's hands with soap gripe water, juice, pita, herbal as juice. • Serve the child in a separate bowl bowl and supervise the child and water before eating. preparations, koko, milk, orother • Feed new foods patiently, and feed or supervise the child when eating. liquids or foods. allowing the child to get used to it. during feeding. •Wash hands with soap and water • Do not give water just before •Wash both adult's and child's before eating. breastfeeding or other feeds. hands with soap and water before • Do not offer child a lot of water •Give breastmilk, not water after feeding. just before eating. naps. • Do not give water just before breastfeeding or other feeds. I~~-;~ I~-:. · l- - l.{j,~ ~ i ..? -it~~~ ~-_;;;;~ -~ ~iV' - ~~ ~ i~ ~ L---· • See ...... for adequate servings of a variety of foods, snacks and fruits

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ------

Porridge Give Fruit every day

Thick (explain) koko made of maize (akasa), millet, sorghum, Such as: pawpaw, banana, avo­ guinea corn or rice; ekwegbemi or other thick pcrridges like cado pear, orange, pineapple, tombrown and weanimix ~ mango or watermelon ~ with sugar and enriched with one or more of the following: pal moil or other vegetable oil, groundnut paste, shea butter, . ~l)fl ... soya flour, bean flower, egg, milk or fish powder. ~:,;) "'\)~ ff) :) ;il ~~·

Give Snacks in between main meals ? For children 12 months and older, porridge should be served E.g. bofrot, koose, maasa, bread, kulikuli, biscuit, with bread, bofrot, koose, maasa, kulikuli, or biscuit doughnuts, egg, roasted or fried plantain or yam

Family foods

Waakye, rice, kenkey, banku, fufu, aboloo, gari, yam, cocoyam, plantain, cassava, sweet potato, kokonte, akple, or tuozafi,

served with at least one ladle of stew such as:kontomire, beans, garden egg, okro, tomato, agushi, aleefu, bra, ayoyo, pumpkin,bokoboko all cooked with palm oil or other vegetable oil and mashed fish or meat & or with at least one ladle of soup such as: groundnut, palmnut, neri, okro, vegetable soup with dawadawa or green leafy vegetabes soup. All prepared with mashed fish, meat, egg or beans

Other family foods: Mpotompoto, gari-foto, aprapransa with palmoil or other vegetable oil and mashed fish ¢r I FOOD & FLUID I

~ Feeding Recommendations for PERSISTENT DIARRHOEA

~ If still breastfeeding, give more frequent, longer breastfeeds, day and night.

~ If taking other milk: - replace with increased breastfeeding OR - replace half the milk with thick porridge (see feeding recomnendations).

~ For other foods, followfeeding recommendations for the child's age. ~-

.--- ·--- ~ Advise the Mother to Increase Fluidand Continue Feeding c:iJring Illness

FOR ANY SICK CHILD: ~ Breastfeed more frequently and for longer at each feed. ~ Increase fluid. For example, give soup, rice water.coconut water, fruit juice or clean water. ~ Continue feeding

FOR CHILD WITH DIARRHOEA: ~ Giving extra fluid can be lifesaving. Give fluid according to Plan A or Plan Bon TREAT THE CHILD chart.

~ Advise the Mother to give 1 or 2 extra feeds per day for 2 weeks after the child gets better ·----·--·

••••••••••••••••••••••••••••••• ------

lwHEN To RETURN I

~ Advise the Mother When to Return to Health Worker

FOLLOW-UP VISIT ·,1.1\'\';\B'..,1· ....rtfr~· ·' Advise the mother to come for followup at the earliest time listed for ,1~=] '"'·· the child's problems.

----·- --·--' ~.-., ' If the child has: Return for •. follow-up in: \. ""'•,, ------' ~, PNEUMONIA DYSENTERY '· MALARIA, if fever persists 2 days J1 '1 .· .. .i;::. MEASLES WITH EYE OR MOUTH COMPLICATIONS ·,, ---·---- PERSISTENT DIARRHOEA WHEN TO RETURN MMEDIATELY ACUTE EAR INFECTION ------·--·-- CHRONIC EAR INFECTION 5 days Advise mother to return immediately if the child has any of these signs: - ·----· FEEDING PROBLEM Any sick child • Not able to drink or breastfeed ANY OTHER ILLNESS, if not improving ·------• Becomes sicker IPALLOR 14 days • Develops a fever --·---·-·------·---·-·---- 30 days _':11,'~~l-~HTFOR AGE If child has NO PNE UMONIA: • Fast breathing COUGH OR COLD also return if: • Difficult breathing ------··------NEXT WELL-CHILD VISIT If child has Diarrho a, also return if: • Blood in stool Advise mother when to return for next immun5ation according to • Drinking poorly immunisation schedule. ------·-··------·-- -···- ---·--· I ANSWERS TO SHORT ANSWER EXERCISES: I I Exercise, Page 14 I I. These children need a feeding assessment: I children ivho have ANAEMIA OR VERY LOW WEIGHT children who are less than 2 vears old I

2. Does the child receive his own serving? I Who feeds the child and how? I 3. Wizar do _vou use to feed the child? I I Exercise, Page 28 I

/. Possible answer: I Give foods that will make your child strong and healthy. not just.fill him up. I Instead olgivingjusr plain rice or koko. mix it with some oil.for enerbry and some foods like mashed vegetables. meat. eggs, or.fish. I (You may have included examples of good complementary.foods in your local I area.) I 2. a. No tick. This comment would make the motherfeel guilty. You might find out [/she would he interested in resuming breastfeeding at night, I and i{so. refer her to a breastfeeding counsellor. I b. ,/ c. ,/ I d. No tick. Thefeeding recommendations say that a non-breastfed 8- month-old child should he given complementaryfoods 5 times per day. I This child is being given 5.formulafeedings plus 3 cerealfeedings per day, which is a total ol8feedings and is plenty/or her age. I e. ,/ I 3. a. ,/ I h. ,/ c. No tick. This comment may make the mother.feel guilty. It is better to I srate this as in "d" below. d. ,/ I e. ,/ I • • • • 55 • I I 4. 1st row: What kinds of thick, nutritious foods will you give? What are some examples offoods you will give? I 2nd row: How will you know when your baby is readyfor these.foods? What I signs will you lookfor? I Exercise, Page 40 I I. Flup: :! days Return immediately if- Not able to drink (since child is 3 years old. there I is no need to say "or breas(/eed"J I - Becomes sicker - Develops afever I 2. Flup: 2 days for dysentery I Return immediately if-Not able to drink or breas(/eed -Becomes sicker I -Drinking poorly I Since the child already has a/ever and blood in the stool. these signs are not I listed. You may have combined the signs. "not able to drink or breastfeed" and "drinking poorly." I Additional (o!lmv-up: 5 days(or ear infection I 3. Flup: 5 days for.feeding problem I Return immediately if-Not able to drink or breas(/eed I -Becomes sicker -Develops afever I -Fast breathing -D([ficult breathing I Flup: 5 days.for.feeding problem I 4. Return immediately if-Not able to drink or breas(/eed I -Becomes sicker -Develops a.fever I -Blood in stool I -Drinking poorly I You may have combined the signs. "not able to drink or breastfeed" and "drinking poorzv. 11 I I Additional.follow-up: 14 days/or pallor. 30 days for very low weight I I I I I