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Essential Nutrition, Hygiene, and Care Practices during Pregnancy

Essential Nutrition, Hygiene, and Care Practices during Infancy

Lesson Plan Part I

Module 3 of 5

2

2

Essential Nutrition, Hygiene, and Care Practices during Infancy

Table of Contents:

Lesson 1: Importance of Postpartum Care7

Lesson 2: Exclusive Breastfeeding: Benefits, Frequency and HIV19

Lesson 3: Exclusive Breastfeeding: Hydration, Emptying the Breast and Complementary Feeding32

Lesson 4: Danger Signs during Childhood Illness43

Lesson 5: Overcoming Breastfeeding Problems: Poor Position, Engorgement and Breast Lumps54

Lesson 6: Clinical Services and Growth Monitoring and Promotion64

Lessons, stories, and activities in the Essential Nutrition, Hygiene, and Care during Infancy Lesson Plan complement the information provided in the Essential Nutrition, Hygiene, and Care during Infancy Leader Mother Flipchart.

Understanding the Lesson Plan

Each lesson begins with objectives. These are the behavior, knowledge and belief objectives that are covered in the lesson. Make sure that each of these objectives is reinforced during the lesson. There are four types of objectives. Each is described below.

Behavior Objectives: Most objectives are behavioral objectives written as action statements. These are the practices that we expect the caregivers to follow based on the key messages in the flipchart.

Knowledge objectives: For example, we want mothers to be able to name the danger signs as well as the five ways that diarrhea-causing germs are transmitted. These are facts that the caregivers must memorize during the lesson, using the pictures as a reminder.

Belief objectives: We know that beliefs and attitudes affect our practices. Many times it is a person’s inaccurate belief or worldview that hinders them from making a healthy behavior change.

Behavioral determinant objectives: Behavioral determinants are reasons why people practice (or don’t practice) a particular behavior. There are eight possible behavioral determinants as identified in the Barrier Analysis[footnoteRef:1] surveys done in each region. The surveys identify the most important determinants for each behavior. By reinforcing the determinants that have helped the doers (caregivers in the community already practicing the new behavior) we are able to encourage the non-doers (caregivers who have not yet tried or been able to maintain the new practices). We also help non-doers (caregivers who are not practicing new behaviors) to overcome obstacles that have prevented them from trying or maintaining the practice in the past. Behavioral determinants will be more prominent in future modules. [1: See http://barrieranalysis.fhi.net for more information.]

Under the objectives, all of the materials needed for the lesson are listed. The facilitator should make sure to bring all of these materials to the lesson. In Lesson 5, we introduce the idea of an Activity Leader who will focus on the needed materials for Module 2. See below for more information.

Each exercise (section of the lesson plan) is identified by a small picture. Pictures are used to remind non-literate Mother Leaders of the order of the activities. For example when it’s time to lead the game the lesson plan shows a picture of people laughing as if they are enjoying a game (see below). The pictures in the lesson plan help to cue Mother Leaders of the next activity. Review the descriptions below for more information.

The first activity in each lesson is a game. Games help the participants to laugh, relax and prepare for the lesson. Some games review key messages that the participants have already learned. Some games promote the belief objectives. Make sure that everyone participates in the games.

Following the game is the attendance and troubleshooting section. All facilitators will take attendance. The troubleshooting questions only apply to facilitators (promoters) training others.[footnoteRef:2] The promoter follows up with any difficulties that the Mother Leaders had teaching the previous lessons. Refer to the role play in Lesson 4 for more information. [2: In the Tubaramure program, paid staff are called promoters. The role of the promoters is to train Mother Leaders to facilitate lessons with their neighbors. A few exercises, noted above, are only for promoters and do not need to be used by the Mother Leaders when sharing with their neighbors.]

Next the facilitator opens the flipchart to the first picture of the lesson. He or she reads the story printed on the back of the flipchart, adding more details and descriptions as desired.

The story in each lesson is followed by discussion questions. These questions help the facilitator to find out the caregivers current practices (related to the lesson). This section is marked by the A (ask) in the ASPIRE method.[footnoteRef:3] This section is meant for discussion, not for teaching. Be sure to let everyone voice their opinions [3: For more information about the ASPIRE method review Lesson 2.]

The second, third and fourth picture in each lesson are for teaching the key objectives of the lesson. After turning to the second flipchart page [the S (Show) - in ASPIRE], ask “What do you see in this picture?” Let the participants respond and describe what they think the flipchart pictures are telling them.

Next, explain the key messages written on the back of the flipchart. The key messages also appear as captions on the flipchart pages. Be sure to explain each picture using the additional bullets printed on the back of the flipchart (or in the lesson plan). The lesson plan also contains additional information for the trainer. The additional information does not need to be discussed during the lesson unless it directly relates to questions by the participants.

After the fourth picture of the lesson, is an activity. Activities are “hands-on” exercises to help the participants understand and apply what they have learned. Most of these activities require specific materials and preparations.

Beginning in Module 2, an activity leader is responsible to organize materials for the Lesson Activity. The Activity Leader for Module 2 is elected in Lesson 5. The Activity Leader meets with the facilitator ten minutes before each lesson to discuss the needed materials for the next lesson’s activity. The Activity Leader is responsible to talk with the others (Mother Leaders or neighbors) during the “Attendance and Troubleshooting” to organize the materials needed for the next meeting, asking them to volunteer to bring the items. The facilitator will lead the activity, but the Activity Leader will support her by organizing the volunteers and aiding the facilitator as needed during the activity.

After the activity, the facilitator completes the P-I of the ASPIRE method. The ASPIRE method is used to reinforce participatory methods of teaching. It is explained in detail in Lesson 2.

In the probe section the facilitator asks if there are any obstacles that may prevent the caregivers from trying the new practices. They discuss these obstacles and then move to the next section.

The facilitator informs the caregivers of ways to overcome the concerns that are mentioned. The facilitator gives more information or a different perspective to help the caregivers understand how to move forward.

Next is Practice and Coaching. This section is required for the training of Mother Leaders. We want to make sure that they understand the material and can present it to others. In this small group activity, the promoter can observe and coach those who are having difficulty.

Finally the facilitator completes the R-E of the ASPIRE method.

The facilitator requests a commitment from the Mother Leader (or caregivers) to begin practicing the new practices they have discussed. If they agree, the caregivers should make a verbal commitment. It is up to the caregivers to make a choice. They should not be forced to make a commitment if they are not ready.

The last section is where the facilitator examines the Mother Leader (or caregivers’) practices based on the teaching from the last lesson. The facilitator encourages them to try the new practices they have not yet done.

All lessons follow the pattern described above. Lessons can be adapted as needed to fit the needs of your care group. Lessons should not exceed two hours in length although some lessons may take longer than others. The suggested time for each section is listed below.

Section name

Time needed for this section

Game

Attendance and Troubleshooting

Story and Ask (picture 1)

Show and Explain (picture 2)



Activity

Probe

Inform

Practice and Coaching

Request

Examine

10 minutes

5- 15 minutes

10 minutes

5 minutes

5 minutes

5 minutes

15 minutes

10 minutes

5 minutes

20 minutes

2 minutes

15 minutes

2 hours

Acknowledgements

Hanold, Mitzi J. (2010) Essential Nutrition, Hygiene, and Care Practices during Infancy Mother Leader Lesson Plan. Washington DC. Food for the Hungry (FH), made possible through support provided by the Office of Food for Peace, Bureau of Democracy, Conflict, and Humanitarian Assistances, and the U.S. Agency for International Development under the terms AID-FFP-09-00004-00. The opinions expressed herein are those of the author and do not necessarily reflect the view of the U.S. Agency for International Development.

Many thanks to our illustrator Ir Leonidas Nisabwe. Editors include Carolyn Wetzel (FH), Dr. Dieudonne Bikorimana (FH), Deanna Olney (IFPRI), Mary Hennigan (CRS), (CRS), Isaac Kilimushi-Hamuli (IMC), and Regine Pachis Nihoreho (CRS). For questions or comments, please contact the author at [email protected].

2

Lesson 1: Importance of Postpartum Care

Women who have delivered a child in the last six weeks will:

Rest more often than normal to help the body recover from the blood loss and strain on the body from delivery.

Continue taking iron supplements (vitamins) for six months after the infant is born. Iron supplements are distributed by the health centers.

Wash their genitals with soap and water each day and after passing feces until the area is healed.

Eat two additional snacks each day to regain strength and to help with milk production.

Drink more liquids than normal to help the body recover and encourage production of breast milk.

Women who have delivered a child will go to the health center for vitamin A and tetanus immunization in the first six weeks after giving birth.

Vitamin A helps improves the health status of the mothers and supplies Vitamin A to the infant through breast milk for improved survival.

Mother will receive a tetanus toxoid immunization at the same time as Vitamin A if she has not already completed the series.

Women who have delivered a child in the last two weeks will go to the health center if one of more of the following danger signs are seen:

High fever, bad smelling genitals, and pains in the belly are all signs of infection. Part of the placenta may be left inside the mother.

Severe bleeding or bleeding that continues for more than two weeks puts the mother’s life at risk.

Leaking urine or stool is caused by long labor. The skin between the anus and vagina dies so the woman is not able to control urine or feces.

Caregivers will discuss methods to help mothers rest and share her work in the weeks after delivery.

Materials:

1. Attendance Registers

Essential Nutrition, Hygiene and Care during Infancy Flipchart

A woman’s health card

Container of iron pills

Sixteen small objects (bottle caps, rocks or leaves)*

Lesson 1 Summary:

Game: I’ve Never


Share the story and ask about current behaviors: Barumwete Goes Back to Work

Show pictures and share key message on flipchart pages 6-11 about Maternal Care after Delivery, Services after Delivery at the Centre de Santé, and Danger Signs after Delivery.

Activity: Care After Delivery

Probe about possible barriers

Inform them of possible solutions to the barriers

Practice and Coaching in pairs

Request a commitment

Examine commitments and behaviors related to newborn care.

1. Game: I’ve Never - 10 minutes

1. Place enough chairs (or mats) for each woman in a circle.

Choose one volunteer. The volunteer stands in the middle. Her chair (or mat) is removed from the circle.

The volunteer names one thing that she has never done, or never been. She should think of something that others in the group have experienced. For example: “I have never had a male child.”

All of the women who HAVE had a male child must stand up and move to a new place in the circle. At the same time, the volunteer tries to sit in one of the open seats. One person will be left without a seat. That person now stands in the middle and names one thing that she has never done, or never been.

The object of the game is to stay in your seat. If you must move, move quickly into an open seat so that you will not have to stand in the middle.

Continue to play until everyone has a chance to stand in the middle.

Now that we are energized, let’s begin our lesson.

2. Attendance and Troubleshooting – 10 minutes

1. The Promoter should fill out the attendance sheets for each Mother Leader following the role play model from Lesson Four of Module 1.

2. Promoter asks if any of the Mother Leaders had problems during their meetings with their mothers. Promoter problem solves with the mothers, helping to solve troubles they are having, and asking other Mother Leaders for advice.

3. Promoter asks about maternal deaths, child deaths or new pregnancies in the neighbor groups. Promoter records new events on the attendance sheet.

4. Promoter thanks all of the mothers for their hard work and encourages them to continue.

Barumwete Goes Back to Work (Picture 1.1) – 10 minutes

3. Story

Read the story on page 4 of the flipchart.

The story encourages discussion about the importance of resting after delivery.

Two days after delivery, Barumwete begins her work again. In the morning, she sweeps her compound and goes to the market. In the afternoon, she begins preparing food, but she is not able to finish. She is exhausted. She lies down and quickly falls asleep. Her son sees that her bleeding is heavy and runs for help.

4. Ask

Read the questions on page 4 of the flipchart.

Ask the first questions to review the story.

We hope the participants will say: Barumwete has not healed from her delivery. She is working too hard and it increases her bleeding.

Ask the second and third question to find out the beliefs of how long women should rest (or is able to rest) after delivery.

We hope the participants will say: It is best for a woman to rest often and work less than normal for up to six weeks. If a mother is bleeding she must rest until her body is healed.

Ask the last question to find out how many days the women in the group rested.

Encourage discussion. Don’t correct “wrong answers.” Let everyone give an opinion. This page is for discussion, not for teaching.

After the participants answer the last question, move to the next flipchart page by saying, “Let’s compare your ideas with the messages on the following pages.”

Why is Barumwete bleeding?

How long should a woman rest after delivery?

How many days did you rest after delivery?

Maternal Care after Delivery (Picture 1.2) – 5 minutes

5. Show:

Ask the caregivers to describe what they see in the pictures on page 7.

What do you think these pictures mean?

6. Explain:

Share the key messages using flipcharts pages 6 and 7.

Use the captions on the flipchart to remind you which images represent each point.

Ask someone to stay with you after delivery for one week or more.

This woman lets Karorero rest.

She cooks for the family.

She cares for the children.

For six weeks after delivery rest often. Work less than normal.

Women lose a lot of blood during delivery.

Women who do not rest bleed more.

Women who bleed too much are at risk of severe sickness and death.

Eat two additional snacks each day to gain strength after delivery.

This mother eats beans, lentils, green leafy vegetables and organ meats, to make her blood strong.

These foods are high in iron.

Additional snacks help her body to make breast milk.

She drinks more water than normal to help her body make breast milk.

Wash yourself each day and each time you pass feces until the skin is healed.

Germs from feces may get into the wounds from childbirth.

Washing with soap or ash will kill germs and help the skin to heal.

Is it difficult to rest after delivery?

Who can help the mother complete her work after the helper leaves?

What advice would you give to a new mother about resting after delivery?

Additional Information for the Trainer

Maternal Mortality Rate

In Burundi one out of every 16 women will die from a maternal cause (pregnancy, birth, delivery or postnatal complications).[footnoteRef:4] [4: (WHO and UNICEF) See http://www.unicef.org/infobycountry/burundi_statistics.html]

In developing countries, over half (60%) of maternal deaths occur in the weeks after delivery. Of those who die after birth, most (45%) of them are within 24 hours after delivery. Another 23% of the deaths are on days 2-7 after delivery.[footnoteRef:5] [5: Li, XF, Fortney, JA, Kotelchuck, M, and Glover, LH. 1996. The postpartum period: The key to maternal mortality. International Journal of Gynecology and Obstetrics 54(1): 1-10.]

The two largest reasons for maternal death are bleeding and infections. Appropriate care in the first hours and days after delivery can prevent the majority of these deaths.

Baseline Data (Postnatal visit within 72 hours)

Only 6.6% of women received a postnatal visit within 72 hours birth in the two provinces. (8.4% of mothers in Ruyigi and 3% in Cankuzo).

Services after Delivery at the Health Facility (Picture 1.3) – 5 minutes

7. Show:



8. Explain:



Show the container of iron pills to the mothers. Explain where they can purchase (or receive) iron pills.

After reviewing the flipchart, point out the place on the health card where tetanus vaccinations are marked.

· Take iron pills each day for six months after giving birth.

· Take iron pills with food.

· Iron helps to make the mother’s blood strong.

· Iron gives energy and strength to the mother.

· Receive Vitamin A in the first six weeks after giving birth.

· The mother receives a drop of Vitamin A during her visit.

· Vitamin A helps to restore the mother’s health.

· Vitamin A in the mother’s breast milk helps the infant to resist sickness.

· Receive a tetanus vaccination if your card is not complete.

· Tetanus causes lockjaw and painful convulsions.

· Vaccinated mothers are protected from germs that may have entered the body during delivery.

· Breastfeeding infants are protected by drinking their mother’s milk.

· Karorero’s vaccination will protect her for 10 years.

· How many of you are taking iron pills?

· How many of you have already received vitamin A?

· Why are these services important?

Additional Information

Iron Pills

Iron pills (also referred to as ferrous sulfate) should be available to pregnant and lactating women at health centers.

Women should take iron pills daily, with food after their first prenatal visit until six months after delivery.

For more information on iron, review Module 2, Lesson 3.

Vitamin A and Mortality

It is estimated that 140-250 million children under five years of age have vitamin A deficiency. These children suffer an increased risk of death, blindness and illness (especially measles and diarrhea).

Providing Vitamin A to the mother not only increases the mother’s health but also provides vitamin A for the breastfeeding infants.

Baseline Data

The percentage of mothers who have received Vitamin A after delivery is very low. Only 45.3% in Cankuzo and 14% in Ruyigi (an average of 22.2% for two provinces.)

The percentage of mothers who have taken iron tablets during the appropriate period (all of pregnancy or more than 6 months) is 38.4% in Cankuzo and 56.2% in Ruyigi (an average of 41.6% for the two provinces).

Tetanus in Infants

Tetanus germs grow in wounds or cuts that are contaminated by dirty instruments or feces. Infants are at risk of tetanus if the umbilical cord is cut with an unsterilized instrument or if the stump is not allowed to dry and heal in the first week of life.

Signs of tetanus in newborns appear 3 to 10 days after birth. The child begins to cry continuously and is unable to suck.

Baseline Data

When asked to name the practices that help to keep a pregnant mother protected during pregnancy and after birth, only 17.7% of mothers mentioned receiving a tetanus vaccination, 13.2% mentioned taking vitamin A and 14.7% mentioned taking iron tablets.

The percentage of mothers of infants 0-23 months who have received the appropriate number of tetanus vaccinations is 27.9% in Cankuzo and 35.4% in Ruyigi (an average of 32.9% for the two provinces).

Tetanus in Adults

Tetanus germs grow in wounds or cuts that are contaminated by dirty instruments or feces. Mothers are at risk of tetanus from unclean deliveries or poor hygiene during the postnatal period.

A woman who has been vaccinated with five properly spaced doses is protected for life. Infants born to this mother are protected for the first few weeks of life and then should receive the appropriate infant and child vaccinations which include tetanus.

An expectant mother whose tetanus immunization status is uncertain or whose last immunization was more than 10 years ago should be immunized against tetanus.

Danger Signs after Delivery (Picture 1.4) – 5 minutes

9. Show:



10. Explain:



· If you see any of these signs, go immediately to the Centre de Santé.

· Fever

· Genitals have a bad odor

· Sharp pains in the belly

· These first three signs are for infection inside the womb.

· Many women die from untreated infections after delivery.

· Heavy bleeding or bleeding that doesn’t stop after two weeks

· Urine or feces leaking from the body

If you see one of these signs do not wait. Go to the Centre de Santé.

· How does a woman know if her bleeding is heavy? What is the normal amount of bleeding after delivery?

· Why is it important to go immediately to the clinic?


Fistula

Leaking urine or feces is a sign that a tear has formed between the vagina and rectum or the woman has a hole in the bladder or bowel. This is caused when labor goes too long and the skin dies between the vagina and anus.

In most cases, surgery can repair these damages and help the woman to live a normal life including the birth of more children.

Additional Danger Signs

Headaches, nausea, vomiting and feeling faint are signs of eclampsia (toxemia).

Calf pain, redness or swelling of calves; shortness of breast or chest pain may be signs of a blood clot.

In general, women should go to the Health Facility if they do not feel “right” or notice any unusual signs.

11. Activity: Care After Delivery – 15 minutes

1. Show the women 16 objects (bottle caps, stones, or leaves).

1. Explain: In Burundi, many women die during pregnancy or just after delivery. These 16 stones represent women in Burundi.

Out of 16 women in Burundi, how many do you think will die because of problems during pregnancy, delivery or recovery?

1. The answer is one. One out of every 16 women dies because of problems during pregnancy, delivery or recovery.

1. Separate the one bottle cap from the others.

(Hold the bottle cap in your hand).

What time is the most dangerous for this mother?

Is it during pregnancy? During delivery? Or after delivery?

1. The majority of mothers die in the first seven days after delivery. This is the most important time for mothers to rest and recover.

How many days is a mother usually given to rest after delivery? Is this enough?

Is there someone watching if she shows a danger sign?

What are things that families can do to help women to recover after birth?

Some possible responses:

Husbands can save a small amount of money (including transportation and money for medication) in case the mother shows danger signs.

The community can organize a vehicle for emergency trips to the hospital or clinic.

Husbands and older children can help with household work so the mother can rest and breastfeed the newborn.

The helpers must know the danger signs. They can watch mothers and help to get them to the Health Facility if there are problems.

Old women in the community can volunteer to do field work for women who have recently given birth.

Ask each mother, “How can women help husbands and others in the community understand the importance of caring for the mother after delivery?”

Ask each mother, “How can you help other mothers who have just delivered?”

Encourage the women to think of one thing they can do to raise awareness or help other women in the community after delivery.

12. Probe: 10 minutes

· What do you think about these ideas? Is there anything that might prevent you from trying these new health practices?

Ask mothers to talk to a woman sitting next to them. They will share barriers and concerns they have about the new teaching. Together they will try to find solutions to these barriers. After five minutes, ask the women to share what they have discussed with the large group.

13. Inform: 5 minutes

Help find solutions to their concerns. If a woman offers a good solution to another woman’s concern, praise her and encourage others to consider this solution.

14. Practice and Coaching - 20 minutes

1. Ask Mother Leaders to share the teachings they have learned today using the first two flipchart pages. They should share with another woman in the care group using the ASPIRE method.

Tell the Mother Leaders listening to the message that they should give one objection to the lesson; one reason that they think this message would be difficult for them.

The Mother Leaders sharing the message should try to help the women overcome this obstacle.

After ten minutes, ask the women to switch roles. The other Leader Mother will share the teachings from the next two flipchart pages.

The Promoter should watch, correct, and help the Mother Leaders who are having trouble.

When everyone is finished, answer any questions that the mothers have about the materials, or today’s lesson.

15. Request ─ 2 minutes

Are you willing to make a commitment to the teachings you have heard today? What is your commitment?

Ask each mother to say out loud a new commitment that she will make today. Each mother can choose the commitment that is most important to her.

For example:

I will work less often in the six weeks after birth.

I will wash myself with soap and water each day after I pass feces.

I will visit the Health Facility for Vitamin A tablets after giving birth.

I will continue taking iron pills for six months after giving birth.

16. Examine ─ 15 minutes

Ask each Mother one-on-one about her commitments.

What was your commitment at the last lesson? Have you kept that commitment?

How – what did you do?

Finally ask each mother one on one about her practices in the last two weeks:

For mothers who have given birth in the past month:

Did your infant receive vaccinations at birth?

How have you cared for the child’s cord?

For all mothers:

What are the infant danger signs?

How should a mother care for the child’s cord after delivery?

What signs tell you that your infant is hungry?

Lesson 2: Exclusive Breastfeeding: Benefits, Frequency and HIV

Mothers will be able to list at least three benefits of exclusively breastfeeding until six months of age:

Exclusively breastfed infants get sick less often and less severely than infants who are given other foods or liquids before six months.

Exclusive breastfeeding prevents pregnancy for the six months that the woman breastfeeds on demand and has no signs of her monthly blood.

Caregivers will believe that exclusively breastfed infants will not be hungry. They will be healthy and stay within the lines on the growth chart (increased perceived action efficacy).[footnoteRef:6] [6: Action efficacy is a behavioral determinant in barrier analysis found to be significant for increasing exclusive breastfeeding. Use this lesson to increase the belief that children will not be hungry or lack nutrition if they are exclusively breastfed. For more information, review “La Structure du Changement de Comportement: L’Allaitement Maternel Exclusif (Burundi) and www.barrieranalysis.com.]

Mothers will exclusively breastfeed, giving only breast milk; never giving water, beer, or other foods to infants less than six months of age.

Even when mothers are sick or malnourished, they will continue exclusively breastfeeding their infants until six months of age. Even a malnourished mother is able to provide healthy and sufficient milk for her child.

Mothers will breastfeed whenever the child is hungry day or night at least 10 times each day (about every two hours).

On demand breastfeeding lowers the possibility of pregnancy in the first six months of life.

On demand breastfeeding prevents the mother’s monthly bleeding from returning.

Breastfeeding women will eat a variety of foods when breastfeeding including beans, organ meats, garlic, whole grain rice, red palm oil, peanuts, squash seeds, fish and eggs.[footnoteRef:7] [7: Foods selected are based on findings of the Local Determinants of Malnutrition Study. Breastfeeding women who ate foods these foods had healthier children compared to mothers who did not eat these foods. For more information, see http://www.slideshare.net/jehill3/local-determinants-of-malnutrition-an-expanded-positive-deviance-study.]

Mothers who exclusively breastfeed can be sure their infant is getting enough food each day by counting the times that the child urinates. After the second day of life, well-fed infants urinate six or more times each day.[footnoteRef:8] [8: Use this lesson to increase the belief that exclusive breastfeeding does NOT lead to child hunger or malnourishment. Mothers can be confident that their breast milk is enough when the infant urinates six or more times a day. For more information, review “La Structure du Changement de Comportement : L’Allaitement Maternel Exclusif (Burundi) and www.barrieranalysis.com.]

Crying does not determine whether a child is receiving enough food. Children cry for many reasons.

HIV positive mothers must exclusively breastfeed their infants for the first six months of life.

Replacement feeding (infant formula or heat-treated, expressed milk) is only recommended during the first six months if environmental circumstances and social circumstances are safe for and supportive of replacement feeding. For the communities in the Tubaramure program area, breast milk is the best choice for HIV positive women. Replacement feeding (infant formula and heat-treated milk) can reduce the chances of passing HIV to the infant. However, the infant is at greater risk for malnourishment and death if the liquids and containers used to feed the infant are not cleaned and prepared correctly at each feeding.[footnoteRef:9] [9: Guidelines on HIV and Infant Feeding. 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. WHO. Available: http://www.who.int/child_adolescent_health/documents/9789241599535/en/index.html ]

Caregivers will believe that many of their friends and family (mother, mother-in-law, husband, and cousins) would support them exclusively breastfeeding until six months of age (increased perceived social acceptability).[footnoteRef:10] [10: Perceived Social acceptability is a behavioral determinant in barrier analysis found to be significant for increasing exclusive breastfeeding. Use this lesson to increase the belief that mother-in-laws, husbands, cousins and mothers would approved of exclusive breastfeeding until six months of age. For more information, review “La Structure du Changement de Comportement : L’Allaitement Maternel Exclusif (Burundi) and www.barrieranalysis.com. ]

Materials:


Essential Nutrition, Hygiene and Care during Infancy Flipchart

A ball of paper, string or cloth

Lesson 2 Summary:

Game: Ball Toss


Share the story and ask about current behaviors: Karorero’s Friends Support Her

Show pictures and share key message on flipchart pages 14-19 about the Benefits of Exclusive Breastfeeding, Breastfeeding Frequency and Maternal Health, and Exclusive Breastfeeding for Mothers with HIV.

Activity: Enough Breast milk





Examine commitments and behaviors related to maternal care after delivery.

1. Game: Ball Toss - 10 minutes

1. The facilitator names a topic from a previous lesson such as “hand washing” and tosses the ball to another woman in the group.

1. The woman who receives the ball must name one practice that she has learned about hand washing. Then she tosses the ball to someone else in the group. That person must also name one practice she has learned about hand washing. She cannot repeat what has already been mentioned.

1. For example, the facilitator says “hand washing” and tosses the ball to Maria. Maria says, “Wash hands with soap after using the latrine.” Then Maria tosses the ball to Elizabeth. Elizabeth says, “Wash hands with soap before touching a newborn baby.” Continue tossing the ball until five or six practices are named. Then begin a new topic.

1. New topics may include: practices to prevent malaria, practices to help women recover after birth, practices that show children they are valued.

1. Continue passing the ball until everyone has had several turns to name practices they have learned.

Now, let’s begin the lesson.






Karorero’s Friends and Family Support Her (Picture 2.1) – 10 minutes

3. Story


Karorero and the other Leader Mothers listen to the teaching about exclusive breastfeeding. Each one of the women in the care group makes a commitment to exclusively breastfeed for the first six months. They know this will be difficult, but they commit to support each other, encourage one another and not give me any other foods or liquids for six months.

4. Ask


Ask the first question to review the story.

We hope the women will respond: They commit to exclusively breastfeeding their infants. They believe it is the best thing for their children for the first six months of life.

Ask the second question to discuss ways the care group (or neighbor groups) can encourage each other to keep a commitment to exclusive breastfeeding.

They can give advice if a woman has breastfeeding troubles.

They can encourage women who have doubts.

They can discuss reasons why exclusive breastfeeding is best.

They can help those whose family members disagree.

Ask the last question to encourage the women to list those they know that would encourage them to exclusively breastfeed.

This might include family members, health workers, and teachers at the school, neighbors, friend, promoters, leader mothers, and religious leaders.

Remind them throughout the lesson that many people would support them to make this change.

Encourage them to join this large group of people and give only breast milk. [footnoteRef:11] [11: From the Barrier Analysis study in Burundi, those who breastfed exclusively were up to ten times more likely to say that mother-in-laws, husbands, cousins and mothers approve of breastfeeding. ]



· What did Karorero and the others mothers do? Why?

· How can these women help each other to keep this commitment?

· Who in your life encourages you to give only breast milk?

Benefits of Exclusively Breastfeeding (Picture 2.2) – 5 minutes

5. Show:



6. Explain:



· Give only breast milk to infants from birth to six months. Never give water, beer or other foods.

· Breast milk is the best food and drink for infants.

· Breast milk does not need to be mixed or prepared.

· Breast milk does not cost money.

· Giving only breast milk for six months prevents new pregnancy.

· Exclusive breastfeeding prevents monthly bleeding.

· Breastfeed whenever the child wants it day or night.

· Giving other foods and liquids allows the women to become pregnant again.

· Giving other foods and liquids before six months brings diarrhea.

· Other foods and liquids make the child sick.

· Many infants die from diarrhea each year.

· Exclusively breastfed infants have diarrhea less often.

· Giving other foods and liquids stops the child from growing tall and fat.

· Giving foods before six months slows the child’s growth.

· Breast milk makes children grow tall and fat.


Breastfeeding in Burundi

According to UNICEF data from 2003 to 2008, less than half (45%) of all children were exclusively breastfed for six months.

Breastfeeding and Pregnancy

Breastfeeding is more than 98% effective in preventing pregnancy during the first six months as long as ALL of the four principles below are true:

1) The mother’s monthly bleeding has not started again

2) She gives only breast milk whenever the infant show signs of hunger—day and night

3) The infant is allowed to empty one breast before the other breast is offered, and

4) The infant is less than six months old.

Breastfeeding and Anemia

Giving only breast milk, whenever the infant shows signs of hunger, delays the return of the mother’s monthly bleeding.

This helps the mother to restore blood and iron lost during delivery. Exclusive breastfeeding thus helps protect the mother from anemia.

Breastfeeding Frequency and Maternal Health (Picture 2.3) – 5 minutes

7. Show:



8. Explain:



· Breastfeed whenever the child is hungry day and night. Breastfeed at least 10 times each day.

· Infants have small stomachs that need food often.

· Breastfeed whenever the child shows signs of hunger.

· Breastfeeding on demand stops the mother’s monthly bleeding.

· Breastfeeding on demand prevents pregnancy for six months.

· Breastfeed even if you are sick.

· Sick mothers still have healthy milk for their infants.

· Even very thin mothers have healthy breast milk.

· Eat beans, organ meats, garlic, whole grain rice, red palm oil, peanuts, squash seeds, fish and eggs.

· Mothers who eat these foods have healthier children.

· Eat two additional snacks each day.

· What are the signs that a child is hungry?

· The infant moves his tongue in an out, makes sucking noises, sucks on his fingers, turns his head from side to side or cries.

· Did you eat any of the foods in this picture yesterday?

· Which one of these foods can you add to your meals tomorrow?


Infant Hunger

Some infants are hungrier on certain days than others. If the infant shows increased hunger, breastfeed more often. After two days of additional breastfeeding, the mother’s milk supply grows to meet the child’s needs.

Exclusive Breastfeeding for HIV Positive Mothers (Picture 2.4) – 5 minutes

9. Show:

Ask the caregivers to describe what they see in the pictures on page 19 of the flipchart.


10. Explain:



· Mothers with HIV offer only breast milk for the first six months of life.

· Infants given infant formula are more likely to die from diarrhea.

· This mother is saying “No” to infant formula.

· She knows infant formula is more likely to make her child sick.

· Even if HIV treatment is not available, breastfeed your child.

· Mothers with HIV do not give animal milk, water, tea, porridge or other drinks for six months.

· All foods other than breast milk are dangerous for infants less than six months.

· These foods cause sickness.

· After six months begin given foods and water.

· Adding other foods and liquids makes it easier for HIV to pass to the child.

· This child has HIV because he was given foods before he was six months old.

· To lower the possibility of passing HIV, give only breast milk.


Mixed Feeding

The risk of HIV transmission from mother to infant from 6 weeks to six months of exclusive breastfeeding is about 4%.

If the breastfed infant is given solid foods in the first six months he has a risk of HIV infection eleven times higher than the exclusively breastfed infant.[footnoteRef:12] [12: Prevention of Mother-to-Child Transmission of HIV. Generic Training Package Draft Trainer Manual. January 2008. Module 6 Infant Feeding in the Context of HIV Infection. WHO, US Department of HHS-CDC, Global AIDS Program. Available: http://www.womenchildrenhiv.org/wchiv?page=gtp-01-00]

HIV Prevalence

HIV prevalence among adults aged 15 to 49 in Burundi is estimated to be 2% (2008 UNAIDS Report).[footnoteRef:13] [13: UNAIDS/WHO Epidemiological Fact Sheets on HIV and AIDS, 2008 Update". Available: http://apps.who.int/globalatlas/predefinedReports/EFS2006/index.asp?rptGrp=4]

Replacement Feeding

For the communities in the Tubaramure program area, breast milk is the best choice for HIV positive women. Replacement feeding (infant formula and heat-treated milk) can reduce the chances of passing HIV to the infant. However, the infant is at greater risk for malnourishment and death if the liquids and containers used to feed the infant are not cleaned and prepared correctly at each feeding.[footnoteRef:14] [14: Guidelines on HIV and Infant Feeding. 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. WHO. Available: http://www.who.int/child_adolescent_health/documents/9789241599535/en/index.html ]

To safely replacement feed, families need to always have clean water, infant formula, cooking fuel, diverse foods, and a clean home environment.

Infant formula milk and heat-treated expressed breast milk are the only two options for the first six months of life. After 6 months, HIV positive mothers can give boiled animal milk, infant formula, or heat-treated expressed milk with complementary foods.

HIV Positive Infants

If the infant is known to be HIV positive, HIV positive mothers can follow guidance for the general population: exclusively breastfeeding for the first six months and continue breastfeeding for two years or more.

Mixed feeding during the first six months of life (giving breast milk and water and other foods before six months) greatly increases the chance of passing HIV to the infant compared to exclusive breastfeeding.

ARV Treatment & Feeding

If ARVs are available the current recommendations suggests that the mother exclusively breastfeeds until six months of age and begins complementary feeding at six months. During these 12 months, the mother or child must take daily ARVs.

If ARVs are NOT AVAILABLE the recommendations suggests that the mother exclusively breastfeeds until six months of age. At six months, if the mother if the mother is able to provide clean and sanitary replacement feeding, she should reduce breastfeeding in a period of three weeks, adding replacement milk (boiled animal milk, infant formula or heat treated expressed milk). At six months if the mother is not able to provide clean and sanitary replacement feeding, she should continue breastfeeding and giving foods following the same guidance for the general population (mothers without HIV).

Non-Breastfed Infants

After breastfeeding stops (either at 6 months or 12 months) for an HIV infected mother, or a mother who is unable to breastfeed for other reasons, nutrient rich foods are needed to replace energy and nutrients that the child would normally receive from breast milk. Non breastfed children are therefore at great risk of malnutrition.

Feed non-breastfed children frequently. Give soft, thick porridge. Add cooking oil, groundnut flour, sugar, honey, groundnuts, milk, soybeans, meat, or fish to increase nutrients for the child.

Feed non-breastfed children four to five meals and two to three snacks per day. Offer nutrient rich foods such as organ meats, eggs, leafy green vegetables, groundnuts (peanuts), beans, red palm oil, squash seeds, fish, and CSB soya flour.

If possible, re-start breastfeeding. In areas where the Tubaramure program meets, the non-breastfed infant (0 to 12 months) is at high risk of malnourishment and death.

11. Activity: Enough Breast Milk – 15 minutes

1. Discuss the following questions. Help affirm the women that they have enough breast milk and it will provide all the food and nutrients a child needs for the first six months.

How can a mother be sure her child is getting enough breast milk?

Add any of the following reasons that are not mentioned:

At the monthly growth monitoring meetings, the child stays within the broad road on the growth chart.

Child appears satisfied after eating.

Child does not show signs of hunger.

Add: There is another way a mother can be SURE that her child is eating enough.

In the first two days after birth, an infant will urinate only once or twice a day.

After the second day, an infant will urinate six or more times each day.

Count the number of times your child urinates each day.

If he urinates six or more times, he is eating enough and is satisfied.

What should a mother do if her child does not urinate six or more times?

Breastfeed more often.

Breastfeed whenever the child shows signs of hunger (moves his tongue in and out, makes sucking noises, sucks on his fingers, turns his head from side to side or cries.

Drink more water each day to increase your milk supply.

Summarize: The mother’s body creates the best food for infants. If a mother is concerned, she can count the number of times a child urinates each day. She can drink more fluids and breastfeed her child more often to ensure that her child will grow well.

If someone mentions that breastfed children cry more often….

Some mothers think that a child that cries a lot is hungry. This is not always true. Children cry for many reasons. Hunger is only one of the reasons.[footnoteRef:15] [15: From the Barrier Analysis studies in Burundi, Non-doers were 7.3 times more likely to believe that a child who is exclusively breastfed will always be hungry. Help mothers to understand that exclusive breastfeeding is enough to satisfy an infant. If a child cries after breastfeeding, it is not necessarily a sign of hunger. Children cry for many reasons.]

A child cries if they are cold, if they are too hot, if they are wet, if they have pain or simply want their mother’s attention.

Children will always show signs of hunger first, before crying from hunger. Watch for signs of hunger first. If your child is crying and you have not seen any signs of hunger, he is probably crying for some other reason.

Some mothers think that boys need more food than breast milk can provide. Giving male infants younger than 6 months of age food or liquids other than breast milk will not make them fatter or stronger. It will put them at greater risk for illness and death.

Additional Information for the Trainer:

Solid Waste (feces)

The color, consistency and odor of feces changes as the infant grows. During the first day 36 hours after birth, the newborn passes one greenish-black, sticky feces called meconium.

During the first three weeks, feces are semi-liquid and green-brown. Semi-liquid feces are normal.

After the third week, breastfed infants pass orange-yellow, loose (soft, watery) feces that smell both sweet and sour. Formula-fed infants pass darker and less frequent feces. As babies grow older, they have feces less often and the feces are more formed.

A normal infant will pass feces three or more times each day during the first six weeks. The number decreases as the infants grows older and begins to eat solid foods.
















For example:

I will breastfeed my child whenever they show signs of hunger.

I will not give other foods and liquids to my child before six months of age.

I will breastfeed even on days when I have sickness.

I will eat two additional snacks of eggs each day to help my child grow well.




How? What did you do?


Have you worked less than normal in the last two weeks?

Have you received your Vitamin A drop? When will you go this week?

Have you received a tetanus vaccination in the last 10 years ? If no, when will you go this week?

Did you take an iron tablet today? If no, when can you go this week to get your tablets?

Lesson 3: Exclusive Breastfeeding: Hydration, Emptying the Breast and Complementary Feeding

Breastfeeding women will avoid beer and all other alcohol. Mothers who drink alcohol in large quantities or daily can negatively affect their child’s health by decreasing milk production, slowing weight gain in the infant, decreasing infant’s motor skills and development, and affecting the infant’s sleep patterns.

Breastfeeding women will drink more water than normal and breastfeed more often to encourage production of breast milk. Mothers will encourage others to drink water instead of beer to increase breast milk.

Breastfeeding women will empty one breast, waiting until the child pulls off or loses interest, and then switch to the other breast if the infant is still hungry. Emptying the breast helps the child to receive both the thin white milk (foremilk) and the thick yellow milk (hind milk).

The fat content of milk in the breast increases the longer the infant breastfeeds. If the mother switches breasts too early, the infant will not receive the milk with high fat content (yellow milk).

Emptying the breast will give infants satisfaction after feeding; they will not suffer from hunger.[footnoteRef:16] [16: This objective is based on a behavioral determinant in barrier analysis found to decrease exclusive breastfeeding. Use this lesson to increase the belief that emptying both breasts satisfies the child’s hunger. This negative attribute found that those not exclusively breastfeeding believed incorrectly that exclusive breastfeeding leads to child hunger. For more information, review “La Structure du Changement de Comportement: L’Allaitement Maternel Exclusif (Burundi) and www.barrieranalysis.com.]

Breastfeeding women whose infants are not gaining weight will breastfeed more often and for a longer time, whenever the infant wants day and night offering one breast and the other once the infant stops breastfeeding on the first breast.

Breastfeeding women will continue exclusive breastfeeding until 6 months. At six months of age, caregivers will begin giving a thick porridge once or twice a day after breastfeeding.

Mothers will continue to breastfeed as often as the child wants until at least 24 months of age.

Materials:


Lesson 3 Summary:

Game: Showing our Emotions


Share the story and ask about current behaviors: Barumwete Drinks Beer

Show pictures and share key message on flipchart pages 22-26: Increasing Milk Production, Empty the Breast before Switching, and Complementary Feeding

Activity: Breastfeeding Song





Examine commitments and behaviors related to exclusive breastfeeding.

1. Game: Showing our Emotions - 10 minutes

1. Choose one volunteer.

1. Ask the volunteer to stand at a distance so she cannot hear what the others discuss.

1. Once the volunteer walks away, the group chooses a descriptive word that describes how someone acts, such as happy, sad, patient, kind, angry, or joyful.

1. When they have chosen a descriptive word, ask the volunteer to return.

1. The volunteer gives them one action to perform such as talking, jumping, singing, washing clothes, etc.

1. The group pretends to do this action using the descriptive word they have chosen. The volunteer must guess what the descriptive word is that they are showing.

1. For example if the group decides that their word is angry, and the volunteer says, “washing,” the women in the group must pretend to wash clothes in an angry way.

1. The volunteer tries to guess the attitude that they are showing. If she guesses correctly, she joins the group and another volunteer is chosen.

1. If she cannot guess, she gives a new action and continues guessing.

1. Allow several women to be a volunteer. Use new descriptive words and activities for each volunteer.

How can feelings affect our behaviors?

The way we do things can help us do things well, or it can prevent us from completing a task.

We may be doing something helpful (like breastfeeding an infant) but do it in an angry or frustrated way. This can prevent the infant from feeding well.

As mothers we need to watch the way that we act when caring and feeding our infants. Our attitudes affect the way our child grows.

Now that we are energized, let’s begin our lesson.






Beer Increases My Breast Milk (Picture 3.1) – 10 minutes

3. Story


Karorero goes to visit Barumwete at her house. When she arrives Barumwete is drinking beer. “Barumwete, what are you doing?” Karorero asks. “I am trying to increase my breast milk for Mvuyekure.” My breasts are not as full as they used to be. Beer will help to bring more milk.”

4. Ask


Ask the first question to review the problem in the story.

We hope the women respond in this way: Barumwete is trying to increase her breast milk. She sees that her breasts are not as full as they used to be.

Ask the second question to listen to the women’s beliefs about beer and health.

Beer is dangerous for adults. When adults drink beer in large quantities or each day, it damages the brain and liver and can cause vomiting, alcohol poisoning and death.

Beer is very dangerous for infants. When breastfeeding mothers drink alcohol it is passed to the infant through breast milk. Alcohol severely damages the child’s growth and brain development.

Ask the last question to find out what the women do to increase their breast milk.



· Why is Barumwete drinking beer?

· Is beer healthy for Barumwete and her child?

What do you do to increase your breast milk?

Increasing Milk Production (Picture 3.2) – 5 minutes

5. Show:



6. Explain:



· Beer decreases a mother’s breast milk.

· This mother drinks beer to increase her breast milk.

· The infant must work harder to get milk from the breasts.

· The child drinks less when beer is in the breast milk.

· As the child feeds less, her breasts produce less milk.

· Beer in breast milk brings hunger and sickness.

· Beer in breast milk damages the child’s body.

· Beer slows the child’s growth.

· Beer in the mother’s milk has made this child very sick.

· Drink more water to increase breast milk.

· Karorero drinks water every time she breastfeeds.

· Breastfeeding reminds her to drink water.

· She drinks more water than normal.

· Breastfeed more often to increase breast milk.

· When a child feeds more often, the mother’s body produces more milk.


Alcohol

Mothers who drink alcohol in large quantities or daily can negatively affect their child’s health by decreasing milk production, slowing weight gain in the infant, decreasing infant’s motor skills and development, and affecting the infant’s sleep patterns. Mothers should avoid drinking beer and giving beer to their infants at all times.[footnoteRef:17] [17: La Leche League International, 2004, page 328-29.]

Studies have shown that infants drink less breast milk after their mother’s drink beer. The infants in the study sucked more frequently during the minute of feeding, but received less breast milk (125 ml versus 150 ml) than those whose mothers had not been drinking.[footnoteRef:18] [18: Koletzko, 2000. ]

Baseline Data

The percentage of mothers with infants two years of age or younger who had already consumed alcohol during the 24 hours prior to the survey were 76% in Cankuzo and 70.3% in Ruyigi (an average of 72.1% for the two provinces).

The frequency of alcohol consumed by these mothers was 1.2 times per week in Cankuzo and 1.4 times per week in Ruyigi.

Empty the Breast before Switching (Picture 3.3) – 5 minutes

7. Show:



8. Explain:



· When the infant begins to feed, the milk is thin and white. As the infant feeds, the milk becomes thicker and yellow in color.

· The thin white milk satisfies the infant’s thirst.

· The thick yellow milk satisfies the infant’s hunger.

· The infant will eagerly suck and swallow often when drinking thin milk.

· The infant will suck slowly and grow sleepy from the thick milk.

· Let the child feed until he is satisfied on one breast and pulls away.

· The child will pull away from the breast when he is full.

· Taking the child away too early does not leave him satisfied.

· Taking the child away before he gets the yellow milk leaves him hungry.

· If he wakes, continue feeding with the other breast.

· Some children are satisfied on one breast only.

· Others feed for a shorter time on the second breast.

· Which breast should the mother begin her next feeding?

· The breast where the child fed the shortest amount of time.

· What do you think of these teachings? Is this new to you?


Foremilk and Hind milk

Foremilk is the thin milk at the beginning of a feed. It contains protein, lactose, vitamins and minerals and liquid for the infant.

Towards the end of the feed, the milk looks much thicker and more yellow. This is hind milk. It is rich in fat which provides energy for the infant.

Greenish Stools

If the mother has a good supply of milk, but infant is still fussy, very gassy and has loose greenish stools, he may not be getting enough of the hind milk that comes later in the feeding. Make sure the mother breastfeeds until the child is satisfied and pulls away from the nipple.[footnoteRef:19] [19: La Leche League International, 2004, page 316.]

Complementary Feeding (Picture 3.4) – 5 minutes

9. Show:



10. Explain:



· Begin giving thick porridge to infants after breastfeeding at six months of age.

· Give breast milk first, before giving porridge.

· At six months, infants are ready for foods.

· At six months, infants are ready for water and juice.

· Continue breastfeeding whenever your child wants it day and night. Breastfeed for 24 months or more.

· Even after foods are given, breastfeed often.

· Breast milk protects infants from illness.

· Breast milk helps infants to grow well.

· At what age should mothers give water or juice to children?

After six months of age

· At what age should mothers give soup or ugali?

After six months of age

· Why do some mothers give foods and liquids other than breast milk before six months of age?

· How can you convince them to wait until six months?


Baseline Data

The percentage of mothers with children 6-23 months of age who are still breastfeeding is 89% in Cankuzo and 92.1% in Ruyigi (an average of 91% for the two provinces).

11. Activity: Breastfeeding Song – 30 minutes

1. Ask each care group to develop a song about breast feeding. They should use the key messages that they have learned from the last two flipcharts and put these messages into a song, chant or poem.

1. Each Leader Mother will then share this song with her neighbor groups.

1. Key messages which can be used to develop the song include:

29. Give breastmilk to infants within the first hour of life.

29. Give only breastmilk to infants for the first six months.

29. Giving other foods and liquids brings sickness.

29. Giving other foods and liquids stops child’s growth.

29. Breastfeed day and night.

29. Breastfeed whenever the child wants it.

29. Don’t drink beer or give it to infants.

1. Practice the song with the women until they know it by heart.

1. Give each mother a chance to sing the song for the others.
















For example:

I commit to breastfeed on one breast until the child pulls off.

I commit to drink water instead of beer to increase my breast milk.

I commit to exclusively breastfeeding for six months.




How – what did you do?

· Did anyone (husband, grandmother, children) interfere or tell you not to follow your commitments? Tell the story of what happened?

· What factors (people, events, and chores) in your life made it difficult to adhere to your commitments?

· How were you able to overcome these problems?


How many times did you breastfeed your infant yesterday?

What foods & drinks did you eat yesterday?

What did you give your infant (under six months) to eat yesterday?

Will you breastfeed if you become sick?

What should a woman with HIV give to her infant less than six months?

Lesson 4: Danger Signs during Childhood Illness

Caregivers will immediately take the child to the health clinic if any of the following danger signs are seen:

Child has a cough for two weeks or more

Child has a cough and has difficulty breathing.

Child has a fever.

Child vomits everything (food, breast milk and water) every time he eats or drinks.

Child is unable to suck or swallow when offered a drink or breast milk.

Child has convulsions, fits or spasms.

Child is lethargic or unconscious.

Caregivers will offer at least one additional breast milk feeding to sick infants (under the age of six months) during illness and for two weeks after illness; no other liquids or foods will be given. The additional fluids help the child recover and regain the energy and water lost during sickness.

Caregivers will actively encourage children older than six months to eat one additional meal or snack during and after sickness.

Caregivers will feed their child even if they do not show signs of hunger. Children often lose their appetite during sickness and need to be encouraged to eat to help recovery.

Offering children their favorite foods or adding sugar or honey to foods may encourage children to eat more.

Caregivers will believe that encouraging a sick infant to eat during sickness will help the child to gain weight and recover more quickly (increased perceived action efficacy).[footnoteRef:20] [20: Use this lesson to increase the belief that helping a sick child to eat will decrease malnutrition and bring good health. This is based on the behavioral determinant action efficacy which was found to be a significant determinant for feeding of sick children. For more information, review “La Structure du Changement de Comportement de Tubaramure et www.barrieranalysis.com.]

Materials:


1. Essential Nutrition, Hygiene and Care during Infancy Flipchart

The Danger Sign Song

Lesson 4 Summary:

Game: Taxi Rides


Share the story and ask about current behaviors: Mvuyekure has Trouble Breathing

Show pictures and share key message on flipchart pages 30-35: Childhood Danger Signs, Breast Feeding during Illness and Feeding during Illness.

Activity: The Danger Sign Song





Examine commitments and behaviors related to hydration, emptying each breast and complementary feeding.

1. Game: Taxi Rides - 10 minutes

1. Divide the women into small groups with an equal number of women in each group. There should be at least three groups.

Each group should choose one taxi driver who "sits up front." The others pretend to climb in the back behind the driver. The "driver" moves around the room and the others in the car must follow her.

The facilitator calls out a new number. The women must quickly make new taxis with that number of people inside the car. Some women may have to find a new car. Once a car is full with the number given by the facilitator, the driver must quickly drive away. Women who are not in a car with the correct number must leave the game.

The facilitator continues to call out new numbers. The women must quickly make new taxis with that number. Those who are not able to enter a taxi (or if a taxi does not have the correct number) must leave the game.

Continue until two people are left.

Repeat the game as needed.

Now that we are energized, let's begin today's meeting.


The Promoter should fill out the attendance sheets for each Mother Leader following the role play model from Lesson Four of Module 1.

Promoter asks if any of the Mother Leaders had problems during their meetings with their mothers. Promoter problem solves with the mothers, helping to solve troubles they are having, and asking other Mother Leaders for advice.

Promoter asks about maternal deaths, child deaths or new pregnancies in the neighbor groups. Promoter records new events on the attendance sheet.

Promoter thanks all of the mothers for their hard work and encourages them to continue.

Mvuyekure Has Trouble Breathing (Picture 4.1) – 10 minutes

3. Story


Yesterday Mvuyekure began to cough. His nose filled with thick liquid. Today, Mvuyekure has trouble breathing. His chest moves up and down but he doesn’t seem to be getting enough air. Barumwete decides to wait until the afternoon. Maybe he will get better.

4. Ask


Ask the first question to review the symptoms mentioned in the story.

We hope the women respond in the following way: He has an infection in his nose and chest. Today, he has trouble breathing.

Ask the second question to see if the women believe that this is a serious problem or sign of danger for the child.

We hope the group responds this way: This is a severe sickness. If Mvuyekure does not have enough air to breathe, his body will begin to slow down and die. This is a danger sign. Barumwete should not wait! She should leave immediately for the health clinic.

Ask the last question to find out the knowledge of the women of childhood danger signs.

Danger signs include fever, difficulty breathing or a cough for two weeks or more, vomiting food and water, the child doesn’t respond when touched or spoken to, and convulsions.



What is wrong with the child?

Is this a severe sickness? Should the mother take the child to the clinic now?

What are the danger signs that tell the mother to take the child to the clinic?

Childhood Danger Signs (Picture 4.2) – 5 minutes

5. Show:



6. Explain:



· If you see any of these signs, take the child to the health clinic immediately. Do not wait to see if the child gets better.

· Child has a fever.

· Fever is the first sign of malaria.

Child has difficulty breathing.

Child coughs for two weeks or more.

Child is unable to suck, swallow or drink.

Child vomits every time he eats or drinks.

· Child vomits every time he breastfeeds.

· Child vomits every time he eats or drinks.

Child doesn’t respond when touched or spoken to.

· Child is sleepy and won’t wake.

· Child is not able to move or respond.

Child has convulsions, fits and spasms.

· The child’s arms and legs stiffen.

· His body shakes.

· Why is it important to go immediately to the Centre de Santé?

· Do you have money set aside for going to the Centre de Santé?

Additional Information for the Trainer:

Vomiting

If the child vomits every time they eat or drink, this means that the child is unable to receive any fluids or nutrients. The child can become dehydrated and severely ill quickly.

Malaria

Fever is usually the first sign of malaria. Take the child to the clinic immediately to test for or treat malaria.

Breastfeeding during Illness (Picture 4.3) – 5 minutes

7. Show:



8. Explain:



When a child is sick offer your breast even if the child does not look hungry. Offer one additional feeding each day.

· Sick children lose water from sweating, fever and diarrhea.

· The additional feeding replaces liquids lost from the body.

· Breastfeeding helps the infant recover quickly.

· Breastfeeding comforts sick infants.

Karorero offered her breast even when Biguvu was not hungry. Now, Biguvu is well.

· Sick children may lose their appetite.

· Karorero breastfed Biguvu one additional time each day.

· Biguvu is no longer sick.

· This mother breastfed less often during sickness. Her child’s sickness is worse.

· Her child is losing weight.

· His sickness is very severe.

· His sickness has lasted much longer than Biguvu’s sickness.

· Do mothers usually offer the breast if a child does not look hungry?

· Do you think these messages will help children recover? How?


Dehydration

A condition caused by the excessive loss of water from the body. Dehydration is most often caused by excessive sweating, vomiting, or diarrhea. If untreated, severe dehydration can lead to shock and death.

During illness, caregivers must breastfeed more often to replace liquids lost from the body so that the child is not at risk of dehydration.

Feeding during Illness (Picture 4.4) – 5 minutes

9. Show:



10. Explain:



· For children older than six months offer one additional snack and one additional breastfeed each day during illness.

· She adds an additional bowl of fruit on days when her child is ill.

· Additional foods and liquids help the child to recover.

· Additional foods and liquids help the child to stop losing weight.

· Encourage sick children to eat even if they are not hungry.

· This mother and father sing to their child to help them eat.

· Eating more during sickness chases the illness away.

· Offer favorite foods to encourage children to eat.

· Add sugar and honey to foods to encourage children to eat.

· Offer one additional snack and one additional breastfeed for two weeks after the child has recovered.

· The calendar shows us the days when the child was sick.

· He looks sad on days of sickness.

· His mother gives one additional snack on each yellow day.

What can a mother give a child with diarrhea?

Mix a packet of SRO with one liter of water.

Offer it to the child each time the child has a loose feces.


Oral Rehydration Salts (SRO)

Oral Rehydration Salts are given to children who have diarrhea (three or more watery feces in 24 hours). Mix one packet of SRO with 1 liter of water for children 6 months and older.

After each liquid feces, give ½ cup of ORS. If the child is vomiting, wait 10 minutes and give ORS again, slowly.

More information will be given on diarrhea and rehydration in Module 5.

Hunger

Mothers may not see signs of hunger when the child is undernourished or very sick. Children often lose their appetite when they have been sick for a long time or if they are severely malnourished.

When caregivers see that the child is ill, or not growing well, they need to encourage eating and increase breastfeeding and foods for children older

11. Activity: The Danger Sign Song – 15 minutes

Program Managers: Develop a song or poem with the promoters adapting the words below. The song/poem should mention all of the danger signs which tell the mother to take the child immediately to the Health Facility.

1. Sample Song:

Chorus: Take your child to the clinic.

Don’t wait another minute.

The child’s life is in danger.

He cannot breath.

He coughs and coughs for 2 weeks

He cannot swallow food or drink.

He vomits every time he eats and drinks (chorus)

His body is hot with fever.

His body shakes with spasms

He does not respond when touched or spoken to. (chorus)

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1. Practice the Danger Sign Song with the women until they know it by heart.

Explain: We don’t want to forget the danger sings.

We must learn them so we will know when a child must go immediately to the clinic.

Each person in your home should learn the song so they will know when they see a danger sign.

Give each mother a chance to sing the song for the others.
















For example:

I will take my child to the clinic on the same day that I see a danger sign.

I will teach all of my family the danger sign song.

I will breastfeed more often when my child is sick.

I will feed my child even when they don’t appear hungry.



What was your commitment at the last lesson?

Have you kept that commitment? How – what did you do?


On average, how long are you breastfeeding your baby each time?

Did you empty your breast at the last feeding?

How old is your youngest child? What did you feed him yesterday?

At what age will you begin giving porridge after breastfeeding?

How can a mother increase her breast milk production?

Lesson 5: Overcoming Breastfeeding Problems: Poor Position, Engorgement and Breast Lumps

Breastfeeding women will reduce breast pain by holding the infant appropriately:

Sucking in a poor position can cause sore and cracked nipples, unsatisfied and fussy infants, infants that fail to grow and engorged breasts.

Position the infant so his whole body is facing the mother’s body and he is at the same level as the nipple.

The infant’s chin is touching the breast; his mouth is wide open with his lower lip curled outwards. More of the dark circled area around the nipple can be seen above the upper lip than the lower lip.

Breastfeeding women whose breasts are too full and hard to breastfeed (engorgement) will

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