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GUIDELINES FOR ENHANCING OP TIMAL INFANT AND YOUNG CHILD FEEDING PR AC TICES MINIStRy OF HEaLtH aND FaMILy WELFaRE Government of India, 2013 For this edition of the summary of evaluation report the editorial inputs of NHSRC team and Anushka Kalita are gratefully acknowledged.
Published by: National Health Systems Resource Centre Technical Support Institution with National Rural Health Mission Ministry of Health and Family Welfare, Government of India NIHFW Campus, Baba Gangnath Marg, Munirka, New Delhi 110067.
Phones: 011-26108982/84/92/93, Fax: 011-26108983/94 e-mail: nhsrc.india@gmail.com, Website: www.nhsrcindia.org Reproduction of any excerpts from this documents does not require permission from the publisher so long it is verbatim, is meant for free distribution and the source is acknowledged.

ISBN 978-82655-01-05 Designed & Printed by: Royal Press # +91 93101 32888 www.
royal-press.com Ac know ledgeme nt s Dr. Ajay Khera, MOHFW Dr. Sila Deb, MOHFW Dr. Deepti Agrawal, MOHFW Ms. Gayatri Singh, UNICEF Dr. Pavitra Mohan, UNICEF Ms. Kajali Paintal, UNICEF Dr. Arun Gupta, BPNI Dr. Umesh Kapil, AIIMS Dr. S. Aneja, Kalawati Saran Children’s Hospital Dr. Karanveer Singh, UNICEF Dr. Anura Kurpad, St. John’s Medical College Dr. R. K. Agarwal, Chairperson, IAP-IYCF Chapter Dr. Nidhi Choudhary, WHO Dr. Ruchika Arora, MoHFW Dr. Anura Kurpad, St. John Medical College Dr. Sheila C. Vir, Public Health Nutrition and Development Centre.
Dr. Pragya Tiwari, Govt.

of MP Dr. Laxmikant Palo, Save The Children Dr. Deepika Choudhury, Micronutrient Initiative Members of Nutrition Action Group, MoHFW: Sh.

P.K.
P.K.

Pradhan, IaS Secretary, health & Family Welfare Hkkjr ljdkj LokLF; ,oa ifjokj dY;k.k ea=ky; fuekZ.k Hkou] ubZ fnYyh & 110108 Government oF IndIa mInIStry oF health & FamIly WelFare nIrman Bhavan, neW delhI - 110108 FOREWORD Since its inception in 2005, the National Rural Health Mission endeavours for reduction of Under Five Mortality and has been developing and implementing unique strategies towards it.

Malnutrition is attributed to more than one third of these under five deaths in the country.
Childhood malnutrition rates are high in the country with 43 percent children in India under five years are reported to be underweight and 48 percent are stunted.

Trend of faltering growth in children begins in critical period of first two years of life and a major cause is due to faulty Infant and Young Child feeding practices.
One of the key reasons for under nutrition 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.

As depicted in National data sets like the National Family health Survey and District level surveys, poor Infant and Young Child feeding practices are observed by care givers.
Dismal rates of early breastfeeding, stagnant rates of exclusive breastfeeding rates and poor rates of appropriate complementary feeding are a cause of concern and would require focussed attention of the health care system.

The present guidelines are designed for interventions at facility and community levels and have been developed by the Child Health division with inputs from experts and in consultation with UNICEF, BPNI, WHO.
National Rural Health Mission 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.

Iam confident these guidelines would enhance capacity of Healthcare System in achieving higher rates of Appropriate Infant and Young Child feeding Practices towards reduction of childhood morbidity and mortality.

October 2012 New Delhi P.K.


Pradhan Hkkjr ljdkj LokLF; ,oa ifjokj dY;k.k ea=ky; fuekZ.k Hkou] ubZ fnYyh & 110108 Government of India ministry of health & Family Welfare nirman Bhavan, new delhi - 110108 Smt.

anuradha GuPta, IAS AS (MD) –Health & FW FOREWORD Addressing infant and young child undernutrition is a national priority.
The Ministry of Health and Family Welfare through its flagship programme, the National Rural Health Mission, is committed towards taking appropriate and adequate steps and contribute towards reduction of undernutrition in children under five years of age.

Events leading to undernutrition often predate the birth of the child; maternal undernutrition, adolescent pregnancy, less spacing between births and high birth order result in birth of low birth weight babies.
Delayed initiation of breastfeeding and inappropriate feeding practices in the new-born period and first year of life exacerbate under-nutrition in infants and children.
Under the National Rural Health Mission, a ‘Life Cycle Approach’ has been adopted for breaking the intergenerational cycle of undernutrition Promotion of optimal infant and young child feeding (IYCF) practices has been recognised as an important intervention not only for preventing undernutrition in children but also for improving child survival as well as development.
While interventions to prevent deaths due to common childhood illnesses in children with severe acute undernutrition have been included in the national health programme, it is equally important that high priority is accorded to preventive measures.

This will ensure that new cases of undernutrition are not added to the already existing burden of child undernutrition in the country.
The reproductive, maternal, child and new born health services delivered through the public health system provide a number of contact opportunities with pregnant and lactating women as well as mothers of young children.

It is extremely important that such opportunities are capitalised for counselling on infant and young child feeding practices and reinforcing the key messages in child care and nutrition.
The Guide on Enhancing Optimal Infant and Young Child Feeding Practices through the Health System reiterates our commitment to improving child nutrition.
It provides the States with guidance on the steps that are to be taken towards the promotion of optimal infant and young child feeding through the health system and making the necessary provisions to deliver these services effectively.. October 2012 New Delhi (Anuradha Gupta) dr. raKeSh Kumar, IAS JoInt Secretary – health & FW Hkkjr ljdkj LokLF; ,oa ifjokj dY;k.k ea=ky; fuekZ.k Hkou] ubZ fnYyh & 110108 Government of India ministry of health & Family Welfare nirman Bhavan, new delhi - 110108 ACKNOWLEDGMENTS Infant and Young Child Feeding is a set of well-known, common and scientific recommendations for appropriate feeding of newborn and children under two years.
The first two years of life provide a critical window of opportunity for ensuring children’s optimal growth and development through adoption of correct infant and child feeding practices.

Early and exclusive breastfeeding along with appropriate complementary feeding is now recognised as one of the most effective interventions for child survival particularly to address morbidity and mortality related to three major problems i.e.

neonatal infections, diarrhoea and pneumonia.


While breastfeeding provides optimal nutrition to an infant, improvements in complementary feeding substantially reduces stunting and related burden of disease.

It is estimated that exclusive breastfeeding prevents 13 percent of the estimated under-five deaths while appropriate complementary feeding prevents another 6 percent of under-five deaths.
Improvement in Infant and Young Child Feeding (IYCF) indicators in the country would require major strengthening of counselling strategies to encourage adoption of appropriate IYCF practices by caregivers.

For this purpose, interventions pertaining to promotion of infant and young child feeding practices are essential to be scaled up in the country through adequate resource allocation, capacity development and effective communication at all levels of the health system.
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 the NRHM.

October 2012 New Delhi Dr. Rakesh Kumar CONTENTS CONTENTS TiTle About the Programme Guide SECTION ONE: PLANNING AND IMPLEMENTATION GUIDELINES INTRODUCTION INTERVENTIONS & JOB RESPONSIBILITY IIA.
Interventions for initiation of early breastfeeding IIB.

Interventions for exclusive breastfeeding upto 6 months IIC.

Interventions for complementary feeding TRAINING OF KEY SERVICE PROVIDERS LOCATED AT HEALTH FACILITIES FINANCIAL GUIDELINES SYSTEMS STRENGTHENING ADVOCACY, IEC/BCC SUPERVISION & MONITORING SECTION TWO : TECHNICAL GUIDELINES Breastfeeding Complementary Feeding HIV and Infant Feeding Feeding in specific situations Feeding of low birth weight babies/preterm infants ANNExUrE I.
Steps to Successful Breastfeeding II.

Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003.

III.

Counselling for recommendation on feeding during illness IV.

Sample material for IEC Page No.
00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 A b b rE v iA TiO N S ANC ANM ASHA A-V AWC AWW BPNI CHC DH DLHS DPMU FRU IAP ICDS ICTC IFA IMS Act IYCF IEC-BCC IMNCI LBW LHV MUAC MCH MO Ante-natal care Auxiliary Nurse Midwife Accredited Social Health Activist Audio-visual Anganwadi Centre Anganwadi Worker Breastfeeding Promotion Network of India Community Health Centre District Hospital District Level Household Survey District Programme Management Unit First Referral Unit Indian Academy of Paediatrics Integrated Child Development Scheme Integrated Counselling and Testing Centres Iron Folic Acid Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003 Infant and Young Child Feeding Practices Information Education Communication- Behaviour Change Communication Integrated Management of Neonatal and Childhood Illnesses Low birth weight Lady Health Visitor Mid Upper Arm Circumference Maternal and Child Health Medical Officer MCP card Maternal and Child Health Protection card NACO NSSK NBSU NFHS NRC OPD PHC PIP RCH SBA SN SNCU SPMU TOT VLBW WHO WFP National AIDS Control Organisation Navjaat Shishu Surakhsa Karyakram Newborn Stabilisation Unit National Family Health Survey Nutrition Rehabilitation Centres Outpatients Department Primary Health Centre Project Implementation Plan Reproductive and Child Health Skilled Birth Attendant Staff Nurse Sick Newborn Care unit State Programme Management Unit Training of Trainers Very low birth weight World Health Organisation World Food Programme ThE iYCF PrOgr AmmE gu idE 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 to achieve appropriate feeding of new-born and children under two years of age so that they achieve optimal nutrition outcomes in populations.
As recommended by the National Guidelines on Infant And Young Child Feeding (2006), the IYCF practices include the well-known practices of (1) initiating breastfeeding within one hour of birth, (2) exclusive breastfeeding for the first six months (180 days of age) of life , (3) initiation of appropriate complementary feeding from the age of 6 months and (4) continued breastfeeding for two years or beyond.
This Programme Guide has been written specifically for the State and District RCH Officers, Child Health & Nutrition Nodal Officers and Programme Managers to provide guidance on the IYCF interventions so that these are integrated effectively in the on-going maternal, newborn and child health activities under the NRHM.

The first section of the Programme Guide deals with Planning and implementation of IYCF practices at the (1) Health Facility (2) Community (home based care) and (3) Community Outreach.
This Guide presents a number of options to the Programme Managers from which best locally suited set of activities can be selected and integrated into the on-going state programmes.

The second section includes technical guidelines developed by the Infant and Young Child Feeding Chapter of the Indian Academy of Paediatrics in 2009,and the National Guidelines for IYCF developed by the Ministry of Women and Child Development in 2006.
The Section on HIV and Infant Feeding has been revised based on the recommendations made in the Nutrition Guidelines for HIV affected children, published recently by National AIDS Control Organisation.

In addition, general recommendations have been included regarding feeding of low birth weight infants based on the WHO Guidelines for optimal feeding of low birth weight infants in low and middle income countries, 2011.
It is expected that by using this Programme Guide, States will bring renewed focus and vitality into programmes/interventions for supporting and promoting, feeding practives, which is evidence based cost-effective strategy for tackling high rates of undernutrition and consequent child mortality in the country .
infant and young child guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 1 SECTiON - i OPErATiONAL guidELiNES ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 1 iNTrOduCTiON 1.1 Defining Infant and Young Child Feeding Infant and Young Child Feeding (IYCF) is a set of well-known and common recommendations for appropriate feeding of new-born and children under two years of age.
IYCF includes the following care practices: oPTimal iYCF PraCTiCes a.

Early initiation of breastfeeding; immediately after birth, preferably within one hour.

b.

Exclusive breastfeeding for the first six months of life i. e 180 days (no other foods or fluids, not even water; but allows infant to receive ORS, drops, syrups of vitamins, minerals and medicines when required) c. Timely introduction of complementary foods (solid, semisolid or soft foods) after the age of six months i. e 180 days.
d. Continued breastfeeding for 2 years or be- yond e. Age appropriate complementary feeding for children 6-23 months, while continuing breastfeeding.
Children should receive food from 4 or more food groups [(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 veg- etables; (6) other fruits and vegetables] and fed for a minimum number of times (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) f. Active feeding for Children during and after illness.
Early Initiation of Breastfeeding means breastfeeding all normal newborns (including those born by caesarean section) as early as possible after birth, ideally within first hour.. Colostrum ,the milk secreted in the first 2-3 days,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.
Exclusive breastfeeding for the first 6 months means that an infant receives only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, not even water.

The only exceptions include administration of oral rehydration solution, oral vaccines, vitamins, minerals supplements or medicines.

.

Complementary feeding means complementing solid/semi-solid food with breast milk after child attains age of six months.
After the age of 6 months, breast milk is no longer sufficient to meet the nutritional requirements of infants .

However infants are vulnerable during the transition phase ,from exclusive breast milk to introduction of complementary feeding over and above breastmilk.

For ensuring the nutritional needs of a young child are met breastfeeding must continue along with observing the following practices for appropriate complementary feeding.The term “complementary feeding” and not “weaning” should be used.
• Timely – meaning that they are introduced when the need for energy and nutrients exceeds what can be provided through exclusive breastfeeding; guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 5 • Adequate – meaning that they provide sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs; • Safe – meaning that they are hygienically prepared and stored, and fed with clean hands using clean utensils, and not bottles and teats.
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 under-nutrition.
1.2 Benefits of optimal Infant and Young Child Feeding Early and exclusive breastfeeding is now recognised as one of the most effective interventions for child survival particularly to address morbidity and mortality related to three major conditions i.e.
neonatal infections, diarrhoea and pneumonia.

Scientific evidence shows that early initiation of breastfeeding can reduce neonatal mortality significantly.

Exclusive breast feeding upto 6 months can prevent upto 13% of the estimated under-five deaths.

Breastfeeding also provides constant positive interactions between mother and child which can contribute to emotional and psychological development of infants.

It has been found to have direct positive impact on brain development.
Breastfeeding has a protective effect against childhood 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 and prevents infections, the timely initiation and age appropriate complementary feeding can substantially reduce stunting and related burden of disease.
Appropriate complementary feeding can prevent 6% of the estimated under-five deaths and have larger impact to lessen morbidity and malnourishment rates.
Optimal breastfeeding and complementary feeding practices together can prevent deaths
To
To summarize, the adoption of appropriate IYCF practices by the families: • • • Reduces the risk of child mortality Reduces the risk of preventable infant and childhood illnesses Enhances cognitive functions and increases productivity • Helps in spacing pregnancies as breastfeeding is the an effective contraceptive (98.2%) 6 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr during the first six months of lactation.
• Reduces burden on health system and costs for societies by protecting against malnutrition (both under-nutrition and obesity) and infectious and chronic diseases.

1.3 IYCF: Situation in India & Need for reinforced action Undernutrition is a contributory factor in one third to half of all deaths taking place in children under five years of age.

43 percent children in India under five years are reported to be underweight and 48 percent are stunted (NFHS-3; 2005-06).
Onset of malnutrition occurs in the very early years of growth.

Even during first six months of life, when most children are breastfed, 20-30 percent are underweight.

Underweight prevalence increases rapidly from birth to age 20-23 months.
One of the key reasons for undernutrition in early life is the faulty and sub-optimal infant and young child feeding practices, which is further compounded by factors such as low birth weight and repeated episodes of illnesses like diarrhoea and acute respiratory infections .

The first two years of life provide a critical window of opportunity for ensuring appropriate growth and development of children through optimal feeding.
Country level trends in 3 major IYCF indicators over past 15 years are depicted in figure no.

xx: Figure: Trends in IYCF indicators- India Over the period, there has been a slow but steady increase in early initiation of breastfeeding, especially after launch and operationalization of NRHM.

However there has been no improvement in the status of exclusive breast feeding for six months and complementary feeding (6- 9 months).
The survey data analysis suggests that introduction of liquids and solid or semi-solid foods often takes place before the recommended age of six months.

Almost 30 percent of children start receiving complementary food(CF) at the age of 4-5 months.

Similarly,delayed CF is also common.
Figure : Feeding practices of children under 6 months of age Source: Report- Nutrition in India, NFHS III (2005-06) Overall, only 21 percent of children aged 6-23 months are fed according to all three quality parameters of IYCF practices recommended by WHO (timely, adequate and safe).
Only 44 percent of breastfed children are fed at least the recommended minimum number of times (NFHS3 ), but only half of them consume food from three or 60 40 20 0 d e y e v r u s p u o r g e g a n i n e r d l i h c f o % 40.2% 41.2% 46.4% 46.4% 35% 56.7% 57% 24.5% 15.8% Initiation of Breastfeeding within 1 hour of birth exclusive breastfeeding (0- 6 months) complementary Feeding (6- 9 months) nFhS-2 (98-99) nFhS-3 (2005-06) dlhS-3 (2007-08) guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 7 more food groups.
Feeding recommendations are even less likely to be followed for non-breastfeeding children age 6-23 months.

Poor IYCF practices and prolonged malnutrition leads to stunting during this critical period of life.

Stunted Children not only falter in physical but in cognitive growth as well.

Stunting is irreversible and can have long-term effects on cognitive development, school achievement, economic productivity in adulthood and maternal reproductive outcomes (Dewey et al 2011)( .
Tackling childhood stunting is a high priority for reducing child morbidity and mortality, and for fostering economic development.

For this, the existing efforts for promotion of infant and young child feeding must be strengthened as well as mainstreamed and scaled up in the country through adequate resource allocation, capacity development, and effective communication at all levels of the health system and the community.
India’s National Nutrition Policy and the National Plan of Action on Nutrition clearly articulates the role of health sector in promoting breastfeeding through training of health workers.
Similarly, the National Guidelines on Infant and Young Child Feeding 2006 and the Infant Milk Substitutes: Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003 also state the role of health care system in ensuring Optimal Infant and Young Child Feeding Practices.

While the adoption of good IYCF practices on the ground remained suboptimal, NRHM provides an immense opportunity to strengthen and scale up IYCF practices.
8 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 2 iNTErv ENT iONS FO r PrOmOT iNg iY CF PrAC TiCES iN hEALTh SY ST EmS The National Rural Health Mission provides a valuable opportunity to bring greater attention and commitment to promote IYCF interventions at the health facility, the community outreach and household levels.
The strengthening of IYCF interventions requires the following three areas of action: 1.

Protection: By ensuring implementation of the IMS Act i.e.

the Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003 (see Annexure for details), 2.

Promotion: By providing accurate information and skilled counselling to all women,family and community members.

3.
3.

Support: By providing support measures for sustained appropriate feeding through maternity protection.

1.

Promoting appropriate through the health network IYCF practices services are consistently The following section presents strategies and actions for integrating and promoting appropriate IYCF practices through the health network since coverage and utilisation for maternal and child health increasing.
Mothers and children have regular contacts with the health service providers during pregnancy and the first two years of life of the child, be it for ANC, SBA, PNC or immunization.

The increased coverage and regular contacts provide great opportunity to influence mothers and caregivers towards optimal feeding practices.
Health service providers are in a position for undertaking timely actions to influence Infant and Young Child Feeding practices through messages, counselling and advice during healthcare service delivery and informal communication with the beneficiaries.

Similarly network of ANMs and ASHAs are in a position to reinforce appropriate IYCF practices during home visits and outreach activities.
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 therefore must try and find unique contact opportunities which must be capitalised to promote optimal IYCF practices including one-to-one infant feeding counselling support for the mothers, and demonstration of appropriate feeding practices.

ii-a.

KeY iNTerVeNTioNs aT HealTH FaCiliTY leVel 1.
Contact opportunities For Promotion of IYCF in a health facility (a) During and after institutional delivery With the launch of Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram, increased numbers of institutional deliveries and skilled attendance at birth provides guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 9 tremendous opportunity for ensuring early initiation of breastfeeding and promoting exclusive breastfeeding during stay at the health facility.
Initiation of breast feeding should be done in labour room itself.

Health facilities must aim for complete coverage for early initiation of breastfeeding for all normal deliveries and at the earliest possible for complicated deliveries.
Staff Nurses and Medical Officers ANMs and LHVs posted at the delivery points are responsibile for communication and counselling of women delivering at the health facility.The staff must undertake the following actions: measure birth weight, identify low birth weight babies, counsel and support mothers to initiate breastfeeding soon after birth.Staff nurses are recommended to be mobilised labour room, postnatal ward; new born care facility or NRC, as is feasible in facility specific context) by rotation specifically for the purpose of counselling mothers in the postnatal wards and for solving common problems related to initiation of breastfeeding.
(from IYCF In high case load facilities (e.g.

; a District Hospital), Nutrition Counsellor/s trained lactation in counselling and management 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 the following: • Sick child admission Wards in Paediatric • Nutrition Rehabilitation Centre (NRC) • New-born care facilities (Stabilisation units, Special New-born Care Units) The key responsibility for communication and counselling of mothers /caregivers on IYCF is that of Staff Nurses and Medical Officers.
In addition, the Staff Nurses should be instructed to take anthropometric measurements of all children admitted to health facilities and appropriate nutrition counselling should be provided to caregivers of children identified as underweight or stunted.

In high case load facilities (eg; a District Hospital), Nutrition 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.

The role of Nutrition counsellor is to provide IYCF counselling to inpatient, outpatient and labour rooms in rounds.

Nutrition Counsellors trained in lactation management may also be employed at health facilities with Special New-born Care Units (SCNU).
As many babies admitted to the SCNU are likely to be low birth weight and/ or preterm and sick babies , optimal support for breastfeeding has to be provided in the follow up period after discharge.

Nutrition counsellors must provide counselling and support not only to mothers/ caregivers of children discharged from SCNU but also to caregivers of other babies including LBW and preterm babies born at these facilities or referred from peripheral health facilities.
They must regularly visit children admitted as inpatients and counsel caregivers of children identified as underweight or stunted.
‘Rooming in’ facilities for mothers of babies admitted to newborn care facilities should be provided as this will go a long way in 10 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr instilling confidence in mothers and improving breastfeeding rates in preterm and sick babies once they are on the way to recovery.
Doctors, Nurses and other staff posted at health facilities, especially those responsible for delivery of MCH services, should be well versed with the IMS Act as they have the responsibility to ensure compliance especially Section 8 and 9 of the Act within the health facility and the health system.

A brief note outlining the key provisions under this law is presented in Annexure II.
c. Outpatient services and consultations for pregnant women, mothers and children: Outpatient services comprise the following: • Antenatal clinic • • IYCF Counselling Centre Sick Child consultation in outpatient department The key responsibility for growth monitoring, 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.

(i) Antenatal Clinics: In high ANC case load facilities (e.g.
; District Hospital, CHC), Nutrition Counsellor/s are recommended to be employed.

The services of the Nutrition Counsellor, trained in IYCF and lactation management, should be used to provide group counselling and inter personal 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).


(ii) IYCF Counselling Centres Establishment of IYCF Counselling Centres in the outpatients’ area in high case load facilities (DH, CHCs) , dedicated Maternal and Child Hospitals, is recommended.

A Nutrition counsellor/ IYCF counsellor should be appointed to manage these centres and should be available for fixed hours (coinciding with timing of outpatient services) at this centre to counsel and solve referral problems.
This centre should also review growth and the immunisation status of the child for the first two years of life and provide appropriate advice and information.

The package of services should include the following: 1.

Growth monitoring (growth curve / pattern may be reviewed and age appropriate advice given; when MCP card is available with the parents/ caregivers, it should be used as the reference point) 2.

Communication and counselling on IYCF 3.


Information about services available through community outreach (e.g.

; immunisation) 4.

Provision for Vitamin A and IFA supplements (if not received in the outreach) for children older than 6 months.

5.

In case child is born prematurely or with low birth weight, one to one counselling session should be conducted with the mother/care givers and follow up visits to the centre requested.
guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 11 guidELiNES FOr ImPlEmENTATION OF THE ImS ACT One key strategy is to protect breastfeeding from commercial influence.

.Health care provid- ers must not allow the health systems to be used for promotion of any baby foods or companies manufacturing such foods.
The Act also prohibits any kind of direct or indirect benefit from the manufacturers of baby food companies includ- ing sponsorships, research grants, funding of seminars or association of health workers.

Activ- ities can include 1-day sensitization programme for Civil Surgeon, Chief Medical Officer, doctors and nurses on IMS Act.

Under the IEC, hoard- ings on IMS Act provisions could be installed outside health facilities and prominent public places.
For details see Annexure V. 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.

Use of audio-visual aids in waiting areas and postnatal ward and at ANC clinics is a good way of reaching out to mothers and family members who also have a critical role in supporting optimal child feeding practices.
Appropriate IEC material (eg; posters) in local language should be displayed at strategic locations (eg; waiting areas, outside labour room, outdoor consultation rooms, obstetric and paediatric wards) in the health facility.

• • Key practices and service providers in Health Facilities: iii).
Activities for reaching out to mothers/care givers at the health facility ANTENATAl ClINIC: at all MCH facilities and PCTC/ delivery points Mothers and caregivers can be reached through: Actions & key practices: • 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 with mother of a sick child for review of child feeding practices and reinforcement of key messages related to feeding during and after illness.

Mothers of undernourished children and low birth weight babies should also receive one to one counselling regarding specific feeding needs.

Communication guides (Flip charts) are recommended to be used along with skilled counselling to make it more effective.
• Group counselling sessions on fixed days and time, should be organised at MCH facilities at pre-decided contact points that • Counselling for early initiation, colostrum and exclusive breast feeding during third trimes- ter • Specific counselling and management if moth- er is HIV positive • Importance of colostrum feeding Primary Responsibility: Staff Nurses; Nutrition Counsellor (when available at the facility) ; ICTC counsellor Supporting Role: Medical officer, ASHA POSTNATAl wARD: at all delivery points Actions & key practices: • • Ensure initiation of breastfeeding within one hour Support for early initiation of breastfeeding , avoiding pre lacteal feeds , promoting colos- 12 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr trum feeding, and establishment of exclusive breastfeeding; al child and nursing mother and counselling on age appropriate infant feeding practices; • Management of breast conditions • • Direct observation by the health service pro- vider for technique and attachment while breast feeding the infant for the first time and on a subsequent occasion • Birth weight, identification of LBW babies and appropriate management • Counselling on infant feeding options in con- text of HIV (for mothers identified as HIV posi- tive) during antenatal period and after birth • • Inclusion of early breastfeeding column in all delivery registers PNC ward and delivery room must have IEC materials on walls for early initiation of breastfeeding & exclusive breastfeeding in lo- cal language Primary Responsibility: SBA/NSSK trained ser- vice provider/s conducting delivery (ANM, SN, MO) ; Nutrition Counsellor at high load facilities Supporting role: Doctors, Staff nurses OUTPATIENT SERvICES/CONSUlTATIONS ( ImmUNISATION, HEAlTHY CHIlD ClINIC, SICk CHIlD ClINIC, ICTC) At all MCH facilities/ delivery points Actions & key practices: • Ensure exclusive breastfeeding
 message and complementary feeding messages are rein- forced • Growth monitoring of all inpatient children and use of WHO Growth charts for identifica- tion of wasting and stunting and appropriate management • Group counselling on IYCF and nutrition dur- ing pregnancy and lactation; • Review of breastfeeding practices of individu- Review of feeding practices, counselling & support on feeding options in context of HIV (for mothers identified as HIV positive) Primary Responsibility: ANM if only she is avail- able, Staff Nurses; Nutrition Counsellor at high case load facilities ; ICTC counsellor Supporting Role: Medical officer INPATIENT SERvICES ADmITTED IN PAEDIATRIC wARDS) (SICk CHIlDREN At all MCH facilities / delivery points Actions & key practices: • Monitoring of lactation and breast conditions, support to resolve any problems • Anthropometric measurements of all inpatient children; identification of children with under nutrition and appropriate nutrition counselling and management • Counselling on early childhood development (play and communication activities) using MCP card • Implementation of IMS Act • Age appropriate messages regarding feeding of sick child and child care practices Primary Responsibility: Staff Nurses; Nutrition Counsellor at high case load facilities Supporting Role: Matron , Medical officer SPECIAl NEw BORN CARE UNITS(SPECIAl NEwBORN CARE UNITS, NEwBORN STABIlIzATION UNITS) Actions & key practices: guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 13 guidELiNES FOr • Counselling on breastfeeding/breast milk feeding of low birth weight and preterm babies, helping mother for cup feeding the baby and, age appropriate feeding advice before discharge • age appropriate advice on discharge Primary Responsibility: Staff Nurses; Nutrition Counsellor at high case load facilities Supporting Role: Medical officer
 NUTRITION (NRCS) REHABIlITATION CENTRES Actions & key practices: • Review of feeding practices of malnourished child and counselling on age appropriate feeding practices including what to feed and how to feed • Counselling on breastfeeding/breast milk feeding of low birth weight babies and, age appropriate feeding advice before discharge • Demonstration of recipes (quantity and consistency) and replacement feed if indicated, and sharing of recipes for optimal use of locally available foods (before discharge from NRCs) • Counselling on early childhood development (play and communication activities) using Mother Child Protection Card Primary Responsibility: Staff Nurse, Nutrition Counsellor Supporting Role: Medical Officer ii-B.
KeY iNTerVeNTioNs aT CommUNiTY oUTreaCH leVel 1. mCH Community outreach contact opportunities during The following contacts are critical opportunities for IYCF promotion.

The key responsibility for communication and counselling of mothers /care givers during these contacts is of ANMs along with support from ASHAs & AWWs.
: • Village Health and Nutrition Days • • • • Routine immunisation sessions Biannual rounds IMNCI/sick child consultation at community level Special campaigns (eg; during Breastfeeding Week) • Any State specific initiative ASHA ,as facilitators of promoting IYCF, need to be provided intensive training so as to equip and position them as effective promoters of IYCF practices 2.
Activities for reaching out to mothers/care givers at community outreach Mothers and care givers should be reached through: » » Growth Monitoring Sessions: Growth monitoring (weight recording in MCP card) is undertaken at AWC and /or during VHNDs, This activity is a good entry point for nutrition counselling and promoting IYCF practices.

Group counselling sessions: at fixed day and time, should be organised at VHND.
Mothers accompanying children for immunisation, micronutrient supplementation provide a captive audience for discussing infant and 14 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr » » » young child feeding practices.
One to one counselling and group counselling should be conducted during outreach by the ANM/ ASHA for children with moderate/ severe under-nutrition.

Children with severe under-nutrition are to be referred to an appropriate facility for further evaluation after screening (using MUAC cut off of < 115 mm as the criteria).

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.
Display of Appropriate IEC material (eg; posters): IEC material in local language should be displayed at strategic locations (eg; community walls, AWC, Panchayat Bhawans etc).

Context specific messages promoting local cultural practices that are beneficial and dispelling locally prevalent myths can be developed and displayed at VHND sessions.

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 aids.

Adequate budget provisions should be available in the PIP to develop, print and disseminate IEC material.
However, the various actions for behaviour change communication on child feeding practices should not be restricted to special events (like the Breastfeeding Week or Nutrition Week) but be a part of all the health related events and activities taking place throughout the year.

This will not only reinforce key messages but also reach to more audiences in the community and promote adoption of correct IYCF practices.
IYCF PRACTICE DISSEmINATION THROUGH wORkERS IN COmmUNITY village Health & Nutrition days (vHND): AWC or Sub Centre , as relevant Actions & key practices to be promoted : Counselling and practical guidance on breastfeeding as an integral component of birth preparedness package – prepare mothers for early initiation of BF; Activities: Group counselling on maternal nutrition and infant feeding Health service provider: ANm feasible, demonstration of Where food preparation and sharing of recipes for optimal use of locally available foods for children 6-23 months; In special situation, demonstrate preparation of safe replacement feed Supporting Role: AWW, ASHA, LHV and ICDS supervisor Routine Immunisation sessions (RI sessions) : AWC or Sub Centre as relevant Activities: Group appropriate nutrition counselling on age IYCF practices and maternal Health service provider: ANM Supporting Role: ASHA, AWW for Rounds Biannual A supplementation; or during months dedicated to child health (e.g.
; Shishu Sanrakshan Maah)- AWC or Sub Centre as relevant Vitamin Activities: Group counselling on IYCF and maternal nutrition; guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 15 guidELiNES FOr Health service provider: ANM Supporting Role: ASHA, AWW ImNCI / sick child consultation : community level, Sub centre, AWC Activities: Assessment of age appropriate feeding and feeding problems; counselling on age appropriate feeding and feeding during illness Health service provider: ANM Supporting Role: ASHA and AWW Community level Actions by ASHA/ANm: Dada-Dadi/Nana-Nani Sammelan: In addition to using the platform of VHND, Monthly group counselling sessions can be held at each vil- lage by ASHA where she communicates and does IPC regarding Infant Young Child Feeding to secondary care givers who are major influ- encers in child feeding at home.
Such an ad- vocacy strategy would contribute in improving IYCF practices.

A register is to be maintained by ASHA for conducting the sessions, signatures/ thumb impression taken of attendees and pay- ment made to ASHA by the ANM after conduct of such meetings.
ii-C. KeY CommUNiTY aND Home BaseD Care iNTerVeNTioNs DUriNg 1. mCH contact opportunities during home visits Community contacts include: • Postnatal Home visits • Home visits for mobilising families for VHND • Growth monitoring and health promotion sessions at AWC • Mothers’ Group Meetings /Self Help Groups’ Meetings Frontline health workers (ANMs and ASHAs) ,as a policy, conduct home visits for providing postnatal and newborn care as part of various MCH schemes.
It has also been proposed that ASHAs make home visits for following up the 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 include IYCF and child care.

2.
2.

Activities for reaching out to mothers/ caregivers during home visits and community level activities: Mothers and caregivers must be reached through: (i) 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.
It is also an opportunity to teach mothers about proper positioning and attachment for initiating and maintaining breastfeeding.

It is critical to solve the problem of ‘not enough milk’, which is almost a universal perception among mothers/ caregivers and family members.

Mothers whose babies are born with low birth weight babies or identified as underweight on the MCP card can be given specific feeding advice.

Any feeding problems must be identified and addressed.
As the Home Based Newborn Care Scheme now requires that every child be visited at home (6-7 times during first 42 days of life), the messages on IYCF can potentially reach every mother and every household.
Specific points for discussion 16 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr on feeding, examination/observation and key messages to be delivered at each of the 6 visits (or 7 in case of home delivery) should be clearly specified to ASHAs and ANMs during the training on IYCF It is important to detect early growth faltering during first few months; it is usually due to faulty feeding and / or infection.
Appropriate diagnosis must be made at this time and faulty feeding practices must be corrected.

Identified children must be referred for suitable management and advice, if required.

(ii) Group counselling sessions, at fixed day and time, should be organised at VHND.

Where possible, Audio-visual aids and tools (like flip charts developed in local languages) are recommended to be used to provide information and counselling by ANMs with adequate facilitation by the AWWs and ASHAs.
AWWs conducting group counselling sessions for expectant mothers and lactating women should ensure key IYCF messages are discussed in all the sessions.Similar approach should be used during Growth Promotion and Monitoring Sessions and Group counselling sessions at AWCs.

Mothers of children identified as moderately or severely underweight or with weight plotting in yellow & orange zone of the growth chart (Mother and Child Protection Card) should be counselled more intensively.
Mothers of children with normal growth pattern should also be included in these discussions (Positive Deviance Model) so that such women are encouraged to share information and experiences with mothers regarding preparation of age appropriate feeding for young children and also offer practical solutions to common feeding these mothers the sessions, problems.During (and /or AWW) should also be encouraged to demonstrate the best use of locally available and acceptable foods.
(iii)_Display of Appropriate IEC material (eg; posters): IEC material in local language should be displayed at strategic locations (eg; community walls, AWC, Panchayat Bhawans etc).

Context specific messages promoting local cultural practices that are beneficial and dispel locally prevalent myths should be developed and displayed.

IPC Tools for home visits (like flipcharts) developed by various organisations /agencies in the state can be made available to community workers as a job aides.
IYCF Practice dissemination through workers in Community - Home contacts Home visits to newborn (up to 42 days) in postnatal period Activities • • • • • • Birth weight recording within 24 hours for home deliveries Support for early initiation of breastfeeding , colostrum feeding and establishment of exclusive breastfeeding ; and support to resolve any problems Identification of low birth weight babies and appropriate feeding advice Advice on feeding frequency and duration and other IYCF advice One to one counselling of mothers, care givers and family members on maternal nutrition during lactation and infant feeding practices Key messages to be delivered at each of the 6 visits (or 7 in case of home delivery) can be provided to ASHAs during the training on IYCF Primary Responsibility: ASHAs Supporting Role: ANMs, AWWs During routine activities of Anganwadi centres: (Growth monitoring and promotion guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 17 guidELiNES FOr sessions; supplementary feeding ; counselling sessions), Anganwadi Centre Activities: • • • • • Growth Monitoring using Mother and Child Protection Card Group counselling /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; Assessment of age appropriate feeding and feeding problems, counselling on age appropriate feeding and feeding during illness • Counselling on early childhood development (play and communication activities) using MCP card Primary Responsibility: AWWs Supporting Role: AWWs/ helpers On any other occasion of home visit by the community health worker: The worker should have a vigil to notice if the infant or under two years child is not feeding well or is appearing malnourished.
Subsequent to necessary advice, this has to be brought to the notice of the ANM for appropriate advice.

The child should also be linked up with the AWW.

SPECIAl ROlE OF ASHAS PROPOSED FOR IYCF: • ASHAs to follow up each child under age of six months through home visits every month (end of 2nd, 3rd, 4th, 5th and 6th) for weight monitoring and ensure exclusive breastfeeding.
The visit at the end of 6th month will also include counselling on initiation of complementary feeding with specific details on how and what to feed the child.. ASHAs to be provided an incentive if the child is in “Green zone” of growth chart in MCP card at end of six months for exclusive breastfeeding and weight gain within normal limits.
List of infants droppedout from being exclusively breastfed along with reasons for discontinuation of exclusive breastfeed to be submitted to ANM who has the supervisory responsibility and could give appropriate timely inputs..

Such an action would be helpful in increasing exclusive breastfeeding rates to a great extent.

ASHAs are expected to undertake two home visits in late infancy-- at the end of 9th and 12th month.
--.During these visits ,ASHAs must ensure continuation of breastfeeding and appropriate feeding of semi-solid foods in terms of quantity, frequency and type of foodsto be fed in right consistency.. Each of these contacts, ASHAs should take weight of the child and record it in the MCP card, if it has not been recorded in the VHND sessions.
An additional incentive may be considered for ASHA for completion of the whole set of these visits over one year provided the child is in Green Zone at the one year of age.
• • She will organize mother-to-mother support groups on IYCF using a participatory methodology She will track every Low Birth Weight baby for continued breastfeeding till 2 years of age along with adequate and appropriate complementary feeding and regular growth monitoring 18 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 3 TrAiNiNg OF KEY SE rviCE PrOvid OrS Health service providers have important role in not only promoting IYCF practices but also in ensuring IYCF practices are followed by providing essential information, counselling and support to mothers/ caregivers on breastfeeding and complementary feeding as well as assisting in solving common feeding 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 • • Infant and Young Child Feeding Counselling for Medical Undergraduates and Nursing Students – A Training Package (Pre Service) Regular Curriculum of Medical and Nursing Students (IYCF counselling component should be included) iN hEALTh SY STEm • • Facility Based Management of Severe Acute Malnutrition trainings IYCF Counsellors for recruited Nutrition However at facility level, advanced set of skills are essential for the service providers who are directly involved in the provision of counselling support to mothers and families so that they are equipped to deal with concerns and problems related to lactation failure or breast problems like engorgement, mastitis etc, and provide special counselling on IYCF to mothers who feel they don’t have enough breast milk, low birth weight babies, sick new-born, undernourished children, adopted baby, twins and babies born to HIV positive mothers and in emergency like floods and earth quake etc.
A detailed, hands-on training for improving counselling skills of health workers should also be provided.

The existing training packages that can be used for this purpose is the Infant and Young Child Feeding Counselling: A Training Course.

The 4 in 1 course (An Integrated course on Breastfeeding, Complementary Feeding & Infant feeding, HIV This counselling and Growth Monitoring).
package provides core training material for all levels including Master trainers, Mid-Level Trainers, facility based service providers and frontline workers.
However, the trainings vary in duration for master trainers and service providers; a 4 days package for frontline workers has also been developed in 2012. guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 19 guidELiNES FOr The pre service training package , a three day training programme, on Infant and Young Child Feeding Counselling for medical undergraduates and nursing students consists of a Student’s Handbook and a Teacher’s guide.
The training package for teaching faculty builds on and complements the skills imparted in IMNCI and aims at building skills of medical and nursing students on IYCF counselling and management of feeding problems.

This.

The training period includes 3 classroom sessions of 3 hours each and 5 clinical sessions.
The training of faculty may be combined with Pre-service IMNCI training and conducted for a total of 8 days (5.5 days for IMNCI and 2.5 days for IYCF).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 lactation management and IYCF counselling skills.

state level Planning: Identifying Training Needs and Preparing Training Plans It is important that all states develop comprehensive state and district training plans.
The training plans must be prepared, taking into account the number of delivery points (especially high delivery case load facilities) and service providers to be provided additional skills on IYCF communication and / or counselling.

Since a large number of frontline workers will have to be trained, stress should be laid on capacity building of supervisors, who could then reinforce these skills during supervision and mentoring.
The state must also identify all personnel who have already been trained/ received orientation on IYCF and related areas through specific ‘in service’ training programmes.
District Training plans should be developed keeping in view the following aspects: » » » » » » Planning for training needs to be done from sub-centre upwards Total training load to be calculated keeping in view the facilities which are functional and availability of District Training Institutions Skills training to be categorised as core skills (for workers at all levels of health facilities) and specialised skills (for ‘counsellors’); Identify core skills already provided through existing training programmes, these are to be reinforced by supervisor/mentors.
For specialised skills , specialised (advanced) IYCF training to be given only to identified service providers Specific time frame set for completion of training of each cadre (may be spread over 1-3 years).

The training plans should approach training timelines with priority and thrust.

Financial allocation for trainings in District Action Plans.

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.

For effective training, achievement of the training targets should be periodically reviewed along with feedback on the delivery of IYCF information and counselling services at community and facility levels.
The State may also take initiative and facilitate trainings of Staff Nurses and ANMs in the private sector.
20 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 4 FiNANCiAL guidELiNES An assessment of resources required for IYCF programme at facility and community outreach level should be undertaken based on the action plans and budgeted as part of Child Health component included under the ‘RCH Flexipool’.
Trainings can be budgeted under ‘Child Health Training’ component under the RCH flexipool.

A consolidated IEC budget is available under the Mission flexipool under which ‘child health specific IEC’ could be included.
An indicative budget for implementing various activities in a district with population of 20 lakhs is presented in the table below : Estimation of number of health facilities and human resources in a district with an average population of 20 lakhs: • (DH)with 2-3 MCH 1 District Hospital Specialists (Gynaecology, Paediatrics), 10-15 staff nurses posted in labour room, postnatal ward and paediatric ward, antenatal and paediatric OPD.
If the DH also has a SNCU and NRC, then the number of doctors and staff nurses who are directly in contact with new born and children will be higher.

(4 doctors and 10 SNs in SNCU ; 1 doctor and 7-8 SNs and 1 Nutrition Counsellor in NRC) • (FRUs) with 2 Specialists 15 CHCs (Gynaecology, Paediatrics), 10-12 staff nurses posted in labour room and postnatal ward in each facility.

Some FRUs have NBSUs, so additional staff is likely to be posted here (1 MO and 4 SNs).
• 60 PHCs with 60-80 Medical officers • 400 SCs with 400 ANMs, 60 LHVs, 2,000 ASHAs (District & state specific variations are to be taken into account) Assessment of Requirements based on Assumptions: There are likely to be about 30 delivery points (excluding sub centres), each will require basic equipment for growth monitoring.

Additionally, the DH and some CHCs will require separate equipment for inpatient and outpatient areas.
Assuming that the DH and 4 CHCs are high case load facilities (&designated delivery points), then 5 IYCF counselling centres and 5 Nutrition/IYCF Counsellors will be required at these facilities.
Training load: For advanced counselling skills: 5 facilities x 2 persons=10 For training of Medical Officers and Staff Nurses: About 100 For training of frontline workers (ANMs + LHVs): 460 For training in ASHA monthly meetings: 2000 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 21 guidELiNES FOr Activity Indicative Unit cost No.
of units Total cost Remarks Equipment (for both inpatient & OPD) District level Health facility 90 x2500 2,25,000 Rs.

2500 per site (Sites in 1 DH (2-one each in paediatric ward & outdoor patients’ clinic), 5 FRU (10- same as in case of DH), 60 PHCs (1 each) Infrastructure IYCF Counselling Centres Rs.
10,000 per centre ( prefer- ably located at DH, FRU) 15 x 10,000 150,000 Weighing scale, Stadiom- eter, 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, equip- ment (infantometer, weigh- ing scales, WHO growth standards (Charts), doll & breast model, syringe pump, 250 ml capacity steel bowl, spoon, specific stationary, counselling flip chart Salary of Lactation/ Nutrition Counsellor at High case load (of pregnant women, moth- ers, children) facilities Subtotal Equipment: weighing machine, MUAC tape, WHO child growth charts, mother child protection card Rs.
12,500- month per counsellor (at high case load facilities: tertiary care centres, DH, FRUs) 10 ( as some DH/FRUs may already have counsel- lors in place) 15,00,000 Indicative cost since these , will vary according to sal- ary scale in the state.

18.75 lakhs Community outreach Rs.

750 per sub-centre 400 3,00,000 Job aides (flip chart etc.)

Rs.
200 per ANM and ASHA trained/ oriented on IYCF Subtotal 400 ANMs (may vary in case there is second ANM also), 60 LHVs, 2000 ASHAs 4,92,000 7.92 lakhs 22 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr As recommended earlier, each facility with high deliv- ery load or MCH case load should train at least two providers as IYCF Counsel- ling Specialists The training should be organised at block/district level, can be held in con- tinuation with IMNCI, or NSSK trainings for ANMs Activity Indicative Unit cost No.
of units Total cost Remarks Trainings Rs.

300,000 per batch of 24 1 batch 3,00,000 ToTs are Paediatrician or F-IMNCI trained MO Training of trainers (ToTs) on IYCF counsel- ling skills (7 days) Training of identified health care providers (MO, SN nutrition counsellor/s) as IYCF Counselling Specialists Rs.
200,000 per batch of 24 2 batches/ district 4,00,000 Training of Frontline workers (ANM, LHVs) for 3-4 days 75,000 per batch (batch size 30) 12 batches 9,00,000 Orientation of ASHAs in monthly meetings 5000/meeting 80 meetings per district /year ( 2 training sessions can be held for ASHAs during block level monthly meetings; 50- 60 ASHAs expected in each meeting Subtotal (One time cost of trainings, mainly in the first year (or spread across two financial years in case the implementation is phased).
4,00,000 Training material for facili- tators, hand-outs, refresh- ments 20 lakhs 46.67 lakhs Subtotal per district Total cost (No.
of districts x cost per district) State Coordination and Resource Centre for IYCF (preferably a Government Teaching Hospital) Translation of training materials into local language/s State level Proposal to be submitted by State One As per proposals State Costs Need based 1,50,000 To be arranged locally; co- ordinated by State resource centre guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 23 guidELiNES FOr Activity Indicative Unit cost No.
of units Total cost Remarks Need based 2,50,000 To be included in budget for CH trainings , based on the number of persons to be trained & training package/s 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 As per plan under NRHM for IYCF activities as proposed in DHAP Meetings of the Coordination Committee on Nutrition Organisation of meet- ing (for planning and review, 6 monthly) Subtotal To be included in consoli- dated IEC budget To be budgeted in pro- gramme management cost under PIP 24 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 5 SYSTEm STrEN gThEN iN g Health System strengthening and support, from National level to Village level as presented below,is essential for effective implementation of IYCF and other nutrition activtiies towards achieving the set goals.
.

1.

National Apex body for IYCF – Child Health Division, moHFw The Child Health Division at the Ministry of Health & Family Welfare will be the nodal agency coordinating various stakeholders in context of IYCF and other nutrition related actions at the national Level.

2.

National Training Centres for IYCF The National Training Centre for IYCF is planned to be established in an apex Medical College for creating resource pool of Master Trainers, developing IEC and other technical materials.
The identified National Training Centre will also be responsible for providing support in the identification and setting up of State Coordination and Resource Centres for Nutrition (SCRCN) in various states so that the training of service providers is undertaken at state level for effectively rolling out of the state based IYCF promoting activities as well as other nutrition initiatives pertaining to micronutrient supplementation and prevention and management of severe acute malnutrition(SAM) cases.

3.
3.

National Technical Nutrition Support Unit A national level Nutrition Technical Support Unit l will be formed by the Ministry Of Health and Family Welfare.This Group will serve as the chief advisory body forthe technical matters for guiding nutrition strategy and policy at the national level.

The members of this Group will include nutrition /public health/IYCF experts and the Group composition may be amended from time to time.
Prominent Civil Society Organisations, NGOs and Research bodies working in the field would be included in this Group as and when required.

4.

State Coordination and Resource Centres for Nutrition (SCRCN) SCRCN will be established in government medical colleges with specific TORs and funding towards creating capacity of State and the Districts in dealing with IYCF, including sensitizing and providing orientation to the health workers in the IMS Act.
,training and These centres will provide technical support forplanning implementation of nutrition interventions including IYCF, micronutrient supplementation, prevention and care of severe acute malnutrition(SAM) as well as management of SAM at the Nutrition Rehabilitation Centres The State Annual Plans for NRHM could therefore include a fully developed plan on SCRCN.. 5.
State Coordination Group on Nutrition A State Coordination Group is recommended to be formed wth members from Departments of Health and WCD, development partners, domain exerts, representatives of professional bodies guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 25 guidELiNES FOr and senior faculty members of medical colleges and home science colleges.
The mandate of this Coordination group would be to provide technical support for all nutrition interventions in the state, facilitate convergence between various departments.

Decisions regarding adaptation of the various existing guidelines, training materials and other technical issues would be taken by this group.
Another important function of the State Coordination Group would be to periodically review the progress made in the implementation of activities and use of funds earmarked for nutrition related activities.

The Group is recommended to meet at least twice a year, first during the PIP planning process and later in the year to review the progress based on the selected monitoring indicators.
A State level officer from the Health Department is recommended to be deputed for The Group activities, including monitoring of the IMS Act.

6.

Developing a detailed Nutrition Action Plan for State and Districts States are advised to formulate a detailed nutrition action plans along with time-line, and incorporating various activities for IYCF promotion.
Earlier section of this guideline provides a menu of options for IYCF activities that can be included in the plan, and which should be reflected in the child health component of the PIP.

As with the state plan, the district plan and budget should be presented in the PIP.

The existing (approved) plans should be reviewed in the light of the recommendations made in this guide and any gaps in planning and monitoring should be plugged.
A District level officer from the Health Department is recommended to be deputed for monitoring of the IMS Act in his/her district.

Similarly at facility level, Matron in the Inpatient Department and Medical Officer in the Out Patient is recommended to be deputed to monitor the strict implementation of the IMS Act.

7.

State and District level Awareness generation for the ImS Act: A large percentage of deliveries take place through the private health care system network..
The states therefore cpuld consider undertaking initiatives to facilitate private sectors in training of the staff, effective implementation of correct IYCF practices, and monitoring adherence to the IMS act.

States are also recommended to take initiative towards convergence of public and private sectors towards ensuring coverage of large number of deliveries taking place in private sector.
26 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 6 AdvOCAY & iEC/bCC PL AN (EBF) Knowledge alone does not lead to behavioural change, particularly for translating knowledge into regarding exclusive breastfeeding adoption of appopriate EBF practice..
Besides advocacy for according policy priorities and undertaking effective communication for influencing community norms and improving household IYCF practices, an enabling environment needs to be created.
The latter includes a reduction in workload, support from family members, as well as counselling support from peers.. • Key elements of a behaviour change communication strategy include the following tasks which must be undertaken a) Behavioural assessment b) targeted, concise messages promoting doable actions with use of consistent messages and appropriate materials c) counselling and communication skill development of health and community workers and d) multiple exposure of specific audiences to messages through appropriate media, and social support 6.1 Behaviour Change Communication (BCC) • A critical window of opportunity to ensure optimal growth and development has been identified and covers the period of pregnancy up to the second year of life.
There are several critical entry points when mothers and children have contact with health services - such as immunization or growth assessment/monitoring – these contacts are excellent opportunities that must not be missed for providing EBF and appropriate complementary feeding support (as in Chapter 2).

1.
1.

Critical points Programmes are: for State & District • Breastfeeding and complementary feeding practices can change over a relatively short period of time and therefore need continued reinforcement for sustaining theinputs and ensuring adoption of the appropriate IYCF practices.

• communication, Interpersonal folk and traditional media, and mass media are chief forms of BCC.

Higher priority and attention needs to be given during training for acquiring interpersonal counselling skills by trainees.
For the State and District Health managers, the key challenge is to integrate high quality breastfeeding counselling and the required support for sustain EBF into the primary health care package for ensuring universal coverage.

In this context, home visits, are essential during the critical first week and months of life when mothers are most likely to abandon exclusive breastfeeding.. • Along with the health system, NGOs could be involved in training and supervising the community cadres,.
2. key elements for Health Facility level counselling delivered through medical Officers, Staff Nurse, ANm during inpatient and out patient interfaces: guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 27 guidELiNES FOr • Right messages (accuracy), on IYCF using a participatory methodology.
» » delivered to the Right person, at the Right time • Impart consistent messages repeatedly and frequently.Repeated contacts and messages to reinforce both knowledge and help practice.

• Provide Counselling to -- » » secondary care givers (mothers-in-law, fathers etc.)

primary care givers (mothers) • Address actively the issue of ‘not enough milk’ which is very often the problem expressed by mothers /caregivers and family members for not sustaining the practice of exclusive breastfeeding.
• • • timely referral for mothers with Ensure breastfeeding and complementry feeding problems when needed.

Ensure mothers are provided the required encouragement, skills and practical help as well as empathetic listening for appropriate IYCF practices..

Remember one to one counselling provides an opportunity to assess the socio economic and cultural barriers regarding optimal IYCF and thus facilitates in accordingly customising the key messages.
One-on-one breastfeeding counselling in promoting exclusive breastfeeding.

is particularly effective • Note maternal counselling during pregnancy, immediately after child birth and at key contacts in the post-natal period has significant effect on continuation of exclusive breastfeeding for the recommended 6 months.

• Organize mother-to-mother support groups 3.


Additional features for counselling in the community by ASHA/Aww/ANm • Community workers to set specific targets for activities, either as individuals or as a group: e.g.

enumerate expected pregnant and lactating women that need to be followed up, number of group sessions to be conducted, number of support groups to be created, number of IYCF contacts to be made each month at growth monitoring sessions, number of community meetings organised etc.
These targets can be discussed and set during the training period and reinforced and followed up during mentoring and supervision.

Setting targets gives a concrete structure and facilitates to focus on implementation of selected set of activities as well as helps in monitoring performance.

• Higher focus to be given to vulnerable groups such as mothers working in unorganised and private sector or mothers belonging to migrant population .
• Besides breastfeeding counselling in health services, provide support to mothers through women’s support groups as well as by peers or lay counsellors .Such actions benefit mothers greatly .
Information 6.2 Communication Education and The State IEC Division is advised to 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 and plan campaign to improve IYCF using audience- appropriate mix of interpersonal, group and mass- media channels.
Appropriate IEC materials must be made available 28 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr to health facilities for display at strategic locations.

Audio-visual resources on breastfeeding and other IYCF practices, in local languages, must be distributed to all health facilities (that have provision of A-V equipment).
These actions should also be linked to training and counselling services.

State Health departments must ensure that all delivery places such as delivery rooms and post -natal wards have messages on early and exclusive breastfeeding , in regional languages, pasted for imparting the information to mothers admitted or visiting the health centres.Where community radio is available, the use of radio is a useful medium for dissemination of IYCF messages.
6.3 Advocacy For impacting on mass levels, along with IEC efforts , effective advocacy through following actions is essential.

• • • • Review Policy and Program Changes required Identify potential influencers.

Identify evidence based approached convince the influencers.

to Involve communication plans.


influencers in developing • Identify the focus group or the audience • Decide on specific advocacy messages • Decide how to best deliver these selected messages • Develop a plan to monitor effectiveness of advocacy.

Public meeting/workshops may be organised for advocacy at each level of governance as suggested below: level State District Block Village Activity Workshops, Public Lecture, Melas, Group Meetings.
Or identify potential activities suited to the population Involvement Leadership, actors, social activists, religious leaders Panchayat leaders, religious heads, teachers, or other potential influencers Care should be taken towards adhering to the IMS Act during advocacy workshops.

meetings and other actions.. to linked Organising campaigns important events.
: ‘World Breastfeeding Week’ is observed globally, including in India, during 1-7 August every year while the National Nutrition Week is observed in India in the first week of September.

A theme or a slogan can be chosen each year for Campaigns during these weeks so that the key message is retained in the community for a long time.
Communication 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.

Print and electronic coverage on breastfeeding could be built around these events targeting mothers, caregivers/families and community leaders /influencers on specific ‘theme for the year’.
guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 29 guidELiNES FOr TV and radio spots on key messages relating to appropriate IYCF practices are already available through various agencies and these materials could be used as such or adapted suitably for state specific /local context.

New spots may be developed by the state IEC cell.


Special guests (eg; community leaders, local influential persons) could be invited to speak during the event.

Competitions for parents, mothers, fathers and family members could also be organised around the theme of breast feeding and IYCF.

Information must be disseminated in an entertaining and interactive way.
The activities could include Nukkad Nataks, puppet shows and similar events that attract and hold attention of local community members.Inviting journalists to cover these events is another way of generating awareness among the general population 30 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 7 SuPErviSiON, mONiTO riNg & EvALuATiON “The World health Organisation has set a global target for IYCF practices in 2012 in 65th World Health Assemble.
Global target is to- Increase exclusive breastfeeding rates in the first six months up to at least 50% by 2022” • Gathering direct feedback from caregivers (e.g.

home visits made by supervisor).

• Conducting periodic group reviews at different levels.
level surveys District like DLHS and AHS provide information for prioritising districts for implementation and for planning state/district level IYCF actions.Supervision and monitoring the implementation of plans of action,as decribed below, is essential part of such plans of actions.

.

Supervision and montoring : Supervision and montoring is crucial for success of IYCF initiatives .
Monitoring of the IYCF Promotion programme should be undertaken as part of a comprehensive Nutrition and /or Child Health interventions in a block/district.

Monitoring should be “institutionalized” as a part of the expected tasks of the health staff, with agreed targets for regularly scheduled supervisory visits.
For effective following supervision strategy supervision,the could be considered: • Adding unscheduled visits (that is, the worker is unaware of the visit in advance) in addition to any planned visits by State/District /Block and PHC level Officials.

• Development Partners to be involved in monitoring.

FOGSI, UNICEF, BPNI to be utilized for supervision and monitoring.
For monitoring implementation of the IMS Act , state, district, block and facility level officials must be designated .A detailed list of Supervisory cadre at each level is given in Chapter 2.

For routine monitoring of IYCF activities, a reporting system which focusses on a few selected key indicators (presented in Table 4) is recommended.These short listed indicators are feasible to collect and are useful for programme planning and implementation at block/district/ state level.
Periodic review of progress against the micro-plan at the block/district level and against the State Programme Implementation Plan is important to ensure that implementation is on track.Moreover,it would facilitate identification of bottlenecks in programme implementation and provide support in strengthening the specific identified problem.

• Observing (using a checklist) performance of Indicators For monitoring a task.
guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 31 guidELiNES FOr A set of indicators that are recommended to be used to monitor various IYCF interventions are presented below: breastfeeding or IYCF campaign (Denominator will be the number of districts identified by the state in the Annual PIP) Table 4: monitoring Indicators for IYCF interventions OUTPUT INDICATORS PROCESS INDICATORS 1.
# and % of health workers (mOs, SNs, ANms, Programme managers, Nodal persons ) trained on IYCF (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 integrated IYCF counselling (Denominator will be the delivery points in the state/district) 3.
# and % of health facilities with a dedicated Nutrition Counsellor/IYCF Counsellor (Denominator will be District hospitals; states can consider including FRUs with high delivery load) 4.

# and % of health facilities with functional IYCF Counselling Centres (Denominator will be delivery points at DH, FRUs identified for establishing Lactation Support Centres during the year) 5.
# and % newborn 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 1.


Early initiation of breastfeeding: % of infants who breastfed within one hour of birth (to be reported in HMIS every month) Other output indicators that are recommended to be collected regularly at the state /district level but assessed through periodic surveys at national/ state level (like the Annual Health Survey and the DLHS) are: 2.
Exclusive breastfeeding under 6 months: Proportion of infants 0–5 months of age who are fed exclusively with breast milk Infants 0-5 months of age who received only breast milk during the previous day Infants 0-5 months of age 3.
Introduction of solid, semi-solid or soft foods: Proportion of infants 6–8 months of age who receive solid, semi-solid or soft foods Infants 6–8 months of age who received solid, semi-solid or soft foods during the previous day Infants 6–8 months of age 4. minimum dietary diversity: Proportion of children 6–23 months of age who receive foods from 4 or more food groups Children 6–23 months of age who received foods from ≥ 4 food groups during the previous day Children 6–23 months of age 32 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr mONTHlY /QUARTERlY REPORTS: The progress should be reviewed by District Child Health/Nutrition nodal officer/s every month.
IYCF progamme 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 report- ing format by the districts and transmitted electron- ically 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.
Assessment from Surveys: District level surveys are conducted such as DLHS and AHS that provide progress in IYCF indicators such as early breastfeeding, exclusive breastfeed- ing and complementary feeding rates.

Planning for IYCF implementation to be in sync with survey reports.

Quarterly Reporting Format (from the district/state) Trainings on IYCF Name of the training Duration No.

of doctors trained No.

of Staff nurses/ GNms trained No.


of frontline functionaries trained (specify the cadre/s) Planned Achieved Planned Achieved Planned Achieved guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 33 guidELiNES FOr Quarterly Reporting Format (from the district/state) Trainings on IYCF Counselling Skills No.

of State master Trainers for IYCF Coun- selling training package No.
of medical Of- ficers/Doctors trained in IYCF counselling No.

of Staff Nurses trained in IYCF counselling No.

of ANms trained in IYCF counselling Planned Achieved Planned Achieved Planned Achieved Planned Achieved State Total 34 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr n o s r e P l a d o N e h t f o t e r u a n g S i - w e n f o .
- i t s n i f o .

 ) T U / e t a t S e h t m o r f ( t a m r o F g n i t r o p e R y l r e t r a u Q / y l h n o m t : h t n o m : .

o N s e i t i l i c a f h t l a e h f o .


 ( s t i n o p y r e v i l e d f o .

o N o w t t s a e l t a h t i w ) s U R F g n i t c u d n o c s t c i r t s i d f o .
o N F C Y I n i d e n a r t i f f a t s i s / guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 35 guidELiNES FOr 36 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr SECTiON - ii TEChNiCAL guidELiNES guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 37 guidELiNES FOr 38 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr iNFA NT A Nd Y O uNg ChiLd F EEdiNg TE ChN iCAL guidELiNES 1. brEASTFEEdiNg (a) Breastfeeding should be promoted to mothers and other caregivers as the gold standard feeding option for babies.
(b) Antenatal Counselling individually or in groups organized by maternity facility should contain messages regarding advantages of breastfeeding and dangers of artificial feeding.

The objective should be to 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 newborn should be encouraged by ‘bedding in the mother and baby pair’ .

The method of “Breast Crawl” can be adopted for early initiation in case of normal deliveries.

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,milk secreted in the first 2-3 days, 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 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.
Human milk provides sufficient energy and protein to meet nutritional requirements of the infant during the first 6 months of life.

Therefore, 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.
guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 39 guidELiNES FOr (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 fulfill 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; they 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 room” may be considered at work places (Hirkani’s room is a 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 continue encouraged should breastfeeding unless it is medically indicated to discontinue breastfeeding.
be to (k) At every health visit, the harms of artificial feeding and bottle feeding should be explained to the mothers.

Inadvertent advertising of infant milk substitute in health facility should be avoided.

Artificial feeding is to be practiced only when medically indicated.

(l) Frontline health workers should be trained in various skills of counselling and especially in handling sensitive subjects like breastfeeding and complementary feeding.
(m)If the breastfeeding is noted to be temporarily discontinued due to an inadvertent situation, “re-lactation” should be tried as soon as possible.

Such cases should be referred to a trained lactation consultant/health worker.

The possibility of “induced lactation” should be explored according to the needs of the specific case.

(n) All efforts should be taken to provide appropriate facilities so that mothers can breastfeed babies with ease even in public places.
(o) Adoption of latest WHO Growth Charts is recommended for growth monitoring.

2.

COmPLEmENTA rY FEE diN g (a) Appropriately thick complementary foods of homogenous consistency made from locally available foods should be introduced at six completed months to all babies while continuing breastfeeding along with it.

This should be the standard and universal practice.

During this period breastfeeding should be actively supported and therefore 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 40 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 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 calorie and nutrient rich with locally available products.

(f) The research has time and again proved the disadvantages of bottle feeding.

Hence bottle feeding should be discouraged at all levels.
(g) Population-specific dietary guidelines should be developed for complementary feeding based on the food composition of locally available list of appropriate, acceptable and avoidable foods can be prepared.

foods.

A (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 start showing 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 dark coloured vegetables, milk and milk products, pulses/legumes, animal foods, oil/butter, sugar/jaggery may be added in the staples gradually.

(j) Junk food and commercial food, ready-made, processed food from the market, e.g.
tinned foods/juices, cold-drinks, chocolates, crisps, health drinks, bakery products etc.

should be avoided (k) Giving drinks with low nutritive value, such as tea, coffee and sugary drinks should also be avoided.

(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 and after preparing and feeding and after using the toilet.

Hand washing should be ensured for the child as well before and after feeding and after using toilet.

(m) Practice of responsive feeding is to be promoted.

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.

Foods which can pose choking hazard are to be avoided.

Introduction of lumpy or granular foods and most tastes should be done by about 9 to 10 months.
Missing this age may lead to feeding fussiness later.

So use of mixers/grinders to make food semisolid/ pasty should be strongly discouraged.

The details of food including; texture, frequency and average amount are enumerated in Table below.
guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 41 guidELiNES FOr w a r f o t n u o m A - ( ) d o o f o t d e d d a 2 ) y a d / g ( n o r I d o o F t n e t n o c n o r I t n e t n o c - m u n g n m u s s A i ( p a g / s l a e m f o r e b ) y a d / g m ( d e s i v d a s a y a d ) 3 n m u o c l n i - e r i u q e r n o r I / g m ( t n e m t n u o m a e g a r e v A 1 ) y a d ) A D r r M C I ( ( ) t n e m u c o d ) s e i r o a C l ( e g A ) s h t n o m ( 5 2 4 3 - g m 0 .
2 - 0 .

1 5 3 2 - - - t s a e r B t n e u q e r f s u p l i g n d n e p e D i .

g n d e e f 2 1 - , - 5 2 0 .

3 5 .

2 - g m 5 .

2 - 0 .

2 5 l m 0 5 2 a f o ½ - t s a e r b s u p l s l a e m 4 3 - l w o b / p u c n o i g n d n e p e D .
d e e f - , - 0 4 5 .

6 5 .

5 - g m 5 .

3 - 5 .

2 9 0 5 2 e n o o t 4 / 3 - t s a e r b s u p l s l a e m 4 3 - , s d o o f y l i m a F l w o b / p u c l m n o i g n d n e p e D .
d e e f r o d e p p o h c - - 42 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 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, the mother should increase the energy density of the meal (adding special foods) or increase the amount of food per meal.

For example: and then lay on a clean wet cloth for 1-2 days.

After germination, the grains can be lightly dry roasted and powdered for cooking.
• If locally available fruits like guava (in children over 1 year of age), papaya, musambi (sweet lime), orange, and lime rich in ascorbic acid are provided as a freshly made mash along with the food, it will increase absorption of iron.

— for 6 to 8 months, increase gradually to two thirds cup • — for 9 to 11 months, give three quarters cup — for 12 to 23 months, give a full cup.

The table should be adapted based on the energy content.
Find out what the energy content of complementary foods is in your setting and adapt the table accordingly.

1Iron requirement is based on 5% bio-availability from cereal-pulse based diets.

2Green leafy vegetables like amaranth (chaulai sag/dantu), spinach (palak), turnip leaves (shalgam ka sag), mint leaves (pudhina) and small amounts of tamarind (imli) added to the diet daily will sum up to provide the amount of iron recommended.

These are broad guidelines.


Recipes should be adapted based on local customs.

Additional pointers to improving quality of feeds: • Complementary feeds containing a cereal- pulse combination of rice/rice flakes (poha)/ wheat and roasted bengal gram dhal/ soyabean/green gram dhal would increase intakes of iron, compared to other cereal: pulse combinations due to either higher absorption and/or higher iron content.
• Soaking, germination/sprouting of cereals and pulses will reduce their phytate content by about half.

To do this, soak grains overnight, If an iron supplement is to be given, it is best provided after meals.

This will reduce the risk of adverse events.

To improve bioavailability of iron taken after the meal, use grains that are less inhibitory for iron absorption.

For this purpose, rice is most neutral, followed by wheat and lastly millets.
Examples of rice based complementary foods with lower inhibitory effect are a cereal: pulse combination of rice: roasted Bengal gram or rice: sprouted and roasted green gram.

These combinations can be made into local recipes like rice khichdi or rice pongal or idlis for younger children.

For older children, poha with crushed groundnuts can also be given.

It is important to remember that the foods listed here are specifically for the day on which iron is given.
3. hiv ANd iNFANT FEEdiNg Principles of feeding HIv exposed and infected infants are as follows: 1.

Exclusive breastfeeding is the recommended infant feeding choice in the first 6 months, irrespective of whether mother or infant is provided with ARV drugs for the duration of breastfeeding.

2.

Mixed feeding should not be practiced.

3.


Only in situations where breastfeeding guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 43 guidELiNES FOr cannot be done or on individual parents’ informed decision, feeding may be considered only if all the criteria for replacement feeding are met (see box in Situation 3).

replacement 4.
replacement 4.

Exclusive breastfeeding should be done for at least 6 months, after which complementary feeding may be introduced gradually, irrespective of whether the infant is diagnosed HIV negative or positive by early infant diagnosis.

5.

Either mother or infant should be receiving ARV prophylaxis or ART during the whole duration of breastfeeding.

ARV prophylaxis should continue for one week after the breastfeeding has fully stopped.

6.
6.

For breastfeeding infants diagnosed HIV negative, breastfeeding should be continued until 12 months of age 7.

For infants breastfeeding diagnosed HIV positive, ART should be started and breastfeeding should be continued till 2 years of age.

8.

Breastfeeding should stop once a nutritionally adequate and safe diet without breast-milk can be provided.

9.

Abrupt stopping of breastfeeding should NOT be done.

Mothers who decide to stop breastfeeding should stop gradually over one month.
Determining the HIV status of mothers is important to make the best feeding choice for the infant.

Women whose status is unknown should be offered HIV testing.

Mothers who do not know their HIV status should know that exclusive breastfeeding will markedly reduce the risk of the infant being infected as compared to mixed feeding.
44 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr INFANTS (0-6 mONTHS) BORN TO HIv- INFECTED wOmEN is For all infants born to HIV-infected women, recommended as strongly breastfeeding the feeding option of choice.
This holds true irrespective of whether the mother is receiving ART, ARV prophylaxis during pregnancy and lactation, or neither.

In view of emerging evidence, extended anti-retroviral (ARV) prophylaxis to infant and/ or mother should be considered for preventing postnatal transmission of HIV.
Infants (0-6 months) born to HIv-infected women Breast Situation 1: mother is on ART for her own health, started before/during pregnancy Maternal antiretroviral therapy significantly reduces the HIV transmission through breast feeding.

Infants born to these mothers are advised 6 weeks of nevirapine (NVP) (for breastfeeding infants) or 6 weeks of zidovudine (ZDV)/ NVP (for non breast feeding infants) to reduce the risk of early post natal transmission as per the new WHO (2009) guidelines.
Subsequently, no further prophylaxis needs to be given to the baby even if he/she is breastfed.

In this group of infants, breastfeeding would provide all its benefits, while eliminating replacement feeding associated morbidity and mortality, with a highly reduced risk of infection transmission.

No additional drugs/interventions are needed for these infants.
Infants (0-6 months) born to HIv-infected women Breast Situation 2: mother is not on ART but has been started on ARv prophylaxis during pregnancy that is continued during lactation: For this group of infants, again, breastfeeding is associated with a reduced risk of HIV transmission by the ongoing ARV prophylaxis and is the feeding option of choice.
WHO (2009) recommendations provide two alternative options for women who are not on ART and breastfeed in resource-limited settings: 1) If a woman received AZT during pregnancy, daily nevirapine is recommended for her child from birth until one week after the end of the breastfeeding period.
or 2) If a woman received a three-drug regimen during pregnancy, starting from as early as 14 weeks of gestation, a continued regimen of triple therapy is recommended till one week after the end of the breastfeeding period.

For all HIV-infected pregnant women who are not eligible for ART, ARV prophylaxis for preventing HIV transmission through breast milk should continue until one week after all exposure to breast milk has ended.
Situation 3: If the ARv prophylaxis to cover period of lactation is not available to the HIv- infected woman: Exclusive breastfeeding (EBF) is still recommended unless conditions suitable for replacement feeding are met with (see box).
This recommendation guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 45 guidELiNES FOr is based on the evidence that EBF is associated with reduced mortality over the first year of life in HIV-exposed as well as unexposed infants as compared to mixed and replacement feeding.
upon the individual circumstances, commercial infant formula may also be used for replacement feeding where it is preferred by the family and is feasible and affordable.
Infants (0-6 months) born to HIv-infected women Infants (0-6 months) born to HIv-infected women Breast Breast Situation 4: when the infant is HIv-infected: If infants and young children are known to be HIV-infected, mothers are strongly encouraged to exclusively breastfeed for the first 6 months of life and continue breastfeeding as per the recommendations for the general population, that is, up to two years or beyond.
HIV-infected women who opt for replacement feeding or in situations where breast milk is not available for the infants e.g.

maternal death, sickness, twins etc.

culturally acceptable These babies should be given locally available animal milk.

Animal milk (pre-packed processed milk or fresh animal milk) is easily available, economical and in comparison to commercial feeding formulas.
As per the Indian adaptation of IMNCI guidelines, it is also recommended for infants of mothers who are HIV-negative/ have unknown status and are not able to breastfeed for any reason.

Animal milk is invariably boiled before consumption in India, a practice that improves its safety.

Commercial infant feeding formula, while offering the advantage of a standard composition, is expensive and often carries a higher risk of bacterial contamination.
However, depending In certain areas of India where wet nursing is culturally accepted and practiced, counsellor should discuss this with the family during the antenatal period.

It is important to be sure that the lactating woman is HIV-negative, follows safe sexual practices throughout the period of lactation to avoid acquiring HIV infection, and is aware of the small but existing risk of reverse transmission of HIV infection to her in case the infant is infected.
Infants (0-6 months) born to HIv-infected women Breast Infants (6-23 months) born to HIV-infected women infants more than 6 months of age, For complementary started irrespective of HIV status and initial feeding options.
should be feeding For situations 1 & 2, where ART or ongoing ARV prophylaxis is being administered to the mother or infant, breastfeeding should be continued for the first 12 months of life along with complementary 46 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr foods.
Breastfeeding should then be stopped only once a nutritionally adequate and safe diet without breast milk can be provided.

Continuing breast feeding for 12 months is feasible in these situations since HIV transmission risk would be further reduced in presence of ARV interventions.

This is a big advantage since stopping breast feeding soon after 6 months without ensuring adequate complimentary feeding may lead to growth faltering.
Mothers or infants who have been receiving ARV prophylaxis should continue prophylaxis for one week after breastfeeding is fully stopped.

Stopping breastfeeding abruptly is not advisable.

Mothers known to be HIV-infected who decide to stop breastfeeding at any time should stop gradually within one month.

For situation 3, where ongoing ARV prophylaxis is not available and the mother had opted for exclusive breastfeeding, a re-evaluation is to be done at 6 months.
If at this time, conditions suitable for replacement feeding are met, cessation of breastfeeding is recommended as quickly as possible taking into account the comfort level of both the mother and her infant.

If replacement feeding is still not feasible at this stage, continuation of breastfeeding with additional complementary foods is recommended.

All breastfeeding should stop only when a nutritionally adequate and safe diet without breast milk can be provided by complementary feeds including animal milk.
For infants who were on replacement feeding, animal milk should be continued as before, in addition to complementary feeds.

These infants should receive two additional complementary feeds as compared to babies who continue to receive breastfeeds.

4.

FEE di Ng i N O ThEr SPECi FiC SiTuATiONS (A) FEEDING DURING SICkNESS Feeding during sickness is important for recovery and for prevention of undernutrition.
Even sick babies mostly continue to breastfeed and the infant can be encouraged to eat small quantities of nutrient rich foods, but more frequently and by offering foods that a child likes to eat.

After the illness (eg; diarrhoea) 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 temporary cessation of may need a breastfeeding.

Treatment of primary condition should be done and breastfeeding should be started as soon as possible after completion of treatment 2.
Chronic infections like tuberculosis, leprosy, or medical conditions like hypothyroidism need treatment of the primary condition and do not warrant discontinuation of breastfeeding.

3.

Breastfeeding is contraindicated when the mother is receiving certain drugs like anti- neoplastic agents, immuno-suppressants, anti- thyroid drugs like thiouracil, amphetamines, gold salts, etc.

Breastfeeding may be avoided when the mother is receiving following drugs- reserpine, psychotropic drugs.
atropine, Other drugs like antibiotics, anaesthetics, anti- epileptics, antihistamines, digoxin, diuretics, prednisone, propranolol etc.

are considered safe for breastfeeding.


guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 47 guidELiNES FOr (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 low birth weight, sick, or depressed babies, alternative methods of feeding can be used based on neuro- developmental 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 a condition when a child regurgitates the feed soon after the feeding.
It is often treated conservatively through thickening the complementary foods, frequent small feeds and upright positioning for 30 minutes after feeds.

(iii) Diarrhoea (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.

(iv) 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.

Infants born into populations affected by emergencies should normally be exclusively breastfed from birth to 6 months i.e 180 days of age.
Every effort should be made to identify alternative ways to breastfeed infants whose biological mothers are unavailable.

Complementary foods should be prepared and fed frequently, consistent with principles of good hygiene and proper food handling.

Safe drinking water Supply should be ensured.

5.


FE E diN g i N PrETErm/ LO w bi r Th w Eigh T iNFANTS Low birth weight (LBW) has been defined by the World Health Organization (WHO) as weight at birth less than 2500 g. LBW can be a consequence of preterm birth (defined as birth before 37 completed weeks of gestation), or due to small size for gestational age (SGA, defined as weight for gestation <10th percentile), or both.
LBW thus defines a heterogeneous group of infants: some are born early, some are born at term but are SGA, and some are both born early and SGA.

Being born with LBW is generally recognized as a disadvantage for the infant.

LBW infants are at higher risk of early growth retardation, infectious disease, developmental delay and death during infancy and childhood.
Infant mortality rates can be substantially reduced by improving the care of LBW infants which includes feeding, temperature maintenance, hygienic cord and skin care, and early detection and treatment of complications and complete timely immunization.

Interventions to improve feeding of LBW infants can improve the immediate and longer term health and well-being of the individual infant and have a significant impact on neonatal and infant mortality levels.
Feeding recommendations for low birth weight infants.

48 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr 1.

All Low-birth-weight (LBW) infants, including those with very low birth weight (VLBW), should be fed breast milk.

2.

3.

4.
2.

3.

4.

LBW infants who are able to breastfeed should be put to the breast as soon as possible after birth (and when they are clinically stable).

If unable to suckle, these babies should be fed with expressed breast milk using a katori and spoon.

LBW infants should be exclusively breastfed until 6 months i.e 180 days of age.

LBW infants who cannot breastfeed and need to be fed by an alternative oral feeding method should be fed by cup or spoon or as prescribed by the paediatrician.

5.
5.

Very low birth weight infants should be given 10 ml/kg of enteral feeds preferably expressed breast milk, starting from 1st day of life with the remaining fluid requirement met by IV fluids.

6.

LBW infants, including those with VLBW, who cannot be fed mother’s own milk should be fed donor (non HIV infected) human milk.

(This recommendation is relevant only to settings where safe and affordable milk banking facilities are available or can be set up such as SNCU).

7.
7.

Facility in work places for expression of breast milk and appropriate storage facility are available.

guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 49 guidELiNES FOr Anne xure 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 one-hour of birth.

5.

Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.

6.
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.
50 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr Anne xure i i The Infant Milk Substitutes, Feeding Bottles and Infant Foods (regulation of Production, Supply and Distribution) Act, 1992 and As Amended Act in 2003 This Act provides for the regulation of production, supply and distribution of infant milk substitutes, feeding bottles and infant foods with a view to the protection and promotion of breastfeeding and ensuring the proper use of infant foods and for matters connected to it.
It extends to the whole of India.

It also lays the responsibility of health workers and of the government to provide accurate information to people.

Following are the basic provisions of the IMS Act.

THE ImS ACT PROvISIONS ImS Act is violated if any baby Food Company, its distributor or supplier, or any person 1.

Promotes any food by whatever name, for children up to two years.

2.

Promotes use of infant foods before the age of six months.

3.
3.

Advertises by any means--television, newspapers, magazines, journals, through SMS, emails, radio, pamphlets etc.

4.

Distributes the product or samples to any person.

5.

Contacts pregnant or lactating mothers using any person.

6.

Gives any kind of inducements like free gifts, tied sales, to anyone.

7.

Distributes information and educational material to mothers, families etc.
(They can give educational material to health professionals like doctors, nurses etc provided it has information prescribed in clause 7 of the IMS Amendment Act, 2003.

The education material should have only factual information and should not promote the products of the company).

8.

Gives tins, cartons, accompanied leaflets of these products having pictures of mothers or babies, cartoons or any other such images to increase saleability.

9.
9.

Displays placards, posters in a hospital, nursing home, chemist shop etc.

for promoting these products.

10.

Provides direct or indirect inducements to health workers 11.

Demonstrates to mothers or their family members how to feed these products.

However, a doctor can demonstrate this to the mother.

12.
12.

Gives benefits to doctors, nurses or associations like IAP, IMA, NNF etc, for example, funds for organizing seminars, meeting, conferences, contest, fee of educational course, sponsoring for projects, research work or tours.

13.

Fixes commission of employees on the basis of volume of sales of these products.
guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 51 guidELiNES FOr HIGHlIGHTS OF THE ACT • • • • • • • Prohibits all persons from any kind of promotion of infant milk substitutes, infant foods or feeding bottles Prohibits the advertisement of infant milk substitutes and feeding bottles to” ensure that no impression is given that feeding of these products is equivalent to, or better than, breastfeeding.
Prohibits providing free samples and gifts to pregnant women, mothers of infants and members of the families.

Prohibits donation of free or subsided supplies of products for health care institutions and prohibits incentives and gifts to health workers.

Prohibits display of posters at health care facilities / hospitals /health centres.

The Act also prescribes that all labels of IMS /Infant food, must say in English and local, languages that breastfeeding is the best.
Also, the labels must not have pictures of infants or women or phrases designed to increase the sale of the product.

Prohibits any contact of employers manufacturing and distributing company with pregnant women, even for providing educational material to them.

PENAlITIES FOR CONTRAvENTION Violations of the Act attract imprisonment for up to three years and/or fine up to Rs.5000.
Penalty with regard to the Label on container or quality of infant milk substitute, feeding bottle and infant food is punishable with imprisonment up to 6 month extended to 3 years and fine at least Rs.2000.

wHAT HEAlTH SERvICE PROvIDERS CAN DO • Seek correct and scientific information about breastfeeding.

feeding bottles and infant foods.

• Understand the hazards of using infant milk substitutes, • Create awareness on promotion and protection of breastfeeding.
• Report violations to the right authorities.

Inform/publicise addresses and names of organisations where you can report violations.

52 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr Anne xure i ii COUNSEl THE mOTHER FEEDING : RECOmmENDATION DURING SICkESS AND HEAlTH Up to 6 months of age • Breasfeed as Often as the child wants.

day & night.
day & night.

at least 8 times in 24 hrs.

Do not give any other food or fluids not even water.

• Remember: • • Continue breastfeeding if the child is sick 6 months up to 12 months • 12 months up to 2 years • • • • • • • Breastfeed as often as the child wants Give at least I katori serv- ing at time of: Mashed roti/bread mixed in thick dal with added ghee/oil or khichdi with added oil/ ghee.
Add cooked vegetables also in the servings or Sevian/dalia/ halwa/ Kheer prepared in millk or Mashed boiled/fried potatoes Offer banana/biscuit/ cheeko/ mango/papaya 3 times per day if breast- fed.

5 times per day if not breastfed.

• • • • • • Breastfeed as often as the child wants Offer food from the family pot Give at least 11/2 ka- tori serving at a time of Mashed roti/bread mixed in thick dal with added ghee/oil or khichdi with added oil/ ghee.
Add cooked vegetables also in the servings or Mashed roti/rice/ bread mixed in sweet- ened milk or.

Sevian/dalia/halwa/ kheer prepared in milk or.


Offer banana/biscuit/ cheeko/ mango/pa- paya 5 times per day if Remember: • Keep the child in your lap & feed with your own & child’s hand with soap & water every time before feeding • Remember: • Sit by the side of child & help him to finish the serving Wash your own & child’s hand with soap & water every time before feeding 2 years & older • Give family foods at 3 meals each day Also, twice daily.
give nutri- tious food between meals, Such as Banana/ biscuigt/cheeko/ mango/papaya as snacks.
• • Remeber: • • Ensure that the child fan- ishes the serving Teach your child wash his hands with soap and water every time before feeding guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 53 guidELiNES FOr Anne xure i v Sample IEC materials on Breastfeeding maa Sab Jaanti Hai Ads_Hindi Primary (P), Secondary (S) audience P: Caregivers and family; s: Frontline worker File Name POSTER Early Initiation of breast- feeding.pdf KeeingNewbornWarm.
pdf Seeking care.pdf Alternative IEC Format Back-light Trans- lides Horizontal posters location for display 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/ Labour room/ SNCU Doctors chambers AWW centres During VHNDs 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 Sakhi dadi Bus-Pannel.jpg P: Community On backs and sides of buses.
Hoardings Wall painting File Name Breastfeeding FAQ Breastfeeding FAQs and Breastfeeding posters Primary (P), Secondary (S) audience P: Caregivers and family; s: Frontline worker/ AWW location for display 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.
Alternative IEC Format Must be distributed during VHNDs and during World Breast Feeding Day (Aug 01-07); National Nutrition Week (Sept 01- 07); World Food Day (Oct 16); Children’s Day (Nov 14) 54 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr Breastfeeding poster P: Caregivers and family; s: Front- line 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) BF_WallPainting.jpg P: Community; Walls of Anganwadi centres, CHCs, PHCs, local markets 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 cen- tres, given during events, VHNDs for carry back by caregivers • • • Newspaper ad Hoarding Kiosks • • • Hoarding Bus panels Stickers Leaflet • (Can be kept at the health cen- tres, given during events, VHNDs for carry back by caregivers Newspaper ad Hoarding Kiosks • • • Hoarding Bus panels Stickers guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 55 guidELiNES FOr 56 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM guidELiNES FOr guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM 57 guidELiNES FOr 58 guidELiNES FOr ENHANCING OPTIMAL INFANT AND YOUNG CHILD FEEDING PRACTICES THROUGH THE HEALTH SYSTEM