February
2012
OPERATIONAL GUIDE FOR
PROMOTING INFANT AND YOUNG CHILD FEEDING
PRACTICES THROUGH THE HEALTH SYSTEM
Ministry of Health and Family Welfare , Government of India |
About the Programme Guide
Section One: Planning and Implementation Guidelines
I. Introduction
II. Interventions for promoting IYCGF practices
II.A. Interventions at Health facility Level
II.B. Interventions during Community Outreach activities
II.C. Interventions during Community and Home based care
III. Training of key service providers located at health facilities
IV. Financial guidelines for IYCF interventions
V. Steps in planning and implementation of IYCF interventions
VI. Monitoring IYCF interventions
CONTENTS
1
Section Two : Technical Guidelines
Annexure
2
About the Operational Guide
Interventions promoting infant and young child feeding are known to improve child survival,
growth and intellectual development. Infant and Young Child Feeding (IYCF) practices are
simply a set of recommendations for appropriate feeding of new-born and children so that
they achieve optimal nutrition status and include the well-known and common practices of
(1) initiating breastfeeding within one hour of birth, (2) exclusive breastfeeding for the first
six months of life and (3) appropriate complementary feeding starting at 6 months of age.
This Operational Guide has been written specifically for the State and District RCH Officers,
Child Health & Nutrition Nodal Officers and Programme Managers in order to provide
guidance on the IYCF interventions that can be integrated into on-going maternal and child
health activities under NRHM.
The first section of the Guide contains detailed information about potential MCH contact
points and possibilities for IYCF practices to be promoted at the (1) Health Facility, (2)
Community Outreach and (3) Community (home based care) level. This Guide presents a
menu of options to the Programme Managers so that the set of activities that are best
suited locally can be selected and integrated into on-going programme activities.
The second section includes technical guidelines developed by Infant and Young Child
Feeding Chapter, Indian Academy of Paediatrics in 2009 through a process of National
Consultation.
It is expected that by using this Operational Guide, states will bring renewed focus and
vitality into promoting infant and young child feeding, which remains an important strategy
for tackling the problem of child malnutrition in the country.
3
4
I.
INTRODUCTION
Presently, 43 percent children in India under five years are reported to be underweight and
48 percent are stunted. Analysis of data from NFHS 3 (2007-08) shows that underweight
prevalence increases rapidly with child’s age from birth to age 20-23 months. Even during
first six months of life, when most children are breastfed, 20-30 percent are underweight.
One of the key reasons for malnutrition setting in early in life is the faulty and sub-optimal
infant and young child feeding practices , which is further compounded by factors such as
repeated episodes of childhood illnesses and low birth weight. Malnutrition in turn is a
contributory factor in one third to half of all deaths taking place in children under five years
of age.
Looking at the national scenario of child malnutrition, it is apparent that early preventive
action is crucial for accelerating reductions in infant and young child undernutrition and
related mortality, on a large scale. NRHM provides a valuable opportunity to bring greater
attention and commitment to promote IYCF interventions through the health system, both
at the health facility and community outreach level.
1.1 Defining Infant and Young Child Feeding
Infant and Young Child Feeding is a set of well-known and common recommendations for
appropriate feeding of new-born and children and include the following care practices:
Optimal IYCF practices
1. Initiation of breastfeeding immediately after birth, preferably within one hour.
2. Exclusive breastfeeding during the first six months of life (no other foods or fluids,
not even water; but allows infant to receive ORS, drops, syrups of vitamins, minerals,
medicines, when required)
3. Timely introduction of complementary foods (solid, semisolid or soft foods) at 6-8
months
4. Age appropriate complementary feeding for children 6-23 months, while continuing
breastfeeding. Children should receive food from 4 or more food groups1 and fed for
a minimum number of times2
5. Active feeding for children during and after illness
(1) Grains, roots and tubers, legumes and nuts; (2) dairy products ; (3) flesh foods (meat
fish, poultry); (4) eggs, (5) vitamin A rich fruits and vegetables; (6) other fruits and
vegetables
2
2 times for breasted infants 6-8 months; 3 times for breastfed children 9-23 months; 4 times
for non breastfed children 6-23 months
1
5
1.2 Benefits of optimal Infant and Young Child Feeding
Optimal infant and young child feeding is recognised as the most effective intervention to
improve child health, prevent malnutrition and reduce child mortality.
Early and exclusive breastfeeding is now recognised as one of the most effective
interventions for child survival. Scientific evidence shows that early initiation of
breastfeeding can reduce neonatal mortality. Neonatal and post-neonatal deaths are less
likely to occur in infants fed with colostrum.
Breastfeeding also provides constant positive interactions between mother and child which
can contribute to emotional and psychological development of infants.
Breastfeeding has a protective effect against child obesity and lowers the risk of several
chronic conditions including asthma, diabetes and heart disease, in adult life and thus
contributes to long-term benefits.
While breastfeeding provides optimal nutrition to the child, improvements in
complementary feeding can substantially reduce stunting and related burden of disease.
Optimal breastfeeding and complementary feeding practices together can prevent deaths in
children under five years by significantly reducing mortality from infections like diarrhoea
and pneumonia. In addition, these practices allow children to reach their full growth
potential and prevent irreversible stunting, as well as acute undernutrition.
In brief, adoption of IYCF practices by the families:
 Reduce the risk of child mortality
 Reduces the risk of infant and child hood illnesses
 Increases productivity by enhancing cognitive functions
 Reduces burden on health system and costs for societies by protecting against
chronic diseases
 Reduces cost of managing malnutrition (both under nutrition and obesity)
1.3 Infant And Young Child Feeding: Situation In India
Key indicators which are important to monitor IYCF practices include (1) early initiation of
breastfeeding (within the first hour), (2) exclusive breastfeeding among children less than six
6
months and (3) complementary feeding after six months together with continued
breastfeeding up to 2 years.
Early initiation of breastfeeding within 1 hour of birth is 25% as per NFHS 3; more recently
CES 2009 reported this to be 33.5%.
Only 46 percent of infants younger than six months are exclusively breastfed. Further
analysis of age wise data of NFHS 3 reveals that exclusive breastfeeding rapidly declines
from 1st month to 6th month of life and only about 20% continue to be exclusively breastfed
up to 6 months.
Introduction of complementary feeding along with continued breastfeeding in 56 percent
children 6-9 months of age.
As a result children are likely to falter in growth during this critical period of life. For this
situation to improve, infant and young child feeding interventions require to be scaled up in
the country through adequate resource allocation, capacity development and effective
communication at all levels of the health system.
7
II. INTERVENTIONS FOR PROMOTING IYCF PRACTICES
There are several entry points into the health system when mothers and children have
contact with the health service providers. For the purpose of this operational guide, actions
to promote infant and young child feeding have been grouped at the following three levels:
(1) at health facilities (2) during community outreach activities and (3) during community
and home based care.
The key contact points that are available at various levels are presented in the following
sections. Each state can, in addition, find other unique contact opportunities within the
NRHM activities. Various contact opportunities should be capitalised to include provision of
services that promote optimal IYCF practices, age-appropriate one-to-one infant feeding
counselling and support for the mothers, communication and demonstration of appropriate
practices.
II.A. KEY INTERVENTIONS AT HEALTH FACILITY LEVEL
Table 1: MCH Contact opportunities at the health facility
MCH Contact
opportunities at
health facility
during various
stages of the
lifecycle
Location
Actions & key practices to
be promoted
Facility Based
Delivery services All delivery Support for early initiation
points
of
breastfeeding
,
(including
colostrum feeding, and
Postnatal wards)
establishment of exclusive
breastfeeding;
Counselling
on
infant
feeding options in context
of HIV (for mothers
identified as HIV positive)
Inpatient services At all MCH
(sick
children facilities
/
admitted
to delivery
wards)
points
Group
counselling
on
maternal nutrition during
lactation and infant feeding
;
Health service
provider/s with
primary
responsibility
Health service
providers
with
supporting
role
SBA/NSSK
trained service
provider/s
conducting
delivery (ANM,
SN,
MO)
;
Nutrition
Counsellor or
Breastfeeding
Counsellor
where available
, at high load
facilities
Staff
Nurses;
Nutrition
Counsellor
(when available
at the facility)
Doctors, Staff
nurses
Medical
officer
Monitoring of lactation
and support to resolve any
8
problems
Outpatient
services
/consultations
(antenatal checkup, immunisation,
Healthy
Child
Clinic, sick child
contact, ICTC)
Age appropriate messages
regarding feeding of sick
child and child care
practices
At all MCH Group counselling on IYCF; Staff Nurses;
facilities/
Nutrition
delivery
Review of breastfeeding Counsellor
points
practices of individual child (when available
and
counselling
of at the facility) ;
appropriate infant feeding ICTC counsellor
practices;
Medical
officer
Review of feeding practices
and counselling & support
on
feeding options in
context of HIV (for mothers
identified as HIV positive)
Special new born Facilities
care units(SCNU, with special
NBSU)
new born
care units
and
stabilisation
units
Nutrition
Facilities
Rehabilitation
with NRC
Centres (NRC)
Counselling on feeding of
low birth weight and
preterm babies, age
appropriate feeding advice
before discharge ;
Staff Nurses;
Nutrition
Counsellor
(when available
at the facility)
Medical
officer
Counselling on feeding of Staff
Nurse, Medical
low birth weight and Nutrition
Officer
preterm
babies,
age Counsellor
appropriate feeding advice
before discharge
Review of feeding practices
of malnourished child and
counselling on age
appropriate feeding
practices;
Demonstration of food
preparation and sharing of
recipes for optimal use of
locally available foods
(before discharge from
NRCs)
9
1. Contact opportunities in a health facility are mainly:
A. During and after institutional delivery
With the launch of JSY, increased institutional delivery and skilled attendance at birth, there
is tremendous opportunity to promote early initiation of breastfeeding and exclusive
breastfeeding at all delivery points.
The key responsibility for communication and counselling of women who have delivered at
the health facility should be that of Staff Nurses and Medical Officers. ANMs posted at the
delivery points can also take on the primary role of informing mothers and supporting them
to initiate breastfeeding soon after birth.
Staff nurses may be mobilised (from labour room, postnatal ward; from new born care
facility or NRC as feasible in facility specific context) by rotation specifically for the purpose
of educating mothers in the postnatal wards and for solving common problems related to
initiation of breastfeeding.
In high MCH case load facilities (eg; a District Hospital), Nutrition Counsellor/s trained in
IYCF and lactation management or Lactation Counsellor/s may be employed for providing
support to mothers delivering in the health facility or referred from peripheral health
facilities for any reason.
B. Inpatient services for children
Inpatient services for the children comprise of the following:



Sick child admission
Nutrition Rehabilitation Centre
New-born care facilities (Stabilisation units, Special New-born Care Units)
The key responsibility for communication and counselling of mothers /caregivers is that of
Staff Nurses and Medical Officers.
In high case load facilities (e.g.; a District Hospital), Nutrition Counsellor/s or Lactation
Counsellor/s may be employed.
Where a Nutrition Counsellor is already associated or part of the NRC, his/her services
should be used to educate and counsel mothers with young children admitted to the
hospital.
10
Nutrition/ Breastfeeding Counsellor trained in lactation management may also be employed
at health facilities with Special New-born Care units. As many babies admitted to the SCNU
are likely to be low birth weight and/ or preterm and sick babies , optimal support for
feeding has to be provided in the follow up period (up to one year in some cases) after
discharge. Nutrition counsellor can provide counselling and support not only to mothers/
caregivers of children discharged from SCNU but also other babies including LBW and
preterm babies born at these facilities or referred from peripheral health facilities.
C. Outpatient services and consultations for pregnant women, mothers and children
Outpatient services comprise of the following:
 Antenatal clinic
 Immunisation clinic
 Lactation Support Centre
 Sick Child consultation in outpatient department
 Integrated Counselling and Testing Centres
The key responsibility for communication and counselling of mothers /caregivers is that of
Staff Nurses and Medical Officers. ANMs posted at a health facility can also take on this role.
In high case load facilities (e.g.; a District Hospital), Nutrition Counsellor/s or Lactation
Counsellor/s may be employed. The services of the Nutrition Counsellor, trained in IYCF,
should be used to provide group counselling to pregnant women and mothers of children
presenting in Outpatients Department on daily basis and on designated days (e.g.
immunization day, antenatal clinic).
Immunisation Clinic:
Presently one of the important services offered in outpatient area of the health facility is the
provision of immunization through Immunisation Clinics or Immunisation Rooms.
Immunisation services are offered on fixed days during the same timing as outpatients’
services. They already have a designated staff to provide immunisation services. The
mandate /scope of the immunisation clinics can be expanded so as to include provision of
other preventive child health services for children under five years.
This will make the visit to immunisation clinic a value added proposition for the
parents/caregivers as children will benefit from a package of preventive and promotive
health services.
11
The package of services can include:
1. Immunisation
2. Growth monitoring (growth curve /pattern may be reviewed and age appropriate advice
given; when MCP card is available with the parents/ caregiver, it should be used as the
reference point)
3. Micronutrient supplementation (Vitamin A is already being given along with
immunisation; deworming syrup/tablets and IFA can be provided with adequate
counselling)
4. Communication and counselling on IYCF
5. Information about services available through community outreach
It is possible to provide these services through existing staff. Additional capacity building will
be required so as to equip them with requisite skills; at least one or two staff will require
advanced set of skills (e.g.; IYCF counselling, lactation management).
Additional staff may be recruited, if required, for providing these services.
Breastfeeding/Lactation Support Centre
In health facilities, a space can be established in the outpatients’ area as
breastfeeding/lactation support centre. A Nutrition counsellor/ Lactation counsellor can be
appointed to manage these centres and is made available for fixed hours (coinciding with
timing of outpatient services) at this centre to counsel and solve referral problems.
This centre should also review the growth of the child and the immunisation status and
provide appropriate advice and information.
In case child is born prematurely or with low birth weight, one to one counselling session
should be conducted with the mother/caregiver and if feasible, follow up visits to the centre
requested.
Integrated Counselling & Testing Centre (ICTC)
HIV testing and counselling, now provided as part of the routine package of screening tests
during pregnancy and delivery, provides a contact opportunity for IYCF counselling of all
pregnant women and specially for those who test HIV positive. The counsellors at ICTC
should be trained to provide counselling services or linked with Nutrition Counsellors
available at the health facility so that all HIV-positive women are able to feed their infants
safely and effectively.
12
3. Activities for reaching out to mothers/care givers at the health facility
Mothers and caregivers can be reached through:
-
One to one counselling by the service provider is the best way to reach out to mothers
and caregivers in the post natal period when they are more receptive to messages on
child care and feeding. Similarly one to one counselling is required for a sick child with
review of child feeding practices. Mothers of children with malnutrition and low birth
weight babies will also require one to one counselling to provide specific feeding advice.
-
Group counselling sessions, at fixed day and time, should be organised at MCH facilities
on pre-decided contact points that include outpatient ANC services, child health
services, immunization points and inpatient areas like postnatal wards and paediatric
wards, new-born care units and Nutrition Rehabilitation Units.
-
Audio-visual aids in waiting areas and postnatal ward and at ANC clinics can be a good
method for reaching out to mothers and family members who also have a critical role in
supporting optimal child feeding practices.
-
Display of Appropriate IEC material (e.g.; posters) in local language should be displayed
at strategic locations (e.g.; waiting areas, outside labor room, outdoor consultation
rooms, obstetric and paediatric wards) in the health facility.
,
13
II.B. KEY INTERVENTIONS AT COMMUNITY OUTREACH LEVEL
Table 2: MCH Contact opportunities during community outreach activities
MCH Contact
opportunities
during community
outreach activities
Location
Community Outreach
Village Health &
AWC or Sub
Nutrition days
Centre as
(VHND)
relevant
Actions & key practices to
be promoted
Health service
provider/s with
primary
responsibility
Health service
providers
with
supporting
role
Counselling and practical
guidance on breastfeeding
as an integral component
of birth preparedness
package – prepare mothers
for early initiation of BF;
ANM
AWW
ASHA
CDPO and
ICDS
supervisor
Group
counselling
maternal nutrition
infant feeding
on
and
Where
feasible,
demonstration of food
preparation and sharing of
recipes for optimal use of
locally available foods for
children 6-23 months
Routine
Immunisation
sessions (RI
sessions)
Biannual Rounds
for Vitamin A
supplementation ;
or during months
dedicated to child
health (eg; Shishu
Sanrakshan Maah)
IMNCI / sick child
consultation at
community level
AWC or Sub
Centre as
relevant
Group counselling on age ANM
appropriate IYCF, practices
and maternal nutrition
ASHA, AWW
AWC or Sub
Centre as
relevant
Group counselling on IYCF ANM
and maternal nutrition;
ASHA, AWW
Sub centre,
AWC
Assessment of age
appropriate feeding and
feeding problems;
counselling on age
appropriate feeding and
feeding during illness
ASHA and
AWW
ANM,
14
1. MCH contact opportunities during Community outreach are mainly the following:
A.
B.
C.
D.
Village Health and Nutrition Days
Routine immunisation sessions
Biannual rounds
Special campaigns (e.g.; during Breastfeeding Week)
The key responsibility for communication and counselling of mothers /caregivers is that of
the ANM with support from ASHA & AWW.
ASHA facilitators can be provided intensive training so as to equip and position them as
ASHA mentors for IYCF.
2. Activities for reaching out to mothers/caregivers at community outreach
Mothers and caregivers can be reached through:
-
Group counselling sessions, at fixed day and time, should be organised at VHND. As
VHND is attended by pregnant women for antenatal check-up, it is a good opportunity
to start preparing mothers for early initiation and exclusive breastfeeding. Mothers
accompanying children for immunisation, micronutrient supplementation provide a
captive audience for discussing infant and young child feeding practices.
As far as possible, pregnant women and mothers of young children should be counselled
in separate groups so that specific and relevant messages can be conveyed (e.g.; group
counselling for pregnant women; mothers with young children; mothers with low birth
weight and malnourished babies and so on).
-
Display of Appropriate IEC material (e.g.; posters): IEC material in local language should
be displayed at strategic locations (e.g.; community walls, AWC, Panchayat Bhavans etc).
Context specific messages promoting local cultural practices that are beneficial and
dispelling locally prevalent myths can be developed and displayed.
Planning for IEC, BCC material and tools should be undertaken as part of the PIP
planning process. This will ensure that appropriate audio-visual aids and IPC-BCC tools
(like flip charts) are available with ANM and ASHA to facilitate discussions.
IPC tools developed at state level can be made available to community workers as job
aides. Adequate budget provisions are available in the PIP to develop, print and
disseminate IEC material.
15
-Organising campaigns: World Breastfeeding Week is observed across India during 1-7
August every year. Campaigns can be planned for increasing awareness about the
benefits of breastfeeding; partnership can be forged with agencies /professional bodies
that are involved in promotion of child health, breastfeeding and IYCF.
A theme or a slogan can be chosen each year for the ‘Breastfeeding Campaign’ so that
the key message is retained in the community for a long time.
Special guests (e.g.; community leaders, local influential persons) can be invited to speak
during the event.
Competitions for parents, mothers, fathers and family members can be organised
around the theme of breast feeding and IYCF.
Information should be disseminated in an entertaining and interactive way. This can
include activities like organising Nukkad Nataks, puppet shows and similar events that
will attract and hold the attention of the local community members.
Inviting journalists to cover these events is another way of generating awareness among
the general population.
16
II.C. KEY INTERVENTIONS DURING COMMUNITY AND HOME BASED CARE
Table 3: MCH Contact opportunities during home visits
MCH Contact
opportunities
during home visits
Location
Community Based (Home contacts)
Home visits to
Home
new born (up to 42
days) in postnatal
period
Postnatal visits to Home
mothers
During routine
activities of
Aanganwadi
centres (Growth
monitoring and
promotion
sessions;
supplementary
feeding ;
counselling
sessions)
Aanganwadi
Centre
Actions & key practices to
be promoted
Health service
provider/s with
primary
responsibility
Health service
providers
with
supporting
role
Support for early initiation
of breastfeeding ,
colostrum feeding (in case
of home delivery) and
establishment of exclusive
breastfeeding ;
ASHA
ANM
One to one counselling of
mothers, caregivers, family
members on maternal
nutrition during lactation
and infant feeding
practices
One to one counselling ANM
with mothers, caregivers,
family
members
on
maternal nutrition during
lactation
and
infant
feeding;
Monitoring of lactation
and support to resolve any
problems
Group
counselling AWW
/communication on IYCF
and maternal nutrition;
Where feasible,
demonstration of food
preparation and sharing of
recipes for optimal use of
locally available foods for
children 6-23 months;
ASHA, AWW
AWW helper,
ASHA
Assessment of age
appropriate feeding and
feeding problems,
counselling on age
appropriate feeding and
feeding during illness
17
1. MCH contact opportunities during home visits are mainly the following:
Community contacts include:
A. Postnatal Home visits
B. Home visits for mobilising families for VHND
C. Growth monitoring and health promotion sessions at AWC
D. Mothers’ Group Meetings /Self Help Groups’ Meetings
Frontline health workers (ANM and ASHA) have the key responsibility for conducting home
visits for providing postnatal and newborn care as part of various MCH schemes. It is also
proposed that ASHAs make home visits for following up newborns with Low Birth Weight for
a longer period (up to 2 years).
At places, Mothers’ Groups and /or Self Help Groups are active and offer a good platform
for discussing IYCF practices. These groups are facilitated by AWWs and themes for
discussion on themes of IYCF and child care.
2. Activities for reaching out to mothers/caregivers during home visits and community
level activities
Mothers and caregivers can be reached through:
-
One to one counselling during home visits by the ANM and ASHA is the best way to
reach out to mothers and caregivers in the community. One to one counselling provides
an opportunity to assess the socio economic and cultural barriers in the practice of
optimal IYCF and then to customise key messages accordingly. The home visits are an
opportunity to provide support to mothers by teaching them about proper positioning
and attachment for initiating and maintaining breastfeeding.
One to one contact with mothers whose babies are born with low birth weight babies or
lagging behind on the growth chart can be given specific feeding advice. Any feeding
problems can be identified and addressed.
From the perspective of the newborn, home visits during the neonatal /postnatal period
provides the most important opportunity to reinforce key messages on IYCF. As the
HBNC scheme now requires that every child be visited at home (during first 42 days of
life) the messages on IYCF can potentially reach every mother and every household.
-
Group counselling sessions, at fixed day and time, should be organised at VHND. Where
possible, Audio-visual aids and tools (like flip charts) can be used to provide information
18
and counselling by ANM with adequate facilitation by the AWW and ASHAs.
AWWs conducting group counselling sessions for expectant mothers and lactating
women should weave in key IYCF messages in all sessions.
Similar approach should be used during Growth Promotion and Monitoring Sessions and
Group counselling sessions at AWC. Mothers of children identified as Grade III /IV
malnutrition or with weight plotted in yellow & orange zone of the growth chart should
be counselled more intensively as a group. Mothers of children with normal growth
pattern can be included in the discussion (Positive Deviance Model) so that they can
share information and experiences with new mothers and offer practical solutions to
common problems.
During the sessions, these mothers (and /or AWW) can demonstrate the best use of
locally available and acceptable foods.
-
Display of Appropriate IEC material (e.g.; posters): IEC material in local language should
be displayed at strategic locations (e.g.; community walls, AWC, Panchayat Bhavans etc).
Context specific messages promoting local cultural practices that are beneficial and
dispelling locally prevalent myths can be developed and displayed.
IPC Tools for home visits (like flipcharts or kanthas for story telling) developed by
organisations /agencies in the state can be made available to community workers as a
job aides.
19
III. Training of key service providers located at health facilities
Health service providers have an important role in not only promoting IYCF practices but
also in providing essential information, counselling and help to mothers on breastfeeding
and complementary feeding and assisting in solving common problems. It is therefore
important that their capacity is augmented through in-service or pre-service training and/or
through special training on counselling for IYCF.
All health care providers who interact with mothers and young children should acquire the
basic knowledge and skills to integrate breastfeeding, lactation management and infant and
young child feeding principles into the care that they routinely provide. Some aspects of
IYCF are integrated in many of the existing pre-service and in-service training programmes
of the health cadre and include:





IMNCI – Pre-Service and In-Service Training
F-IMNCI – Pre-Service and In-Service Training for Doctors and Nurses
Skilled Birth Attendance Training
ASHA module 6 & 7
Regular Curriculum of Medical and Nursing Students
However at facility level, advanced set of skills is required for some of the service providers
directly involved in provision of maternal and child health services so that they can deal with
concerns and problems related to lactation failure or breast problems like engorgement,
mastitis etc, and provide special counselling to mothers with less breast milk, low birth
weight babies, sick new-born, undernourished children and babies born to HIV positive
mothers. More detailed, hands-on training on counselling skills should be provided to them.
The existing training packages that can be used for this purpose is the Infant and Young
Child Feeding Counselling: A Training Course, The 3 in 1 course (An Integrated course on
Breastfeeding, Complementary Feeding & Infant feeding and HIV counselling).
This package makes available the core training material for all levels including Master
trainers, Mid-Level Trainers, facility based service providers and frontline workers. Trainings
vary in duration for master trainers and service providers; a 3 days package for frontline
workers has also been developed in 2008.
State/s should develop the IYCF training plan, depending on the number and cadre of health
personnel and level of skills to be developed at various levels of the health system.
It is recommended that FRUs with high delivery load, District Hospitals and facilities with
New-born Care Units and Nutrition Rehabilitation Centres should have 2 or more facility
based service providers trained in advanced IYCF counselling skills.
20
IV.
Financial guidelines for IYCF interventions
An assessment of resources required for IYCF programme at facility and community
outreach level should be made based on the action plan and budgeted as part of Child
Health component included under ‘RCH Flexipool’. Trainings can be budgeted under ‘Child
Health training’ component under RCH flexipool. A consolidated IEC budget is available
under Mission flexipool under which ‘child health specific IEC’ can be included.
An indicative budget for various activities proposed in the previous section is presented in
the table below:
Activity
Health facility
Equipment (for both inpatient &
OPD)
Indicative
No. of
Unit cost
locations
District Level
Rs. 5000 per
site /delivery
point (DH,
FRU, PHC)
Infrastructure Lactation Support
Corner
Rs. 10,000 per
health facility
(DH, FRU)
Salary of Lactation/Nutrition
Counsellor at High case load (of
pregnant women, mothers, children)
facilities
Rs. 10,000 per
counsellor (at
DH, FRU,
tertiary care
facilities)
Subtotal
Community outreach
Equipment: weighing machines,
MUAC tapes
Job aides (flip chart etc.)
Subtotal
Trainings
Training of trainers on IYCF
counselling skills
Total
cost
Remarks
Weighing scale,
Stadiometer, Infantometer,
WHO growth standards
(Charts) at each health
facility , separately for
inpatient and outpatient
areas; a facility may have
more than one site where
equipment is required
Infrastructure cost includes
minor renovations, paint,
curtains, furniture,
equipment (Infantometer,
weighing scales, WHO
growth standards (Charts)
Indicative cost, will vary
according to salary scales in
the state
Rs. 750 per
sub-centre
Rs. 250 per
community
worker
trained in IYCF
Rs. 300,000
per batch of
24
21
Activity
Training of health care providers
(including nutrition counsellors) in
IYCF counselling skills, lactation
management (3 days)
Training of Frontline workers
(ANM, LHVs) for 3 days
Indicative
Unit cost
Rs. 150,000
per batch of
24
No. of
locations
80,000 per
batch (batch
size 25-30)
Total
cost
Remarks
Should be organised at
block/district level
Subtotal
Theme Based events (eg; during Breastfeeding Week)
Hiring song and drama groups
Rs. 10,000 per
block
Prizes , certificates for competitions
Rs. 5,000 per
block
Mobility support for volunteers
Rs. 5,000 per
block
Subtotal per district
Total cost (No. of districts x cost per
district)
State Level
Printing of modules, training
material
IEC, BCC
Printing of IEC for state , districts;
production of AV material
Development of audio-visuals and
print material
IEC campaign in districts
Meetings of the Coordination Committee on Nutrition
Organisation of meeting (for
planning and review, 6 monthly)
To be included in budget
for CH trainings , based on
the number of persons to
be trained & training
package/s
To be included in
consolidated IEC budget for
child health under ‘Mission
Flexipool’
To be budgeted in
programme management
cost under PIP
22
V. STEPS IN PLANNING AND IMPLEMENTATION OF IYCF INTERVENTIONS
1. State Coordination Group on Nutrition
A State Coordination Group should be formed which includes members from departments
of Health and WCD, development partners, representatives of professional bodies and
senior faculty members of medical colleges and home science colleges. The mandate of this
Coordination group would be to provide technical support from planning and
implementation of nutrition interventions and facilitate convergence between various
departments for training, referrals and linkages. (The same group should also provide
technical advice on other nutrition interventions including micronutrient supplementation,
nutrition rehabilitation centres and other strategies to manage children with SAM).
The Group should formally meet at least twice a year in order to support planning at state
level and then for review of progress of nutrition interventions including IYCF.
2. Developing a detailed IYCF plan for State and Districts
States should formulate a detailed plan along with time-line incorporating various activities
for IYCF promotion. This earlier section provides a menu of options for IYCF activities that
can be included in the plan. The plan should be reflected in the child health component of
the PIP. As with the state plan, the district plan for this intervention should be planned and
presented together with the District NRHM / RCH II plan along with the budget.
3. Identifying training needs and preparing a training plan
It is important that the states develop comprehensive state and district training plans. The
training plan must be prepared, taking into account the number of delivery points
(especially high delivery case load facilities) and service providers to be provided skills in
IYCF communication and /or counselling. Since a large number of frontline workers will have
to be trained and mentored, stress should be laid on capacity building at the district level
itself.
The state must also identify all personnel who have already been exposed to the training
/orientation on IYCF and related areas through specific ‘in service’ training programmes.
District Training plans should be developed keeping in view the following aspects:
23
-
Planning for training needs to be done from sub-centre upwards
Total training load is to be calculated keeping in view the facilities which are functional
and availability of District Training Institutions
Skills training to be categorised in core skills (for workers at all levels of health facilities)
and specialised skills (for ‘counsellors’)
Specific time frame set for completion of training of each cadre (may be spread over 1-3
years)
Financial allocation for trainings in District Action Plan
A plan for training of trainers should be prepared at state level so as to undertake all the
training planned by the districts. Database of trained manpower must be available in the
state. The state should prepare & project the resources (financial as well as otherwise) in
their PIP for their TOT and training of state level officials.
Achievement of the training targets should be periodically reviewed as also the delivery of
IYCF information and counselling services at community and facility level.
4. State IEC/BCC plan
States should formulate and implement a comprehensive BCC- IEC strategy on Child Health
(as part of MCH or RCH programme) and plan campaign to improve IYCF using audienceappropriate mix of interpersonal, group and mass-media channels.
The State IEC Division may draw out a comprehensive plan for IEC on MCH/RCH issues,
clearly delineating the key child health issues to be covered through various media
segments.
Appropriate IEC material should be made available to health facilities for display at strategic
locations. Audio-visual resources on breastfeeding and other IYCF practices, in local
languages, can be distributed to all health facilities (that have provision of A-V equipment).
Print and electronic coverage on breastfeeding can be built around the Breastfeeding
Day/Week (in August) targeting mothers, caregivers/families and community leaders
/influencers. TV and radio spots on key messages relating to appropriate IYCF practices are
already available through UNICEF and may be used as such or adapted suitably for state
specific /local context. New spots may be developed by the state IEC cell.
Where community radio is available, it could be one good medium for dissemination of
health messages.
24
VI. Monitoring IYCF interventions
Monitoring of the IYCF Promotion programme should be undertaken as part of the
comprehensive Nutrition and /or Child Health interventions in the block/district.
Routine monitoring can be done through a reporting system, focusing on a few key
indicators (presented in Table 4) which are feasible to collect and will be useful to the
programme planning and implementation at district/state level.
Periodic review of progress against the micro-plan at the district level and against the state
PIP is important to ensure that implementation is on track and to provide support for
programme components or districts/provinces which face bottlenecks.
A set of indicators that can be used to monitor various IYCF interventions are given below:
Table 4: Monitoring Indicators for IYCF interventions
Process indicators:
1. # and % of health workers (MOs, SNs, ANMs, Programme Managers, Nodal persons )
trained on integrated IYCF counselling
(Denominator will be the training load identified by the state for each cadre)
2. # and % of health facilities with at least two HW/s trained on IYCF counselling
(Denominator will be the delivery points in the state/district)
3. # and % of health facilities with a dedicated Nutrition Counsellor/Lactation Counsellor
(Denominator will be District hospitals; states can consider including FRUs with high
delivery load)
4. # and % of health facilities with functional Lactation Support Corners
(Denominator will be delivery points at DH, FRUs identified for establishing Lactation
Support Corner during the year)
5. # and % new born received at least 6 visits in the postnatal period by a community
worker
(Denominator will be total number of live birth in the state during the reporting period)
6. % and # of districts conducting breastfeeding campaign
(Denominator will be the number of districts identified by the state in the Annual PIP)
Output indicator
1. % of infants who breastfed within one hour of birth (to be reported in HMIS every
month)
25
Monthly reports:
District Child Health/Nutrition nodal officer/s should review the progress every month. IYCF
program should be one of the agenda items of RCH or Child Health & Nutrition review
meetings at the different levels.
Each month the data relating to progress of IYCF activities should be collected on a standard
reporting format by the districts and transmitted electronically to the State Programme
Management Unit. The Nodal person at the DPMU and SPMU should analyse the reports
and provide relevant feedback to the officers responsible for implementation.
Sample
reporting
formats
are
provided
on
the
next
two
pages:
26
27
Monthly Reporting Format 1 (from the state)
State:
Reporting period/ month:
Districts
No. of live
births in
the month
No. of newborns
initiated
breastfeedi
ng in first
hour of
birth
No. of delivery points
with at least two staff
trained in IYCF
counselling
Planned
Achieved
No. of health
facilities with
dedicated Nutrition
Counsellor (trained
in lactation
management) and/
or Lactation
Counsellor
Planned Achieved
No. of facilities with
functional Lactation
Support Corner
No. of districts
conducting
Breastfeeding
campaign/s
Planned
Planned
Achieved
No. of new-borns
received at least 6
home visits by
community worker
in postnatal period
Achieved Planned
Achieve
d
State
Total
Signature of the Nodal Person
Monthly Reporting Format 2 (from the state)
Trainings on IYCF Counselling
No. of State Master Trainers for
IYCF Counselling training
package
Planned
Achieved
No. of Programme Managers
& RCH officers trained/
oriented
Planned
Achieved
No. of Medical Officers/
Doctors trained in IYCF
counselling
Planned
Achieved
No. of Staff Nurses trained in
IYCF counselling
No. of ANMs trained in IYCF
counselling
Planned
Planned
Achieved
Achieved
State Total
Signature of the Nodal Person
27
Section 2
Technical Guidelines
INFANT AND YOUNG CHILD FEEDING TECHNICAL GUIDELINES
A National Consultative Meet was organised by Indian Academy of Paediatrics in 2009
where IYCF and Nutrition chapters of IAP, BPNI, WHO, UNICEF, USAID, WFP, Child Welfare
Department and academicians were present. These technical guidelines have emerged
from the consensus reached during the consultative meet.
1. Breastfeeding
(a) Breastfeeding should be promoted to mothers and other caregivers as the gold standard
feeding option for babies.
(b) Pre-birth counselling individually or in groups organized by maternity facility regarding
advantages of breastfeeding and dangers of artificial feeding should prepare expectant
mothers for successful breastfeeding.
(c) Breastfeeding must be initiated as early as possible after birth for all normal newborns
(including those born by caesarean section) avoiding delay beyond an hour. In case of
operative birth, the mother may need motivation and support to initiate breastfeeding
within the first hour. Skin to skin contact between the mother and new born should be
encouraged by ‘bedding in the mother and baby pair’. The method of "Breast Crawl" can be
adopted for early initiation. Mother should communicate, look into the eyes, touch and
caress the baby while feeding. The new born should be kept warm by promoting Kangaroo
Mother Care and promoting local practices to keep the room warm.
(d) Colostrum must not be discarded but should be fed to newborn as it contains high
concentration of protective immunoglobulins and cells. No pre-lacteal fluid should be given
to the newborn.
(e) Baby should be fed "on cues"- The early feeding cues includes; sucking movements and
sucking sounds, hand to mouth movements, rapid eye movements, soft cooing or sighing
sounds, lip smacking, restlessness etc. Crying is a late cue and may interfere with successful
feeding. Periodic feeding is practiced in certain situations like in the case of a very small
infant who is likely to become hypoglycemic unless fed regularly, or an infant who ‘does not
demand’ milk in initial few days. Periodic feeding should be practiced only on medical
advice.
(f) Every mother, especially the first time mother should receive breastfeeding support from
the doctors and the nursing staff, or community health workers (in case of non-institutional
28
birth) with regards to correct positioning, latching and treatment of problems, such as
breast engorgement, nipple fissures and delayed ‘coming-in’ of milk.
(g) Exclusive breastfeeding should be practiced from birth till six months requirements.
Mean intakes of human milk provide sufficient energy and protein to meet requirements
during the first 6 months of infancy. Since infant growth potential drives milk production,
the distribution of intakes likely matches the distribution of energy and protein. This means
that no other food or fluids should be given to the infant below six months of age unless
medically indicated. After completion of six months of age, with introduction of optimal
complementary feeding, breastfeeding should be continued for a minimum for 2 years and
beyond depending on the choice of mother and the baby. Even during the second year of
life, the frequency of breastfeeding should be 4-6 times in 24 hours, including night feeds.
(h) Mothers need skilled help and confidence building during all health contacts and also at
home through home visits by trained community worker, especially after the baby is 3 to 4
months old when a mother may begin to doubt her ability to fulfil the growing needs and
demands of the baby.
(i) Mothers who work outside should be assisted with obtaining adequate
maternity/breastfeeding leave from their employers, should be encouraged to continue
exclusive breastfeeding for 6 months by expressing milk for feeding the baby while they are
out at work, and initiating the infant on timely complementary foods. They may be
encouraged to carry the baby to a work place crèche wherever such facility exists. The
concept of "Hirkani’s rooms" may be considered at work places (Hirkani’s rooms are
specially allocated room at the workplace where working mothers can express milk and
store in a refrigerator during their work schedule). Every such mother leaving the maternity
facility should be taught manual expression of her breast milk.
(j) Mothers who are unwell or on medication should be encouraged to continue
breastfeeding unless it is medically indicated to discontinue breastfeeding.
(k) At every health visit, the harms of artificial feeding and bottle feeding should be
explained to the mother. Inadvertent advertising of infant milk substitute in health facility
should be avoided. Artificial feeding is to be practiced only when medically indicated.
(l) Health and Nutrition (ICDS) workers should be trained in various skills of counselling and
especially in handling sensitive subjects like breastfeeding and complementary feeding.
(m)If the breastfeeding was temporarily discontinued due to an inadvertent situation, "relactation" should be tried as soon as possible. Such cases should be referred to a trained
lactation consultant/health worker. The possibility of "induced lactation" shall be explored
according to the situation.
29
(n) All efforts should be taken to remove hurdles impeding breastfeeding in public places.
(o) Adoption of latest WHO Growth Charts is recommended for monitoring growth.
2. Complementary Feeding
(a) Appropriately thick homogenous complementary foods made from locally available
foods should be introduced at six completed months to all babies while continuing
breastfeeding ad libitum. This should be the standard and universal practice. During this
period breastfeeding should be actively supported and the term "Weaning" should be
avoided.
(b) To address the issue of a small stomach size which can accommodate limited quantity at
a time, each meal must be made energy dense by adding sugar/jaggery and ghee/butter/oil.
To provide more calories from smaller volumes, food must be thick in consistency - thick
enough to stay on the spoon without running off, when the spoon is tilted.
(c) Foods can be enriched by making a fermented porridge, use of germinated or sprouted
flour and toasting of grains before grinding.
(d) Adequate total energy intake can also be ensured by addition of one to two nutritious
snacks between the three main meals. Snacks are in addition to the meals and should not
replace meals. They should not to be confused with foods such as sweets, chips or other
processed foods.
(e) Parents must identify the staple homemade food comprising of cereal-pulse mixture (as
these are fresh, clean and cheap) and make them caloric and nutrient rich with locally
available products.
(f) The research has time and again proved the disadvantages of bottle feeding. Hence
bottle feeding shall be discouraged at all levels.
(g) Population-specific dietary guidelines should be developed for complementary feeding
based on the food composition of locally available foods. A list of appropriate, acceptable
and avoidable foods can be prepared.
(h) Iron-fortified foods, iodized salt, vitamin A enriched food etc. are to be encouraged.
(i) The food should be a "balanced food" consisting of various (as diverse as possible) food
groups/ components in different combinations. As the babies show interest in
complementary feeds, the variety should be increased by adding new foods in the staple
food one by one. Easily available, cost-effective seasonal uncooked fruits, green and other
30
dark coloured vegetables, milk and milk products, pulses/legumes, animal foods, oil/butter,
sugar/jaggery may be added in the staples gradually.
(j) Avoid Junk and Commercial food. Avoid giving ready-made, processed food from the
market, e.g. tinned foods/juices, cold-drinks, chocolates, crisps, health drinks, bakery
products etc
(k) Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks.
(l) Hygienic practices are essential for food safety during all the involved steps viz.
preparation, storage and feeding. Freshly cooked food should be consumed within one to
two hours in hot climate unless refrigerated. Hand washing with soap and water at critical
times- including before eating or preparing food and after using the toilet.
(m) Practice responsive feeding. Young children should be encouraged to take feed by
praising them and their foods. Self-feeding should be encouraged despite spillage. Each
child should be fed under supervision in a separate plate to develop an individual identity.
Forced feeding, threatening and punishment interfere with development of good / proper
feeding habits. Along with feeding mother and care givers should provide psycho-social
stimulation to the child through ordinary age-appropriate play and communication activities
to ensure early childhood development.
(n) A skilled help and confidence building is also required for complementary feeding during
all health contacts and also at home through home visits by community health workers.
(o) Consistency of foods should be appropriate to the developmental readiness of the child
in munching, chewing and swallowing. Avoid foods which can pose choking hazard.
Introduce lumpy or granular foods and most tastes by about 9 to 10 months. Missing this
age may lead to feeding fussiness later. So do not use mixers/grinders to make food
semisolid/pasty. The details of food including; texture, frequency and average amount are
enumerated in Table.
Table: Amount of Food to Offer at Different Ages
Age
Texture
Frequency
Average amount of each meal
6-8 mo Start with thick porridge, 2-3 meals per day plus frequent Start with 2-3 tablespoonfuls
well mashed foods
Breastfeeding
Finely chopped or mashed
9-11 mo
½ of a 250 ml cup/bowl
3-4 meals plus breastfeed.
foods,
and foods that baby can Depending on appetite offer 1-2
pick up
snacks
12-23 Family foods, chopped or
3/4 to one 250 ml cup/bowl
3-4 meals plus breastfeed.
31
mo
mashed if necessary
Depending on appetite offer 1-2
snacks
If baby is not breastfed, give in addition: 1-2 cups of milk per day, and 1-2 extra meals per day. The
amounts of food included in the table are recommended when the energy density of the meals is
about 0.8 to 1.0 Kcal/g. If the energy density of the meals is about 0.6 Kcal/g, recommend to
increase the energy density of the meal (adding special foods) or increase the amount of food per
meal. Find out what the energy content of complementary foods is in your setting and adapt the
table accordingly.
3. HIV and Infant Feeding
(a) As regards infant feeding the earlier 2006 guidelines suggested that health workers
should individually counsel all HIV positive mothers and help them each determine the most
appropriate infant feeding strategy for their circumstances. However, the current 2009
recommendations state that national health authorities should promote a single infant
feeding practice as the standard of care. Hence based on various considerations like
international recommendations, socioeconomic and cultural contexts of the country’s
population, the availability and quality of health services, the local epidemiology including
HIV prevalence among pregnant women and main causes of infant mortality and undernutrition, the National health authorities should decide upon the strategy that will most
likely give infants the greatest chance of remaining HIV uninfected and alive. They will have
to decide whether they will recommend that all HIV infected mothers will breastfeed and
receive ARV interventions OR will avoid all breastfeeding. Currently WHO is developing
guidance to assist countries in this decision-making process and will lay out steps to reach
these standards of care. Whichever option is chosen, mothers should be helped and
empowered to sustain that option.
(b) Current WHO recommendations advocate that all mothers known to be HIV-infected
should be provided with antiretroviral therapy or antiretroviral prophylaxis to reduce
mother to child transmission and in particular to reduce postnatal transmission through
breastfeeding. Details about these interventions can be seen in the document- Revised
WHO recommendations on the use of antiretroviral drugs for treating pregnant women and
preventing
HIV
infection
in
infants
2009
are
available
at
http://www.who.int/hiv/topics/mtct/.
(c) Pregnant women and mothers known to be HIV infected should be informed of the
infant feeding strategy recommended by the national authority to improve HIV free survival
of HIV exposed infants and informed that there are alternatives that mothers might wish to
adopt.
32
(d) Hence, mothers who are known to be HIV negative OR whose HIV status is unknown OR
infants of HIV positive mothers known to be HIV-infected should exclusively breastfeed their
infants for the first six months of life and then introduce complementary foods while
continuing breastfeeding for 24 months or beyond.
(e) HIV-infected mothers on antiretroviral therapy or prophylaxis (whose infants are HIV
uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first
6 months of life, introducing appropriate complementary foods thereafter, and continue
breastfeeding for the first 12 months of life. Breastfeeding should then only stop once a
nutritionally adequate and safe diet without breast milk can be provided. As per the new
guidelines, baby should receive daily Nevirapine from birth until one week after all exposure
to breast milk has ended if the mother received only Zidovudine prophylaxis and Nevirapine
from birth to 6 weeks if mother has received triple ARV prophylaxis.
(f) If a HIV positive mother chooses not to breast feed in spite of receiving ARV prophylaxis,
Zidovudine or Nevirapine is indicated for 6 weeks for the baby from birth. Replacement
feeding as mentioned below is advocated in this situation.
(g) Whenever HIV-infected mothers decide to stop breastfeeding, it should be done
gradually within one month. Mothers or infants who have been receiving ARV prophylaxis
should continue prophylaxis for one week after breastfeeding is fully stopped.
(h) Infants born to HIV infected women receiving ART for their own health should receive
daily Nevirapine from birth till 6 weeks of age and for those being breastfed daily,
Zidovudine or Nevirapine from birth until 6 weeks of age is recommended.
Alternatives to breastfeeding include
For infants less than 6 months of age
(i) Expressed, heat-treated breast milk
(ii) Unmodified animal milk
(iii) Commercial infant formula milk.
(The choice/selection shall be based on AFASS criteria given below)
For children over 6 months of age
(iv) All children can be given complementary foods from six months of age (as discussed in
the section on complimentary feeding). Meals including; foods, combination of milk (based /
33
containing) feeds (especially in those who consume strict vegetarian diet) and other foods,
should be provided.
Other options for all ages
(v) Breastfeeding by another woman who is HIV negative (wet-nursing)
(vi)Human milk from breast milk banks
Replacement feeding (RF) is the process of feeding a child who is not receiving any breast
milk, with a diet that provides all the nutrients until the child is fully fed on family foods. The
replacement feeding option should be selected, only if all of the AFASS criteria are
completely fulfilled (AFASS refers to Acceptability, Feasibility, Affordability, Safety and
Sustainability). Cup feeding should be the method of choice if replacement feeding needs to
be done and bottles should be totally avoided. If any of the AFASS criteria is not met, the
mother should practice exclusive breastfeeding till 6 months along with early treatment of
breast and nipple problems of HIV +ve mother.
Mixed feeding must be avoided (except the short transition period of around a month when
breast-feeding is being gradually stopped) as it causes a two fold increase in the risk of
postnatal HIV transmission. Local breast conditions like nipple fissures can increase the risk
of HIV transmission and hence should promptly be treated.
Mothers known to be HIV infected may consider expressing and heat-treating breast milk as
an interim feeding strategy in special circumstances such as:
When the infant is born with low birth weight or is otherwise ill in the neonatal period and
unable to breastfeed;
or
When the mother is unwell and temporarily unable to breastfeed or has a temporary breast
health problem such as mastitis;
or
If antiretroviral drugs are temporarily not available.
4. Feeding in Other Specific Situations
(a) Feeding during sickness is important for recovery and for prevention of under nutrition.
Even sick babies mostly continue to breastfeed and the infant can be encouraged to eat
small quantities of nutrient rich food but more frequently and by offering foods that the
34
child likes to eat. After the illness the nutrient intake of child can be easily increased by
increasing one or two meals in the daily diet for a period of about a month; by offering
nutritious snacks between meals; by giving extra amount at each meal; and by continuing
breastfeeding.
(b) Infant feeding in maternal illnesses
1. Painful and/or infective breast conditions like breast abscess and mastitis and psychiatric
illnesses which pose a danger to the child’s life e.g. postpartum psychosis, schizophrenia
may need a temporary cessation of breastfeeding. Treatment of primary condition should
be done and breastfeeding started as soon as possible.
2. Chronic infections like tuberculosis, leprosy, or medical conditions like hypothyroidism
need treatment of the primary condition and don’t warrant discontinuation of
breastfeeding.
3. Breastfeeding is contraindicated when the mother is receiving certain drugs like antineoplastic agents, immunosuppressants, anti-thyroid drugs like thiouracil, amphetamines,
gold salts, etc. Breastfeeding may be avoided when the mother is receiving following drugsatropine, reserpine, psychotropic drugs. Other drugs like antibiotics, anaesthetics, antiepileptics, antihistamines, digoxin, diuretics, prednisone, propranolol etc. are considered
safe for breastfeeding.
(c) Infant feeding in various conditions related to the infant
(i) Breastfeeding on demand should be promoted in normal active babies. However, in
difficult situations like very LBW, sick, or depressed babies, alternative methods of feeding
can be used based on neurodevelopmental status. These include feeding expressed breast
milk through intra-gastric tube or with the use of cup and spoon. For very sick babies, expert
guidance should be sought.
(ii) Gastro-Oesophageal Reflux Disease (GERD): Mild GERD is often treated conservatively
through thickening the complementary foods, frequent small feeds and upright positioning
for 30 minutes after feeds.
(iii) Primary Lactose Intolerance is congenital and may require long term lactose restriction.
Secondary Lactose Intolerance is usually transient and resolves after the underlying GIT
condition has remitted. Most of the cases of diarrhoea do not require stoppage of
breastfeeding.
35
(iv) Various Inborn Errors of Metabolism warrant restriction of specific offending agent and
certain dietary modifications e.g. in Galactosemia, dietary lactose and galactose should be
avoided. This is probably the only absolute contraindication to breastfeeding.
(v) During emergencies, priority health and nutrition support should be arranged for
pregnant and lactating mothers. Donated or subsidized supplies of breast milk substitutes
(e.g. infant formula) should be avoided, must never be included in a general ration
distribution, and must be distributed, if at all, only according to well defined strict criteria.
Donations of bottles and teats should be refused, and their use actively avoided.
36
Annexure I
Ten Steps to Successful Breastfeeding
Every facility providing maternity services and care for newborn infants should:
1. Have a written breastfeeding policy that is routinely communicated to all health care
staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within a half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should
be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically
indicated.
7. Practice rooming-in -- allow mothers and infants to remain together -- 24 hours a
day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding
infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital.
In order to achieve a much wider scale of implementation of actions to improve
breastfeeding practices in maternity facilities, it is proposed that up to seven of the Ten
Steps may be prioritized for rapid and at-scale implementation (Steps 1, 3, 4, 6, 7, 8 and 9).
37
Annexure II
A1. Key IYCF practices to be promoted at delivery points
Key Infant and young child feeding practices can be promoted before and soon after
delivery and during 48 hours stay in the facility (postnatal wards).
Key practices to be promoted during this period are:
1. Initiation of breastfeeding immediately after birth, preferably within one hour
2. Colostrum feeding
3. No prelacteals (no other foods or fluids, not even water)
4. Exclusive breastfeeding during the first six months of life
5. Ensuring good maternal nutrition during lactation
B1. Key practices that can be promoted for children through health facilities
Age appropriate infant and young child feeding practices that may seek consultation or are
admitted at a health facility include:
1. Exclusive breastfeeding during the first six months of life
2. Timely introduction of complementary foods, at six months
3. Age appropriate complementary feeding for children 6-24 months, while continuing
breastfeeding until 24 months and beyond
4. Active feeding for children during and after illness such as diarrhoea
3.2 Key practices to be promoted through community outreach activities and home based
care
Age appropriate infant and young child feeding practices to be promoted include:
1. Early Initiation of breastfeeding
2. Exclusive breastfeeding during the first six months of life (no other foods or fluids, not
even water)
3. Timely introduction of solid, semi solid or soft complementary foods, at six months
4. Age appropriate complementary feeding for children 6-24 months : Bringing dietary
diversity in complementary food, inform mothers about food groups ;Giving
complementary food for minimum number of time (2 times for breasted infants 6-8
months; 3 times for breastfed children 9-23 months; 4 times for non-breastfed children
6-23 months)
5. Active feeding for children during and after illness such as diarrhoea
38
Annexure III: Existing IEC material on Breastfeeding
FOLDER-1: Newborn care (15 poster files, each focused on a key message in
effective newborn care.
Sub-folder 2: Maa sab jaanti Hai ads_Hindi
File Name
Primary (P),
Secondary (S)
audience
Location for display
POSTER
P: Caregivers
and family; S:
Frontline worker
Primarily newspaper ads to be released
accordingly during special events.
If converted to
Posters/translides, can be displayed in
waiting area at CHCs/PHCs/Dist hosp/
Labor room/ SNCU
Doctors chambers
AWW centers
During VHNDs
Early Initiation of
breastfeeding.pdf
KeeingNewbornWarm.pdf
Seeking care.pdf
Alternative IEC
Format
 Back-light
Translides
 Horizontal
posters
Use during world health promotion days
such as
World Breast Feeding Day (Aug 01-07);
National Nutrition Week (Sept 01-07);
World Food Day (Oct 16); Children’s
Day (Nov 14)
BUS PANEL
P: Community
On backs and sides of buses.
 Hoardings
 Wall painting
Sakhi dadi Bus-Pannel.jpg
FOLDER-2: Breast Feeding
Sub-folder: Breastfeeding FAQ and Breastfeeding poster
File Name
Primary (P),
Secondary (S)
audience
Location for display
Alternative IEC
Format
Breastfeeding FAQ
P: Caregivers
and family;
S: Frontline
worker/
AWW
Primarily to be printed and widely
distributed during:
ASHA visits to homes with
pregnant women, or mother of
newbon child.
Community meetings (for
women)
Should be available at
Anganwadi centres/CHCs/PHCs.
Should be used during training
and orientation of frontline
workers on breast feeding
practices.
Must be
distributed during
VHNDs and
during World
Breast Feeding
Day (Aug 01-07);
National Nutrition
Week (Sept 0107); World Food
Day (Oct 16);
Children’s Day
(Nov 14)
Breastfeeding poster
P: Caregivers
and family; S:
Frontline
worker/
AWW
Anganwadi centres,
CHCs/PHCs/Dist hosp/ Labour
room/ SNCU/Doctors chambers
During VHNDs
Must be used during World
Breast Feeding Day (Aug 01-07);
National Nutrition Week (Sept
01-07); World Food Day (Oct 16);
Children’s Day (Nov 14)
 Leaflet
(Can be kept at
the health centres,
given during
events, VHNDs for
carry back by
caregivers
 Newspaper ad
 Hoarding
 Kiosks
39
BF_WallPainting.jpg
P: Community;
Walls of Anganwadi centres,
CHCs, PHCs, local markets
 Hoarding
 Bus panels
 Stickers
POSTER
Breastfeeding and complementary
feeding
P: Caregivers and
family;
S: Frontline worker/
AWW
Anganwadi centres,
CHCs/PHCs/Dist hosp/
Labour room/ SNCU/
Doctors chambers
Display during VHNDs
Must be used during World
Breast Feeding Day (Aug
01-07); National Nutrition
Week (Sept 01-07); World
Food Day (Oct 16); Children’s
Day (Nov 14)
BF_WallPainting.jpg
P: Community;
Walls of Anganwadi centres,
CHCs, PHCs, local markets
 Leaflet
(Can be kept at
the health centres,
given during
events, VHNDs for
carry back by
caregivers
 Newspaper ad
 Hoarding
 Kiosks
 Hoarding
 Bus panels
 Stickers
40
41
Part of the
Sakhi Dadi
campaign
including TV
and radio
spots.
42
Annexure IV: Training Tools
43