Module 5 Counsel Nov 2011

Integrated Management of
Newborn and Childhood Illness
Counsel the Mother

(Module 5)
November 2011
Addis Ababa, Ethiopia
INTEGRATED MANAGEMENT OF NEWBORN
AND CHILDHOOD ILLNESS
COUNSEL THE MOTHER
November 2011
CONTENTS
Introduction ........................................................................................................................ 1
Learning Objectives ............................................................................................................. 1
Feeding Recommendations ................................................................................................ 2
Exercise A ............................................................................................................. 12
1.0 Assess the child's feeding ..................................................................................... 13
2.0 Identify feeding problems..................................................................................... 15
Exercise B.............................................................................................................. 17
3.0 Counsel the mother about feeding problems ........................................................ 18
3.1 Give relevant advice ................................................................................ 18
Exercise C.............................................................................................................. 22
3.2 Use good communication skills ............................................................... 26
3.3 Use a mother's card .................................................................................. 29
Exercise D .............................................................................................................. 31
4.0 Advise the mother to increase fluid during illness ............................................... 33
5.0 Advise the mother when to return to a health worker .......................................... 33
Exercise E ............................................................................................................. 36
6.0 Counsel the mother about HIV testing ................................................................. 40
7.0 Counsel the mother of a child with HIV infection or HIV exposed ...................... 40
8.0 Counsel the mother about her own health ............................................................ 41
Exercise F .............................................................................................................. 43
Annex: Family Health Card .............................................................................................. 44
Answers to short answer exercises.................................................................................... 45
Counsel the Mother i

INTRODUCTION
You have learned how to treat the sick child and how to teach the mother to continue treatment at
home. For many sick children, you will also need to assess feeding and counsel the mother about
feeding.
For all sick children going home, you will also advise the mother when to return for follow-up
visits and teach her signs that mean to return immediately for further care.
Recommendations on FOOD, FLUID, and WHEN TO RETURN are given on the chart titled
"Counsel the Mother" (called the COUNSEL chart in this module).
LEARNING OBJECTIVES
This module will describe and allow you to practice the following tasks:
* assessing the child's feeding practice
* identifying feeding problems
* counselling the mother about feeding problems
* advising the mother to increase food and fluid during illness
* advising the mother:

- when to return for follow-up visits,
- when to return immediately for further care,
- when to return for immunizations.
In practising these tasks, you will focus on:
* giving relevant advice to each mother

* using good communication skills
* using a Mother's Card as a communications tool.
Even though you may feel hurried, it is important to take time to counsel the mother carefully and
completely. When counselling a mother, you should use communication skills that you have
already practised when assessing and treating the child.
For example, you will ask the mother questions to determine how she is feeding her child. You
will then listen carefully to the mother's answers so that you can make your advice relevant to
her.
You will praise the mother for appropriate practices and advise her about any practices that need
to be changed. You will use simple language that the mother can understand. Finally, you will
ask checking questions to ensure that the mother knows how to care for her child at home.
Counsel the Mother 1

FEEDING RECOMMENDATIONS
This section of the module will explain the feeding recommendations on the COUNSEL chart and
any local adaptations. The recommendations are presented in the subsequent pages for the 4 age
groups. You will give only the advice that is needed for the child's age and situation.
These feeding recommendations are appropriate both when the child is sick and when the child is
healthy. During illness, children may not want to eat much. However, they should be offered the
types of food recommended for their age, as often as recommended, even though they may not
take much at each feeding. After illness, good feeding helps make up for weight loss, helps
prevent malnutrition, and helps prevent future illness.
Sick child visits are a good opportunity to counsel the mother on how to feed the child both
during illness and when the child is well.
RECOMMENDATIONS FOR AGES UP TO 6 MONTHS
Up to 6 months of age
• Initiate breastfeeding within 1 The best way to feed a child from birth to
hour of birth at least 6 months of age is to breastfeed
• Breastfeed as often as the child exclusively. Exclusive breastfeeding
wants, day and night, at least 8 means that the child takes only
times in 24 hours. breastmilk and no additional food, water,
• Feed your child only breastmilk or other fluids (with the exception of
for the first 6 months, not even giving water medicines and vitamins, if needed).
• Empty one breast before switching to the other Advise the mother to empty one breast
for your baby to get the most nutritious hind first before switching to the second to
milk ensure the baby gets the nutrient rich
• During illness and for at least up to 2 weeks hind milk.
after the illness increase the frequency of
breastfeeding to recover faster
• Do not give other foods or fluids including
water
• Expose child to sunshine for 15 to 20 minutes
daily starting from 2 weeks of age.
Some of the advantages of breastmilk

• Breastmilk contains the necessary nutrients needed by an infant.
• The nutrients in the breastmilk are easily absorbed.
• It provides all the water an infant needs, even in a hot, dry climate.
• It protects an infant against infection.
• It helps maternal-infant bonding.
• It helps in child spacing.
• Facilitates uterine contractions thereby reducing post-partum bleeding.
• It may also reduce the mother's risk of ovarian and breast cancers.
• It is free and does not cost any money.

Some of the disadvantages of replacement feeding
• Reduces the breastmilk production and intake.
• Predisposes the infant to infections.
• If dilute, it will lead to malnutrition.
• The infant may have difficulties digesting and absorbing nutrients from breastmilk
substitutes.
• Could lead to allergic diseases.
• Could increase the risk of persistent diarrhoea.
Exclusive breastfeeding will give an infant the best chance to grow and stay healthy.
RECOMMENDATIONS FOR AGES 6 MONTHS UP TO 12 MONTHS

6 months up to 12 months
By 6 months of age, all children should be
receiving a soft, nutritious complementary food.
It is important to actively feed the child. Active

feeding means encouraging the child to eat. The
child should not have to compete with older
• Breastfeed as often as the child wants.
brothers and sisters for food from a common
• Start complementary foods at 6 months plate. He should have his own serving. Until
• Give adequate servings of freshly prepared the child can feed himself, the mother or another
and enriched; porridge made of cereal and caretaker (such as an older sibling, father, or
legume mixes, Shiro fitfiit, Merek fitfit, grandmother) should sit with the child during
mashed potatoes and carrot, mashed meals and help get the spoon into his mouth.
kaleundiluted milk, egg and fruits
• Enrich the food by adding some oil or butter An "adequate serving" means that the child
every time; give also animal foods (meat, does not want any more food after active
liver, fish, eggs), legumes, vegetables (green feeding.
leafy, carrots) and yellow fruits (orange,
papaya, mangoes)
A good daily diet should be adequate in
• Give these foods; 3times/day plus 2
quantity and include an energy-rich food (for
snacks/mekses, if breast feeding or taking example, soft cereal based porridge with added
other milk. oil); meat, fish, eggs, or pulses; and fruits and
• Give these foods; 5 times/day plus 2 snacks / vegetables.
mekses, if not breast feeding or taking other
milk feeds.
• Babies who stopped breast feeding at 6
months should also get adequate replacement
milk besides semi-solid complementary feeds
• Increase intake of food and fluids during
illness, and give one additional meal of solid
food for about 2 weeks after illness for fast
recovery
• Give Vitamin A supplements from the age of
6 months, every 6 month
• Expose child to morning sunshine for 15-20
minutes daily

GOOD COMPLEMENTARY FOODS
Good complementary foods are energy-rich, nutrient-rich, and locally affordable. Examples in
some areas are soft cereal based porridge with added oil or milk; fruits, vegetables, pulses, meat,
eggs, fish, and milk products. If the child receives cow's milk or any other breastmilk substitute,
these and any other drinks should be given by cup, not by bottle.
Foods that are appropriate in your area are listed in the feeding recommendations on the
COUNSEL chart.
 Mashed potatoes softened with milk, shiro fitfit, merek fitifit, and porridge made of cereal
and legume mixes with butter or oil added are nutrient rich complementary foods to start
in a child 6-12 months of age and can also be recommended for a child 12 months up to 2
years.
 Porridge can be made from wheat, barley or teff with legumes added. Ask what cereals
are available in the house. If feasible, advise the mother to make flour from several
different grains plus peas. The consistency of the porridge should be thick enough to be
fed by hand. When possible, use undiluted milk instead of water to prepare the porridge.
Multi-mixes such as Fafa are very good if available.
 Kitta, softened in milk or prepared soft with oil or butter added, is another good alternate
complementary food.
 Eggs provide good nutrition for infants and young children. They can be prepared by
frying or hard boiling. Then break the egg up and feed it to the child or add it to the fitfit.
Egg can also be stirred into the porridge. Even if an egg can only be given once or a few
times in a week it is very good for the child - especially if the child is malnourished.
 Breastfeeding is not enough for a child over 6 months of age.
 A variety of thick, nutritious foods are needed to prevent malnutrition.
 Also give mashed and boiled kale (gommen) and carrots, banana, oranges and other fruits
(e.g. avocado, papaya)

12 Months up to 2 Years
During this period the mother should continue
• Breastfeed as often as the to breastfeed as often as the child wants and
child wants. also give nutritious complementary foods. The
 Give adequate servings of variety and quantity of food should be
enriched family foods: and increased. Family foods should become an
porridge made of cereal and important part of the child's diet. Family foods
legume mixes, shiro, kik, should be appropriately prepared, so that they
merek fitfit, mashed potatoes and carrot, are easy for the child to eat.
kale, undiluted milk and egg and fruits.
• Add some extra butter or oil to child’s food. Give nutritious complementary foods or family
Give also animal products (meat, liver, fish, foods 5 times a day.
eggs), legumes, vegetables (green leafy,
carrots) and yellow fruits (orange, papaya, Adequate servings and active feeding
mangoes) (encouraging the child to eat) continue to be
• Give these foods at least 3-4 meals plus 2 important.
snacks / mekses if breast feeding or taking
other milk
• Give these foods; 5 times/day plus 2 snacks
/ mekses, if not breast feeding or taking
other milk feeds.
• Babies who stopped breastfeeding at early
age should also get adequate other milk
feeds besides complementary feeding.
• Give your baby his/her own servings and
actively feed the child
• Give freshly prepared food and use clean
utensils
• Increase intake of food and fluids during
illness, and give one additional meal of
solid food for about 2 weeks after illness
for fast recovery
• Give Vitamin A supplements and
Mebendazole/Albendazole every 6 months

RECOMMENDATIONS FOR AGES 2 YEARS AND OLDER
2 Years and Older

At this age the child should be taking a
 Give adequate servings of freshly variety of family foods in 3 meals per day.
prepared enriched family foods, 3-4 The child should also be given 2 extra
meals a day. feedings between meals (snacks) per day.
 Also, twice daily, give nutritious These may be family foods or other
food between meals, such as: Egg, nutritious foods which are convenient to
milk, fruits, kitta, bread, ripe yellow fruits give between meals. Examples are listed
 Give your baby his/her own servings and actively on the COUNSEL chart and below.
feed the child.
 Give freshly prepared food and use clean utensils
 Increase intake of food and fluids during illness, and
give one additional meal of solid food for about 2
weeks after illness for fast recovery.
 Give Vitamin A supplements and Mebendazole or
Albendazole every 6 months.
Kitta (flat bread of non-fermented wheat flour) and home-made bread softened with milk are
good protein and energy-rich complementary foods for children over 2 years.
In addition, consumption of potatoes and fruits, such as oranges and banana should be
encouraged.
SPECIAL RECOMMENDATIONS FOR CHILDREN WITH

PERSISTENT DIARRHOEA
Children with persistent diarrhoea may have difficulty in digesting milk other than breastmilk.
There is a need to temporarily reduce the amount of other milk in their diet. They must take
more breastmilk or other foods to make up for this reduction.
Feeding recommendations for a child who has PERSISTENT DIARRHOEA
• If still breastfeeding, give more frequent, longer breastfeeds, day and night
• If taking other milk:
- replace with increased breastfeeding OR
- replace with fermented milk products, such as yoghurt OR
- replace half the milk with nutrient rich semisolid food.
• For other foods, follow feeding recommendations for the child’s age.
Continue other foods appropriate for the child's age.
The child with persistent diarrhoea should be seen again in 5 days for follow-up. Further feeding
instructions are described in the Follow-up module.

SPECIAL RECOMMENDATIONS FOR CHILDREN WITH
UNCOMPLICATED SEVERE ACUTE MALNUTRITION
RUTF (Ready to Use Therapeutic Food): RUTF can be used in both in-patient and out-patient
settings. For out-patients explain to the caretaker how to give the RUTF at home:
• RUTF is a food and a medicine for malnourished children only. It should not be shared with
the other family members even if the child does not consume all the diet offered. Opened
packets of RUTF can be kept safely and eaten at a later time – the other family members
should not eat any that is left over at a particular meal.
• Wash with soap child’s hand and face before feeding. Keep food clean and covered.
• These children often only have moderate appetites and eat slowly. Give small regular meals
of RUTF and encourage the child to eat as often as possible (every 3 to 4 hours). The child
can keep the RUTF with him/her and eat steadily throughout the day – it is not necessary to
have set meal times if the food is with the child all the time. Tell the mother how much her
child should eat each day (this is given in the look-up table for RUTF).
• RUTF is the only food the child needs to recover during his time in the programme. It is not
necessary to give other foods; a lot of other foods will delay the recovery of your child. If
other foods are given, always give RUTF before other foods.
• For breastfed children, always give breastmilk before the RUTF
• Always offer plenty of clean water to drink while eating RUTF
For children that have been in a Therapeutic Feeding Unit (TFU), a transfer form needs to be
filled in with the SAM-Unique Number (Registration number) of the child. The child should be
transferred with sufficient RUTF to last until the next day of operation of the Outpatient
Therapeutic Program (OTP) site closest to the child’s home.
For children that are first admitted directly into OTP, the amount of RUTF should be enough for
the next visit to the OTP site.
Amounts of RUTF to give:

RUTF (Plumpy Nut) BP 100 biscuits
(500 Kcal/92 gm sachet) (1 BP100 Bar = 56.7gm=
300Kcal)
Weight of child (kgs) Sachet per day Sachet per week Bars per day Bars per week
3.0 up to 3.5 1¼ 9 2 14
3.5 up to 5.0 1½ 11 2½ 17 ½
5.0 up to 7.0 2 14 4 28
7.0 up to 10 3 21 5 35
10 up to 15 4 28 7 49
15 up to 20 5 35 9 63
20 up to 30 6 40 10 70
30 up to 40 7 50 12 84
40 up to 60 8 55 14 98

FEEDING RECOMMENDATIONS IF MOTHER IS HIV POSITIVE
The preferred method for infant feeding in HIV-infected women is exclusive breastfeeding for the
first six months of life. Early cessation of breastfeeding should be avoided since it is associated
with increased risk of death from diarrheal illnesses, malnutrition and pneumonia.
• She should give breastmilk only and medication. No other feed or drink should be given,
not even water.
• Avoid mixed feeding during the first six months since this is associated with increased risk
of HIV transmission
• Counseling and support on “safer breastfeeding practices” is an effective way to encourage

exclusive breast feeding at every visit during antenatal, immediate postpartum, within the
first week after delivery, during routine postnatal care, and at every follow-up visit.
Mothers should be counseled on advantages and disadvantages of breastfeeding. It helps
prevent breast problems which increase the risk of viral transmission (mastitis, cracked
nipples etc.).
• Advise about risks of relactation [restarting breastfeeding after weaning] which is

associated with increased breast milk viral load
Check and treat breast problems and lesions in the infant’s mouth.
• Check mothers’ CD4 status during lactation and start eligible women on HAART
• Lactating mother should be provided with nutritional support for herself.
Alternative Infant Feeding Option:

• A minority of women may choose to use replacement feeding in which case every effort
should be made to ensure that it is done safely.
• Counsel the mother by telling the advantages and disadvantages of replacement feeding.
• Ensure that there is an uninterrupted supply of formula for at least twelve months
• For replacement feeding commercial infant formula should be used. Home-modified

animal milk do not provide all the micronutrients needs for the infant and be used as a
temporary measure.
• As mentioned above there should not be mixed feeding.
• Mother should be taught how to prepare replacement feeds hygienically.
• Encourage the mother to use cup feeding and avoid bottle feeding, in order to avoid risk of
diarrhoea and malnutrition
• Ensure close follow-up to monitor growth and nutritional status monthly to prevent
malnutrition and gastroenteritis during the first two years of life.
Initiate complementary feeding at six months for all infants whether exclusively breastfed or on
replacement feeding.

Complementary foods should be made from nutrient rich foods, preferably use local energy-dense
foods and increase use of fruits and vegetables
Encourage continuation of breastfeeding after six months. Infants should be weaned completely
only when an adequate diet without breast milk is ensured, usually around 12 to 18 months.
Promote good hygiene, proper food safety and handling.

Feeding Recommendations for HIV Exposed Infant & Child
Up to 6 Months of Age 6 Months Up to 12 Months 12 Months Up to 2 Years 2 Years and Older
 Consider replacement feeding and discontinuation of • Discontinue breast feeding

 Breastfeed as often as the child
wants, day and night, at least 8 times Continue breastfeeding. breast feeding as early as possible if mother can  Give adequate servings of freshly
in 24 hours. • Start complementary foods at 6 month provide adequate and safe replacement. (Give at prepared enriched family foods, 3-4
• Give adequate servings of freshly prepared and least 3 cups (3X300ml) of boiled full cream milk per meals a day
 Feed your child only breastmilk for enriched; porridge made of cereal and legume day)
the first 6 months, not even giving mixes, shiro fitfiit, merek fitfit, mashed potatoes and  Give adequate servings of enriched family foods:  Also, twice daily, give nutritious food
water carrot, mashed gommen, eggs and fruits. porridge made of cereal and legume mixes, shiro, kik, between meals, such as: Egg, milk,
 Enrich the food by adding some oil or butter every merek fitfit, mashed potatoes and carrot, gommen, fruits, kitta, Dabo, ripe yellow fruits
 Empty one breast before switching to time; give also animal foods (meat, liver, fish, eggs), undiluted milk and egg and fruits.
the other for your baby to get the legumes, vegetables (green leafy, carrots) and  Add some extra butter or oil to child’s food. Give also  Give your baby his/her own servings and
most nutritious hind milk yellow fruits (orange, papaya, mangos) animal foods (meat, liver, fish, eggs), legumes, actively feed the child
 Give these foods; 3–4 times/day on top of breast vegetables (green leafy, carrots) and yellow fruits
 During illness and for at least up to 2 feeding or replacement milk. (orange, papaya, mangos)  Give freshly prepared food and use clean
weeks after the illness increase the  Give these foods at least 5 times per day (3-4 meals utensils
 Increase intake of food and fluids during illness, and
frequency of breastfeeding to recover give one additional meal of solid food for about 2 and 2 snacks/mekses).
faster weeks after illness for fast recovery  Babies who stopped breastfeeding at early age  Increase intake of food and fluids during
should also get adequate milk replacement besides illness, and give one additional meal of
 Give Vitamin A supplements from the age of 6 months,
 Breastfeed exclusively (Do not give complementary feeding. solid food for about 2 weeks after illness
2 times per year for fast recovery
other foods or fluids including water)  Give your baby his/her own servings and actively feed
 Expose child to sunshine for 15 to 20 minutes daily
the child
 Expose child to sunshine for 15 to 20  Give Vitamin A supplements and
 Give freshly prepared food and use clean utensils
minutes daily starting within 2weeks Mebendazole/Albendazole every 6
of age  Increase intake of food and fluids during illness, and months
give one additional meal of solid food for about 2
weeks after illness for fast recovery
 Give Vitamin A supplements and Mebendazole
/Albendazole every 6 months

Feeding advice for the mother of a child with HIV infection
• The child with HIV infection should be encouraged to breastfeed. There is no further danger
of infection through breastmilk when the child has HIV infection.
• These children often suffer from poor appetite and mouth sores; give appropriate advice
(Page: 40)
• If the child is fed with bottle, advice the mother to use a cup, as this is more hygienic and will
reduce episodes of diarrhoea.
• Advise her about her own nutrition and the importance of a well balanced diet to keep herself
healthy.

EXERCISE A
In this exercise you will answer questions about the feeding recommendations.
1. Write a "T" by the statements that are True. Write an "F" by the statements that are False.
___ a. Children should be given fewer feedings during illness.

___ b. 3-month-old child should be exclusively breastfed.
___ c. Thin cereal gruel is a nutritious complementary food.
___ d. 3-year-old child needs 5 feedings each day of family foods or other nutritious
foods.
___ e. 5-month-old child should be breastfed as often as he wants, day and night
2. When should complementary foods be added to the child's diet?
3. List 5 locally available, nutritious complementary foods:
4. Samuel is 15 months old. He has PERSISTENT DIARRHOEA and NO

DEHYDRATION. He is classified as NO ANAEMIA AND NO ACUTE
MALNUTRITION. He stopped breastfeeding 3 months ago and has been taking cow's
milk since then. He also eats a variety of family foods about 5 times a day. What
recommendations should the health worker make for feeding Samuel during persistent
diarrhoea?
When should Samuel return for a follow-up visit?
When you have completed this exercise, please discuss your answers with a
facilitator.
Your facilitator will lead a drill on the feeding recommendations.

1.0 ASSESS THE CHILD'S FEEDING
You will assess feeding of children who:
* are classified as having ANAEMIA OR MODERATE ACUTE MALNUTRITION
* are less than 2 years old.
However, if the mother has already received many treatment instructions and is overwhelmed,
you may delay assessing feeding and counselling the mother about feeding until a later visit.
Assess the child’s feeding according to the table on page 42 of the chart booklet. These questions
will help you find out about the child's usual feeding and feeding during this illness:
Listen for correct feeding practices as well as those that need to be changed. You may look at the
feeding recommendations for the child's age on the COUNSEL chart as you listen to the mother.
If an answer is unclear, ask another question. For example, if the mother of a very-low-weight
child says that servings are "large enough," you could ask, "When the child has eaten, does he
still want more?"

Short answer exercise for possible group discussion
1. Which sick children need a feeding assessment?
2. Which of the questions in the box titled "Assess the Child's Feeding" are intended to find
out about active feeding?
3. Which of the questions is intended to find out whether a feeding bottle is being used?
Check your own answers to this exercise

by comparing them to the answers given at the end of this module.

2.0 IDENTIFY FEEDING PROBLEMS
It is important to complete the assessment of feeding and identify all the feeding problems before
giving advice.
Based on the mother's answers to the feeding questions, identify any differences between the
child's actual feeding and the recommendations. These differences are problems. Some examples
of feeding problems are listed below.
Insert examples of local feeding problems & corresponding recommendations in blank spaces.
EXAMPLES OF FEEDING PROBLEMS
CHILD'S ACTUAL FEEDING RECOMMENDED FEEDING

A 3 month old is given sugar water as A 3 month old should be given only breastmilk and no other
well as breastmilk. food or fluid.
A 2 year old is fed only 3 times each A 2 year old should receive 2 extra feedings between meals,
day. as well as 3 meals a day.
An 8 month old is still exclusively A breastfed 8 month old should also be given adequate
breastfed. servings of a nutritious complementary food 3 times a day.
A 7 month old is given gruel with A 7 month old should be give soft porridge in addition to
bottle. breastmilk
A 12 month old is given plain A 12 month old should receive adequate servings of nutritious
injera in addition to breastmilk foods in the form of fitfit, porridge, with some oil or butter
added. In addition he should be given fruit and vegetables.
A 9 month old is not breastfed and is A 9 month old who is not breastfed should receive adequate
given one third strength cow’s milk. servings of nutritious foods 5 time per day
In addition to differences from the feeding recommendations, some other problems may become
apparent from the mother's answers. Examples of such problems are:
* Use of feeding bottle

Feeding bottles should not be used.
* Lack of active feeding

Young children often need to be encouraged and assisted to eat.
* Not feeding well during illness

The child may be eating much less, or eating different foods during illness. Children often
lose their appetite during illness. However, they should still be encouraged to eat the types
of food recommended for their age, as often as recommended, even if they do not eat much.
They should be offered their favourite nutritious foods, if possible, to encourage eating.
* Relying on diluted milk or thin gruel (“muk”) for nutrition

Dilution makes food less energy and nutrient dense and therefore might lead to
malnutrition. Remind the mother that thick foods which are dense in energy and nutrients are
necessary for infants and young children to grow.

* Not enough variety in the diet
The mother may mention that she gives one bulky food (such as maize porridge) to the child.
One bulky food alone does not provide adequate nutrient intake. Give other varieties of food
to enrich locally available staple foods.
* Not giving the young child a share of meat, chicken or fish when this is eaten by the
family.
Young children often need to be given portions of the protein and nutrient-rich family foods
(meat, liver, chicken, etc.). Encourage mothers to provide such foods whenever they are
available in the household.
* Not giving kale or other foods with Vitamin A
Mothers should always be encouraged to provide kale or other food items (liver, carrot) which are
rich in Vitamin A.
On the Sick Child Recording Form, next to the feeding questions, there is a box labelled "Feeding
Problems." Use that space to record any feeding problem found. You will counsel the mother
about these feeding problems.
EXAMPLE
Here is part of the Sick Child Recording Form for a 4-month-old child with the classification
NO ANAEMIA AND NO ACUTE MALNUTRITION.
ASSESS CHILD’S FEEDING if child has ANAEMIA OR MAM or is less than 2 Feeding Problems:
years old
• Do you breastfeed your child? Yes  No ____ Not breastfed often
If Yes, how many times in 24 hours? 5 times. enough
Do you breastfeed during the night? Yes  No___
Giving cow’s milk
Does the child take any other food or fluids? Yes  No ___
If Yes, what food or fluids? cow’s milk Using feeding bottle
How much is given at each feed? _____________________
How many times in 24 hours? ______ times.
What do you use to feed the child? Cup___ Bottle  Other_______
• If on replacement milk: What replacement milk are you giving?_____

How many times in 24 hours? _____times
How much is given at each feed?_________
How is the milk prepared?_______________
How are you cleaning the utensils?________
• If very low weight for age: How large are servings? _____________
Does the child receive his own serving? Yes___ No __
Who feeds the child and how? ___________________
• During the illness, has the child’s feeding changed? Yes __ No 
If Yes, how? __________

EXERCISE B
In this exercise, there will be a role play of a feeding assessment.
Role Play Situation
The child's name is Zenebech and she is 7 months old female. Zenebech has no general danger
signs. She has:
NO PNEUMONIA: COUGH OR COLD
NO ANAEMIA AND NO ACUTE MALNUTRITION
No other classifications
The health worker has already told the mother about a soothing remedy for cough.
HEALTH WORKER: Use the questions at the bottom of the Sick Child Recording Form
(reprinted below) to assess feeding. Record the mother's answers and any feeding problems.
Below the form, also record correct feeding practices.
MOTHER: You will be given a card that describes your attitude and situation.
OBSERVERS: Listen carefully and record the mother's answers on the form below. Also record
feeding problems and correct feeding practices.
Record any CORRECT feeding practices below:

ASSESS CHILD’S FEEDING if child has ANAEMIA OR MAM or is less Feeding Problems:
than 2 years old
• Do you breastfeed your child? Yes____ No ____
If Yes, how many times in 24 hours? ___ times.
Do you breastfeed during the night? Yes___ No___
Does the child take any other food or fluids? Yes___ No ___
If Yes, what food or fluids? _______________________________
How much is given at each feed?_____________________
How many times in 24 hours? ___ times.
What do you use to feed the child? Cup___ Bottle___ Other_______

• During the illness, has the child’s feeding changed? Yes __ No ____
If Yes, how? ____________________________________________

3.0 COUNSEL THE MOTHER ABOUT FEEDING
PROBLEMS
Once you have identified feeding problems, you should limit your advice to what is most relevant
to the mother.
3.1 GIVE RELEVANT ADVICE

If the feeding recommendations are being followed and there are no problems, praise the mother
for her good feeding practices. Encourage her to keep feeding the child the same way during
illness and health! If the child is about to enter a new age group with different feeding
recommendations, explain these new recommendations to the mother.
If the feeding recommendations for the child's age are not being followed, explain those
recommendations.
In addition, if you have found any of the problems listed on the chart in the section "Counsel the
Mother about Feeding Problems," give the mother the recommended advice:
► If the child is less than 6 months old and is taking

other milk or foods:
- Build the mother’s confidence that she can produce all

the breastmilk that the child needs.
- Suggest giving more frequent, longer breastfeed, day and
night, and gradually reducing other milk or foods, and re-
establish exclusive breastfeeding.
If other milk needs to be continued, counsel the mother to:
- Breastfeed as much as possible, including at night.

- Make sure that other milk is a locally appropriate
breastmilk substitute.
- Make sure other milk is correctly and hygienically
prepared and given in adequate amount.
- Finish prepared milk within an hour.
- Ask the mother to return for follow up in 5 days.
In some cases, changing to more or exclusive breastfeeding may be impossible (for example, if
the mother never breastfed). In such cases, ensure that the mother knows how to correctly prepare
the recommended breastmilk substitutes.
For example; to prepare cow's milk for infants less than 3 months of age, mix 3 portions of boiled
whole cow's milk with one portion of boiled water and 2 level teaspoons1 of sugar.
1
Each level teaspoon of sugar should equal 5 grams. A cup contains 200 ml. Adjust the recipe if you
have different size cups or teaspoons.

► If the mother is using a bottle to feed the child:
- Recommend substituting a cup for bottle.

- Show the mother how to feed the child with a cup.
A cup is easier to keep clean and does not interfere with breastfeeding. To feed a baby by cup:
- Hold the baby sitting upright or semi-upright on your lap.
- Hold a small cup to the baby's lips. Tip the cup so the liquid just
reaches the baby's lips.
- The baby becomes alert and opens his mouth and eyes.
- A low-birth weight baby takes the milk into his mouth with the
tongue.
- A full-term or older baby sucks the milk, spilling some of it.
- Do not pour the milk into the baby's mouth. Just hold the cup to
his lips and let him take it himself.
- When the baby has had enough, he closes his mouth and will not take more.
► If the child is not being fed actively, counsel the mother to:
- Sit with the child and encourage eating.

- Give the child an adequate serving in a separate plate or bowl.
This child must compete with

This mother is actively siblings and may not get
feeding her child enough to eat

If the child is not feeding well during illness, counsel the mother to:
- Breastfeed more frequently and for longer.
- Use soft, varied, appetizing, favourite foods to encourage the child

to eat as much as possible, and offer frequent small feedings.
- Clear blocked nose if it interferes with feeding.
- Expect that appetite will improve as the child gets better
 If the child is being given diluted milk or thin muk
- Do not dilute the milk.

- Remind the mother that soft foods
which are dense in energy and nutrients are
needed by infants and young children.
Gruel (Muk/Atmit) and porridge are made of the

same ingredients but muk is too thin - it is not
energy and nutrient dense enough to make it a
good complementary food for young children.
It fills the child's stomach without providing
adequate nutrition. This can contribute to
malnutrition. Thin muk should be considered a
fluid rather than a food. Breastmilk plus animal
milk and thin muk are not enough to keep the
child growing and to avoid malnutrition. It is
important to emphasize to mothers that soft
Feeding during illness foods are important for adequate nutrition after
6 months of age.
 If the mother is not giving kale or other foods with Vitamin A

Encourage her to provide Vitamin A rich foods frequently - kale, liver, carrot. Kale is
one of the few sources of Vitamin A although it is only available 1-2 months of the year
(in the rainy season). Kale should be chopped small and then boiled. Carrots can also be
recommended if they are locally available.
 If the mother is not giving the young child a share of meat, chicken or fish
when these are eaten by the family
Explain that the young child needs them and encourage her to provide them whenever
they are available in the household. If the family is eating meat, chicken or fish, they
should be encouraged to give some portion to the child. Some families think that children
must be older or demand meat before giving it to them. Meat, chicken and fish are good
sources of proteins and other essential nutrients.
If an animal is slaughtered, make sure that the young child is fed some of the liver,
because it is particularly nutritious and it contains Vitamins A and D.

 If the child has poor appetite
 Plan small frequent meals
 Give milk rather than other fluids except where there is diarrhoea with some
dehydration
 Give snacks between meals
 Give high energy foods
 Check regularly for oral thrush or ulcers
 If the child has sore mouth or ulcers

 Give soft foods that will not burn the mouth, such as eggs, mashed potatoes…
 Avoid spicy, salty or acid foods
 Chop foods finely
 Give cold drinks or ice, if available before feeding to relieve the pain.

EXERCISE C
In this exercise you will identify feeding problems and relevant advice for written cases.
None of these cases needs referral. The health worker has asked the questions to assess feeding.
Read the information about feeding on the recording form. Then describe the correct feeding
practices, feeding problem(s) and relevant feeding advice.
1. The child is 2 months old and is classified as NO ANAEMIA AND NO ACUTE

MALNUTRTITION. The mother has started giving cow's milk and is thinking of stopping
breastfeeding soon. She thinks that her child may gain more weight on cow's milk than
breastmilk.
Briefly describe the feeding problems in the box on the right of the form.
ASSESS CHILD’S FEEDING if child has ANAEMIA OR Feeding Problems

MODERATE ACUTE MALNUTRION or is less than 2 years old.
• Do you breastfeed your child? Yes  No __
If Yes, how many times in 24 hours? 5 times.
Do you breastfeed during the night? Yes  No___
If Yes, what food or fluids? _____cow’s milk_________________
How many times in 24 hours? _2_ times.
What do you use to feed the child? Cup___ Bottle  Other_______

During the illness, has the child’s feeding changed? Yes __ No 

If Yes, how? __________
What is this mother doing correctly to feed her child?
What feeding advice is needed?
2. The child is 15 months old and has SEVERE MALNUTRITION. The child shares a plate
with 3 brothers and sisters and sometimes does not get much food.
Briefly describe the feeding problems in the box on the right of the form.

ASSESS CHILD’S FEEDING if child has ANAEMIA OR MAM or is less
than 2 years old. Feeding problems:
• Do you breastfeed your child? Yes____ No 
If Yes, how many times in 24 hours? __ times.
If Yes, what food or fluids? _____family food, usually thin soup___
How many times in 24 hours? _3_ times.
What do you use to feed the child? Cup___ Bottle  Other______

• If very low weight for age: How large are servings? Not very much__
Does the child receive his own serving? Yes___ No 
Who feeds the child and how? _child feeds him self, shares with
siblings
• During the illness, has the child’s feeding changed? Yes __ No 
If Yes, how? __________
What is this mother doing correctly to feed her child?
What feeding advice is needed?
3. An 11-month-old male is classified as NO ANAEMIA AND NO ACUTE

MALNUTRITION. He is primarily breastfed but normally also takes other fluids and a thin
cereal gruel twice a day. He does not use a feeding bottle. During the illness, his mother has
stopped giving cereal gruel and given more breastmilk. His mother believes that, before 1
year of age, children do not really need foods in addition to breastmilk. Foods available to the
family are cow's milk, flat bread, rice, cooking oil, vegetables, fruits, and occasionally fish
and eggs.
The Sick Child Recording Form for this child is on next page. Briefly describe his feeding
problem(s) in the appropriate box on the front of the form.
Then fold the edge of the form back and write the relevant advice on the reverse side.
When you have finished this exercise, discuss your answers with a facilitator.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Child’s Name: _____________Mesfin___________ Age__11_ months Sex _M Weight: _9__kg Lt/Ht __70__ cm Temp _37.5__0C
ASK: What are the child’s problems? _______________________Ear problem_______________ Initial visit? _____ Follow-up visit? ____
ASSESS (Circle all signs present, tick or fill dashes/spaces) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS General danger sign
NOT ABLE TO DRINK OR BREASTFEED CONVULSING NOW present?
VOMITS EVERYTHING LETHARGIC OR UNCONSCIOUS
History of CONVULSIONS Yes ____No____
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes _____ No_____
• Count the breaths in 1 minute. ______ breaths/minute. Fast breathing?
For how long? ______ Days • Look for chest indrawing.
• Look and listen for stridor.
DOES THE CHILD HAVE DIARRHOEA? Yes _____ No____
• Look at the child’s general condition. Is the child:
For how long? _________ Days Lethargic or unconscious? Restless and irritable?
• Look for sunken eyes.
Is there blood in the stool?
• Offer the child fluid. Is the child:
Not able to drink or drinking poorly? Drinking eagerly, thirsty?
• Pinch the skin of the abdomen. Does it go back:
Very slowly (> 2 seconds)? Slowly?
DOES THE CHILD HAVE FEVER? ( by history/feels hot/temperature ≥37.50C ) Yes___ No____
- Decide MALARIA risk: High Low No, • Look or feel for stiff neck.
- If “low or no” malaria risk, Has child traveled to • Look for bulging fontanel
malarious area in the last 30 days? • Look for runny nose
- For how long has the child had fever? _3_ Days • Look for signs of MEASLES NOW : Generalized rash, Malaria
- If >7 days, has fever been present every day? And one of these: Cough, Runny nose or Red eyes.
- Has child had measles within the last 3 months? • Blood Film or RDT: Positive___ Negative____ Not Done ____
• Look for mouth ulcers: If Yes, are they deep and extensive?
If the child has measles now or • Look for pus draining from the eye.
within the last 3 months: • Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes___ No ____
- Is there ear pain? • Look for pus draining from the ear. Acute ear infection
- Is there ear discharge ? If Yes, for how long? _1_days • Feel for tender swelling behind the ear.
THEN CHECK FOR ANAEMIA Look for palmar pallor: Severe pallor? Some pallor? No anemia
THEN CHECK FOR MALNUTRITION
- For all children. For children aged ≥ 6 months ( Lt/Ht 65 -110cm)
- Check edema of both feet: +, ++, +++ - If WFH not done, Determine MUAC <11cm, 11-12 cm, ≥12 No acute malnutrition
- Determine WFH: - <70% (< -3Z), - If child has edema, or WFH <70% (<-3Z) or MUAC <11cm;
- 70 to <80% (-3Z to <-2Z), - Look for medical complications,
- ≥ 80% (≥ -2Z) - Look for Dermatosis: +, ++, +++
- For children < 6 months - Assess appetite (as per the criteria ),
Look for visible severe wasting - Passed Failed
THEN CHECK FOR HIV INFECTION

 HIV antibody status of the mother? Positive_____ ,Negative____ ,Unknown _____ HIV status unknown
 HIV Antibody status of the infant? Positive_____, Negative____ , Unknown _____
 HIV DNA/PCR status of the infant? Positive_____ , Negative____ , Unknown _____
 Is child on breast feeding? Yes ____, No ____ If no, was he breastfed in the last 6 weeks? Yes ____, No ____
CHECK THE CHILD’S IMMUNIZATION AND VITAMIN A STATUS Circle immunizations/Vitamin A needed today. Return for next
____ ________________ __________ _______________ __________ ___ ____ Immunization/Vitamin A
BCG DPT1-HepB1-Hib1 PCV1 DPT2-HepB2-Hib2 PCV2 DPT3-HepB3-Hib3 PCV3 dose on:
_____ _____ _______ _______ ___________ ____________ ________
OPV 0 OPV 1 OPV 2 OPV 3 Measles Vitamin A (Date)
ASSESS CHILD’S FEEDING if child has ANAEMIA or underweight or MAM or is < 2 years old.
Note whether the mother is HIV infected, uninfected, or unknown. Compare the mother’s answers to the Feeding Recommendations for the child’s age.
• Do you breastfeed your child? Yes____ No ____
If Yes, how many times in 24 hours? __6_ times. Do you breastfeed during the night? Yes__ No___ Feeding problem
• Does the child take any other food or fluids? Yes___ No ___
If Yes, what food or fluids? ___________water, juice, muk____________________________ How many times in 24 hours? ___ times.
How much is given at each feed?_______________________ What do you use to feed the child? Cup___ Bottle___ Other_______ spoon_________
• If on replacement milk: What replacement milk are you giving?________________________________
How many times in 24 hours? ______ times How much is given at each feed?_______________
How is the milk prepared?_____________________ How are you cleaning the utensils?__________________________
• If very low weight for age: How large are servings? __________________________________________
Does the child receive his own serving? Yes____ No ____ Who feeds the child and how? _________________________
• During the illness, has the child’s feeding changed? Yes ____ No ____ If Yes, how? _________________________________________

TREAT
Remember to refer any child who has a danger sign
and no other severe classification.
Oral antimalarial
F/up: 2 days if fever persists
oral antibiotic 5 days (Cotrimoxazole 5m / 2 x daily)

Dry ear by wicking
Paracetamol for ear pain.
F/ up : 5 days
• Counsel the mother for HIV testing for herself & the child
Advise the mother to give home care
Assess feeding / counsel mother.

F/ up : 5 days for feeding problem
Return for follow - up 5 days (or 2 days if fever persists )
Advice mother when to return immediately.

Give any immunizations or Vitamin A supplementation needed today ____ __________Measles ________________
Feeding advice_________________________________________________

3.2 USE GOOD COMMUNICATION SKILLS
When counselling mothers, it is important to use the following skills:
ASK and LISTEN: You have already learned the importance of asking questions to
assess the child's feeding. Listen carefully to find out what the
mother is already doing for her child. Then you will know what
she is doing well, and what practices need to be changed.
PRAISE: It is likely that the mother is doing something helpful for the child,
for example, breastfeeding. Praise the mother for something
helpful she has done. Be sure that the praise is genuine, and only
praise actions that are indeed helpful to the child.
ADVISE: Limit your advice to what is relevant to the mother at this time.
Use language that the mother will understand. If possible, use
pictures or real objects to help explain. For example, show
amounts of fluid in a cup or container.
Advise against any harmful practices that the mother may have
used. When correcting a harmful practice, be clear, but also be
careful not to make the mother feel guilty or incompetent.
Explain why the practice is harmful.
CHECK
UNDERSTANDING: Ask questions to find out what the mother understands and what
needs further explanation. Avoid asking leading questions (that
is, questions which suggest the right answer) and questions that
can be answered with a simple yes or no.
Examples of good checking questions are: "What foods will you

give your child?" "How often will you give them?" If you get an
unclear response, ask another checking question. Praise the
mother for correct understanding or clarify your advice as
necessary.

1. How could you restate the following advice in simpler words?
Give foods that are high in energy and nutrient content in relation to volume.
2. The mother of an 8-month-old girl says that her child usually takes infant formula by cup
about 5 times a day and plain cereal 3 times per day. The mother stopped breastfeeding about
1 month ago when she had to return to work, which requires that she be away from the child
for 10 hours each working day. The child has taken the same amount of food during the
illness. Which of the following comments are appropriate when counselling this mother?
(Tick appropriate comments)
_____ a. You should still be breastfeeding this child.
_____ b. It is good that your child is still eating as usual during the illness.
_____ c. It is good that you are using a cup instead of a feeding bottle.
_____ d. Your child needs food more often. Try to increase the number of times you give
the cereal gruel to 5 times a day.
_____ e. The cereal is good for your child. Add a little oil and some mashed vegetables or
peas, or bits of meat to the cereal gruel. Then it will be even better for your child.

3. You are talking with the mother of a 15-month-old child who is no longer breastfed. The
child has PERSISTENT DIARRHOEA. He normally takes 2 feedings of cow's milk and 1
meal of family foods each day. His diet has not changed during the diarrhoea. Which of the
following are appropriate to say when counselling this mother? (Tick appropriate
comments.)
_____ a. You were right to keep feeding your child during the diarrhoea.
He needs food to stay strong.
_____ b. Your child needs more food each day. Try to give him 3 family meals plus
2 feedings between meals.
_____ c. Cow's milk is very bad for your child.
_____ d. Your child may be having trouble digesting the cow's milk, and that may be
the reason that the diarrhoea has lasted so long.
_____ e. Give your child yoghurt instead of milk (until follow-up visit in 5 days). Or give
only half the usual milk & increase the amount of family foods to make up for
this.
4. A health worker has just counselled the mother of a 6-month-old about starting
complementary foods. The first and second columns below show the health worker's first
checking questions and the mother's responses. In the third column, write another
checking question to clarify that the mother knows how to feed the child correctly.
First Checking Question Mother's Response Second Checking

Question
What are some good foods Thick, nutritious foods
to give to your baby?
When will you begin giving Now

these foods?
Check your own answers to this exercise

by comparing them to the answers given at the end of the module.

3.3 Use a Family Health Card
A Family Health Card can be given to each mother to help her remember appropriate food and
fluids, and when to return to the health worker. The Family Health Card has words and pictures
that illustrate the main points of advice.
An example of a page from Family Health Card is given in the Annex on pages 45 and 46 of this
module.
Take a moment to study the Family Health Card given in this course. The card shows advice
about foods, fluid, and signs to return immediately to the health worker. There is also a place to
tick appropriate fluids for diarrhoea and record when to return for the next immunization.
There are many reasons a Family Health Card can be helpful:
- It will remind you or your staff of important points to cover when counselling mothers about
foods, fluid, and when to return.
- It will remind the mother what to do when she gets home.
- The mother may show the card to other family members or neighbours, so more people will
learn the messages it contains.
- The mother will appreciate being given something during the visit.
- It can be used as a record of treatments and immunizations given.
When reviewing a Family Health Card with a

mother:
1. Hold the card so the mother can easily see the

pictures, or allow her to hold it herself.
2. Explain each picture. Point to the pictures as

you talk. This will help the mother remember
what the pictures represent.
3. Circle or record information that is relevant to

the mother. For example, circle the feeding
advice for the child's age. Circle the signs to return immediately. If the child has diarrhoea,
tick the appropriate fluid(s) to give. Record the date of the next immunization needed.
4. Watch to see if the mother seems worried or puzzled. If so, encourage questions.
5. Ask the mother to tell you in her own words what she should do at home. Encourage her to
use the card to help her remember.
6. Give her the card to take home. Suggest that she shows it to others in her family.
If you cannot obtain a large enough supply of cards to give to every mother, keep several in the
health facility to show to mothers.

EXAMPLE
In this example, your facilitator will counsel a mother about feeding. He will demonstrate
communication skills and use of a Mother's Card. The child in this example is named Yukuno. He
is 8 months old male, has no general danger sign, and has:
NO PNEUMONIA: COUGH OR COLD

MALARIA
NO ANAEMIA AND NO ACUTE MALNUTRITION
Tell the facilitator when you are ready for the demonstration to begin. During the demonstration,
record information on the form below. Record any feeding problems that the "health worker"
uncovers. Below the form, record feeding advice given.
Notice use of the following communication skills as your facilitator points them out:
ASK and LISTEN

PRAISE, when appropriate
ADVISE, using simple language and giving only relevant advice
CHECK UNDERSTANDING
ASSESS CHILD’S FEEDING if child has ANAEMIA OR MAM or is less than 2 years
old. Note whether the mother is HIV infected, uninfected, or does not know her status.
Compare the mother’s answers to the Feeding Recommendations for the child’s age.

If Yes, how many times in 24 hours? ___ times. Do you breastfeed during the night?
Yes___ No___
• Does the child take any other food or fluids? Yes___ No ___
If Yes, what food or fluids? _________________________________________
How much is given at each feed?_______________________________
What do you use to feed the child? Cup___ Bottle___ Other_______________
If on replacement milk: What replacement milk are you giving?_____________
How many times in 24 hours? ______ times
How much is given at each feed?______________________________
How is the milk prepared?____________________________________
How are you cleaning the utensils?_____________________________
•If very low weight for age: How large are servings? __________________________
Does the child receive his own serving? Yes____ No ____
Who feeds the child and how? ________________________________
• During the illness, has the child’s feeding changed? Yes ____ No ____
If Yes, how? _____________________________________________________
Feeding Advice Given:

EXERCISE D
In this exercise, there will be a role play of feeding assessment and counselling.
HEALTH WORKER: Ask the questions on the recording form to assess feeding. Identify and
record feeding problems. Record the feeding advice to be given. Then counsel the mother about
feeding, using good communication skills. Use the FOOD section of the Mother's Card. Feel
free to refer to the COUNSEL chart as necessary.
MOTHER: Try to behave as a real mother might behave. For example, you may be confused,
timid, worried, or anxious to leave the clinic. You will be given a card with details about your
child's feeding and age and suggestions about your attitude.
OBSERVERS: Watch the role play and record information on the form given. Be prepared to
answer the questions in the module.
Role Play
Rezene is a 7-month-old boy with a cough and runny nose. He has no general danger signs and
has been classified as NO PNEUMONIA: COUGH OR COLD and NO ANAEMIA AND NO
ACUTE MALNUTRITION. He has no other classifications. The mother has been taught to
soothe the throat and relieve the cough. In the role play the health worker will assess feeding and
counsel the mother about feeding.
ASSESS CHILD’S FEEDING if child has ANAEMIA OR MODERATE ACUTE

MALNUTRITION or is less than 2 years old. Note whether the mother is HIV infected,
uninfected, or does not know her status. Compare the mother’s answers to the Feeding
Recommendations for the child’s age.

If Yes, how many times in 24 hours? ___ times.
If Yes, what food or fluids? _____________________________________________
How much is given at each feed?___________________________________
What do you use to feed the child? Cup___ Bottle___ Other___________________
• If on replacement milk: What replacement milk are you giving?____________________
How many times in 24 hours? ______ times
How much is given at each feed?___________________________________
How is the milk prepared?_________________________________________
How are you cleaning the utensils?__________________________________
• If very low weight for age: How large are servings? _____________________________
Does the child receive his own serving? Yes____ No ____
Who feeds the child and how? _____________________________________
• During the illness, has the child’s feeding changed? Yes ____ No ____
If Yes, how? ___________________________________________________________

After the role play you will discuss the following questions:
a. Did the health worker ask all of the necessary questions to assess Rezene's feeding? Did
the health worker finish the feeding assessment before identifying the feeding problems
and giving advice?
b. What feeding problems did the health worker find?
c. Did the health worker give appropriate praise for something the mother had done?
d. Did the health worker give advice relevant to this child's situation?
Was any advice given that was not relevant? If so, what?
e. Was the advice correct and complete for the child's age and any problems identified?
f. Did the health worker use clear, simple language?
g. What checking questions were asked? Were they good checking questions? If they were
answered incompletely or incorrectly, did the health worker clarify the advice?

4.0 ADVISE THE MOTHER TO INCREASE FLUID DURING
ILLNESS
A sick child requires extra fluids. Advice about fluid is summarized in the box below. Give this
advice to every mother who is taking her child home UNLESS she has already received many
instructions and may be overwhelmed by more advice or has already been taught Plan A.
FLUID
 Advise the Mother to Increase Fluid During Illness
FOR ANY SICK CHILD:
 Breastfeed more frequently and for longer each feed.
 Increase fluid. For example give soup, rice water, yoghurt drinks or clean water
FOR CHILD WITH DIARRHOEA:
 Give extra fluid can be life saving. Give fluid according to Plan A or Plan B on
TREAT THE CHILD chart.
5.0 ADVISE THE MOTHER WHEN TO RETURN TO A

HEALTH WORKER
EVERY mother who is taking her child home needs to be advised when to return to the health
worker. She may need to return:
- for a FOLLOW-UP VISIT in a specific number of days (for example, when it is necessary to
check progress child on an antibiotic)
- IMMEDIATELY, if signs appear that suggest the illness is worsening, or
- for the child's next immunization (the next WELL-CHILD VISIT).
FOLLOW-UP VISITS
In the module Identify Treatment and Treat the Child, you learned that certain problems require
follow-up in a specific number of days. For example, pneumonia, dysentery, and acute ear
infection require follow-up to ensure that an antibiotic is working. Persistent diarrhoea requires
follow-up to ensure that feeding changes are working. Some other problems, such as fever or pus
draining from the eye, require follow-up only if the problem persists.
At the end of the sick child visit, tell the mother when to return for follow-up. Sometimes a child
may need follow-up for more than one problem. In such cases, tell the mother the earliest
definite time to return. Also tell her about any earlier follow-up that may be needed if a problem
such as fever persists.
The COUNSEL chart has a summary of follow-up times for different problems, as summarized
in the next box.

Return for
If the child has follow-up in:
 PNEUMONIA
 DYSENTERY 2 days
 MALARIA, if fever persists
 FEVER MALARIA UNLIKELY, if fever persists
 FEVER NO MALARIA (NO MALARIA RISK), if fever persists
 MEASLES WITH EYE OR MOUTH COMPLICATIONS
 PERSISITENT DIARRHOEA
 ACUTE EAR INFECTION 5 days
 CHRONIC EAR INFECTION
 FEEDING PROBLEM
 ANY OTHER ILLNESS, if not improving
 UNCOMPLICATED SEVERE ACUTE MALNUTRITION 7 days
 ANAEMIA 14 days
 MODERATE ACUTE MALNUTRITION
30 days
Notice that there are several different follow-up times related to nutrition: e.g. feeding problem,
pallor, SEVERE ACUTE MALNUTRITION. A system should be established to facilitate
management of Follow-up patients according to their illness. Avoid leaving them in the general
queue.
WHEN TO RETURN IMMEDIATELY
Remember that this is an extremely important section of WHEN TO RETURN.

Advise the mother to return immediately if the child has any of these signs:
Any sick child • Not able to drink or breastfeed
• Becomes sicker
• Develops fever
• Convulsions
• Vomits everything
If child has NO PNEUMONIA: COUGH OR • Fast breathing
COLD, also return if: • Difficult breathing
If child has Diarrhoea, also return if: • Blood in stool
• Drinking poorly
Use the Mother's Card when teaching the signs to return immediately. Use local terms that the
mother can understand. The Mother's Card presents the signs in both words and drawings. Circle
the signs that the mother must remember. Be sure to check the mother's understanding.
NEXT WELL-CHILD VISIT
Remind the mother of the next visit her child needs for immunization, Vitamin A and deworming
unless the mother already has a lot to remember and will return soon anyway. For example, if a
mother must remember a schedule for giving antibiotic, home care instructions for another
problem, and a follow-up visit in 2 days; do not describe a well-child visit needed one month
from now. However, do record the date of the next immunization on the Mother's Card.
Monitor the weight of the child regularly using the growth chart on the immunization/family card
and give appropriate feedback and advice to the mother.

1. A 3-year-old female is being treated with an antibiotic for PNEUMONIA. The child has no
other problems that require follow-up. She has no fever.
When should you ask the mother to return for follow-up?
What are the signs that this child should return immediately?
2. A 6-month-old child is being treated for DYSENTERY and an ACUTE EAR INFECTION.
He has a fever.
After the first follow-up visit, what additional follow-up will be needed?
3. A 5-month-old female child has diarrhoea with NO DEHYDRATION and ANAEMIA OR

SEVERE ACUTE MALNUTRITION. She has no fever. She has some palmar pallor as well
as very low weight. The child's main food is a breastmilk substitute which is made with too
much water and given in a feeding bottle. You have counselled the mother on how to prepare
breastmilk substitute correctly and give it with a cup. You have also counselled the mother
about complementary feeding.
After the first follow-up visit, what additional follow-up will be needed?

EXERCISE E
In this exercise, there will be a role play of the entire process covered by the COUNSEL chart:
assessing feeding, identifying feeding problems, counselling about feeding, advising about fluid,
and advising about when to return.
HEALTH WORKER: Assess feeding, identify feeding problems, and counsel the mother on
feeding, fluid, and when to return. Use good communication skills. Use the Sick Child
Recording Form given in this exercise. Also use the Mother's Card.
MOTHER: Try to behave as a real mother might behave. For example, you may be worried,
timid, confused, or anxious to leave the clinic. You will be given a card with details about your
child's illness, age, and diet, and other information.
OBSERVERS: Listen and watch carefully. On the recording form given in this exercise, write
the answers to the feeding questions and any feeding problems. Notice whether the feeding
questions are used, advice is correct and complete, and good communication skills are used. Be
prepared to discuss the questions given on the next page.
Role Play:
Sosina is 2 years and 2 months old female. Her Sick Child Recording Form follows. She has
MODERATE ACUTE MALNUTRITION (but no palmar pallor) and an ACUTE EAR
INFECTION.
The health worker has already given the mother instructions on wicking the ear and giving an
antibiotic for the ear infection. Now the health worker will assess feeding and counsel the mother
about FOOD, FLUID, and WHEN TO RETURN.

Questions for Discussion after Role Play:
1. Were all the necessary questions asked about the child's feeding? Did the health worker
finish the feeding assessment before identifying the feeding problems and giving advice?
2. What feeding problems were identified, if any?
3. Was the mother praised for something she has been doing correctly?
4. Was counselling about FOOD complete and correct for the child's age and feeding problems?
5. Was advice on FLUID complete and correct?
6. Was advice on WHEN TO RETURN complete and correct? Did it include signs to return
immediately?
7. Did the health worker ask appropriate checking questions?
8. If no to any of the above, what could have been done better? Be prepared to make
suggestions.

MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Child’s Name:_Sosina___________________ Age__26__ months Sex _F_ Weight: 9.5___kg Lt/Ht __86____ cm Temp __37_0C
ASK: What are the child’s problems? _______________________ear problem_________________ Initial visit? __ ___ Follow-up visit? ____
ASSESS (Circle all signs present, tick or fill dashes/spaces) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS General danger sign present?
NOT ABLE TO DRINK OR BREASTFEED CONVULSING NOW
VOMITS EVERYTHING LETHARGIC OR UNCONSCIOUS Yes ____No__ __
History of CONVULSIONS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes _____ No__ ___
• Count the breaths in 1 minute. ______ breaths/minute. Fast breathing?
For how long? ______ Days • Look for chest indrawing.
• Look and listen for stridor.
DOES THE CHILD HAVE DIARRHOEA? Yes _____ No__ __
• Look at the child’s general condition. Is the child:
For how long? _________ Days Lethargic or unconscious? Restless and irritable?
• Look for sunken eyes.
Is there blood in the stool?
• Offer the child fluid. Is the child:
Not able to drink or drinking poorly? Drinking eagerly, thirsty?
• Pinch the skin of the abdomen. Does it go back:
Very slowly (> 2 seconds)? Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature ≥37.50C) Yes___ No_ ___
- Decide MALARIA risk: High Low No, • Look or feel for stiff neck.
- If “low or no” malaria risk, Has child traveled to
• Look for bulging fontanel
malarious area in the last 30 days?
- For how long has the child had fever? _____ Days • Look for runny nose
- If >7 days, has fever been present every day? • Look for signs of MEASLES NOW : Generalized rash,
- Has child had measles within the last 3 months? And one of these: Cough, Runny nose or Red eyes.
• Blood Film or RDT: Positive____ Negative____ Not Done ____
If the child has measles now or • Look for mouth ulcers: If Yes, are they deep and extensive?
within the last 3 months: • Look for pus draining from the eye.
• Look for clouding of the cornea.
DOES THE CHILD HAVE AN EAR PROBLEM? Yes__ _ No ____
- Is there ear pain ? • Look for pus draining from the ear. Acute ear infection
- Is there ear discharge? If Yes, for how long? ____days • Feel for tender swelling behind the ear.
THEN CHECK FOR ANAEMIA Look for palmar pallor: Severe pallor? Some pallor?
THEN CHECK FOR MALNUTRITION
- For all children. For children aged ≥ 6 months ( Lt/Ht 65 -110cm)
- Check edema of both feet: +, ++, +++ - If WFH not done, Determine MUAC <11cm, 11-12 cm, ≥12 Moderate Acute
- Determine WFH: - <70% (< -3Z), - If child has edema, or WFH <70% (<-3Z) or MUAC <11cm;
malnutrition
- 70 to <80% (-3Z to <-2Z), - Look for medical complications,
- ≥ 80% (≥ -2Z) - Look for Dermatosis: +, ++, +++
- For children < 6 months - Assess appetite (as per the criteria ),
Look for visible severe wasting - Passed Failed
THEN CHECK FOR HIV INFECTION
 HIV antibody status of the mother? Positive_____ ,Negative____ ,Unknown _____ HIV uninfected
 HIV Antibody status of the infant? Positive_____, Negative____ , Unknown _____
 HIV DNA/PCR status of the infant? Positive_____ , Negative____ , Unknown _____
 Is child on breast feeding? Yes ____, No ___ If no, was he breastfed in the last 6 weeks? Yes ___, No ___
CHECK THE CHILD’S IMMUNIZATION AND VITAMIN A STATUS Circle immunizations/Vitamin A needed today. Return for next
____ ________________ __________ ________________ __________ ________________ ____ Immunization/Vitamin A dose
BCG DPT1-HepB1-Hib1 PCV1 DPT2-HepB2-Hib2 PCV2 DPT3-HepB3-Hib3 PCV3 on:
_____ _____ _______ _______ ___________ ____________ ______________________
OPV 0 OPV 1 OPV 2 OPV 3 Measles Vitamin A (Date)
ASSESS CHILD’S FEEDING if child is < 2 years old or, has ANAEMIA or, has MAM or, is UNDER WEIGHT.
Note whether the mother is HIV infected, uninfected, or unknown. Compare the mother’s answers to the Feeding Recommendations for the child’s age.
• Do you breastfeed your child? Yes____ No ____ Feeding problem
If Yes, how many times in 24 hours? ___ times. Do you breastfeed during the night? Yes___ No___
If Yes, what food or fluids? ________________________________________________ How many times in 24 hours? ___ times.
How much is given at each feed?_______________________ What do you use to feed the child? Cup___ Bottle___ Other________________
• If on replacement milk: What replacement milk are you giving?________________________________
How many times in 24 hours? ______ times How much is given at each feed?_______________
How is the milk prepared?_____________________ How are you cleaning the utensils?__________________________
• If very low weight for age: How large are servings? __________________________________________
Does the child receive his own serving? Yes____ No ____ Who feeds the child and how? _________________________
• During the illness, has the child’s feeding changed? Yes ____ No ____ If Yes, how? _________________________________________

6.0 COUNSEL THE MOTHER ABOUT HIV TESTING
The mother of a child classified as HIV EXPOSED OR HIV UNLIKELY need to be counseled
about an HIV test for the mother or the child.
This is sometimes a sensitive subject. Many mothers, and even health workers, are reluctant to
discuss HIV. However HIV is present in the community and the problem will not be solved as
long as there is secrecy. All health workers must be able to discuss HIV, ask questions, and give
appropriate advice.
When you have identified a young infant or child who is in need of HIV testing you should
provide the mother with information: Tell the mother that the condition of the child makes you
think that HIV may be the cause of the illness. Explain that if the child has often been ill, this can
be a sign of HIV infection.
Help the mother to understand that the reason for HIV testing is so that the child can receive
treatment which will improve his quality of life. He should have antibiotics to prevent infections,
vitamin supplementation, regular growth monitoring, prompt treatment of any illnesses and
antiretroviral therapy if it is needed. Interventions can also prevent other members of the family
from becoming infected.
When you have explained, allow the mother to ask questions. When she has agreed to the test,
arrange for proper VCT in the normal way at your clinic.
7.0 COUNSEL THE MOTHER OF A CHILD WITH HIV

INFECTION OR HIV EXPOSED
 Reassure her that with the help of the clinic staff much can be done to improve and
maintain the child’s health.
 Advise about future pregnancies, safe sex and early treatment of sexually transmitted
diseases.
 Encourage mother to seek voluntary counseling and testing.
 Ensure good nutrition; counsel the mother on feeding practices. Avoid giving both
breastmilk and other foods (mixed feeding) in the first 6 months of life.
 Explain the importance of early treatment of infections.
 Emphasize personal hygiene and the importance of hand washing.
 With the mothers consent refer her to the community health worker and/or a local support
group.

8.0 COUNSEL THE MOTHER ABOUT HER OWN HEALTH
During a sick child visit, listen for any problems that the mother herself may be having. The
mother may need treatment or referral for her own health problems.
 If the mother is sick, provide care for her, or refer her for help
 If she has a breast problem (such as engorgement, sore nipples, breast infection), advise her
not to feed her baby from the affected breast, until it heals express and discard the milk from
the affected breast. Provide clinical care for the mother or refer her for help.
 Advise her to eat well to keep up her own strength and health.
 If she is breastfeeding, advise her to eat 2 more varied extra meals a day to maintain her
health and health of the baby.
 Advise her to take Vitamin A supplementation within 45 days of delivery for the baby’s
health and strength
 Advise a mother from malarious area for her and under five children to sleep under ITN to
prevent malaria (page 42)
 If pregnant, advise the mother to get one additional meal.
 Make sure that the pregnant and lactating mother gets Iron/folate tablets
 Advise the mother to ensure that all family food is cooked using Iodized salt so that family
members remain healthy
 Check the mother’s immunization status and give her tetanus toxoid if needed.
 Make sure she has access to:

- Family planning
- Counseling on STD and AIDS prevention
- Antenatal care if she is pregnant
 Encourage her to seek voluntary HIV counseling and testing
 Reassure her that with regular follow-up, much can be done to prevent serious illness, and
maintain her and the child’s health.
 Emphasize good hygiene, and early treatment of illnesses

Advice Mothers in Malarious Areas on the Use of Insecticide Treated Nets
 All children under five years of

age and pregnant women should
sleep under ITN,
 ITN should always be hanging

over the sleeping place,
 During day time, the ITN

should be rolled up and tied,
 When sleeping, untie the ITN and the bottom end of

the ITNs should be completely tucked under the
mattress or sleeping pad,
 Any hole on the ITN caused by fire, rodent or cuts

should be repaired. Care should be taken to prevent
ITN from fire, rodents and sharp objects that can
shred the fabric,
 Nets that are not Long Lasting Insecticide Treated

(LLIN) should be treated during the re-treatment
campaigns,
 ITNs/LLINs should not be frequently washed. When

washing excessive use of detergent and rinsing
should be avoided to prevent weakening of the
insecticide on the netting material,
 Inform mother not to paint or mud wash the interior

of insecticide sprayed houses for up to 6 months.

EXERCISE F
Your course facilitator will lead a group discussion of common local feeding problems observed
during the previous clinical session.
You will discuss the following questions:
- Have the major local feeding problems been described in this module? If not, what are
additional or different problems that you have observed?
- Is the recommended advice for local feeding problems practical? Are mothers likely to
follow the advice? If not, can you think of alternative suggestions that would improve
feeding, be practical, and be followed by mothers?

ANNEX:
Family Health Card
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ለመከላከል ሊጎለብቱ የሚገቡ ቁልፍ ተግባራት

ANSWERS TO SHORT ANSWER EXERCISES:
COUNSEL THE MOTHER

Answers to Short Answer Exercise, Page 14
1. These children need a feeding assessment:
Children who have ANAEMIA OR MODERATE ACUTE MALNUTRITION

Children who are less than 2 years old
2. Does the child receive his own serving?

Who feeds the child and how?
3. What do you use to feed the child?
Answers to Short Answer Exercise, Page 27
1. Possible answer:
Give foods that will make your child strong and healthy, not just fill him up. Instead of
giving just plain rice or gruel, mix it with some oil for energy and some foods like mashed
vegetables, meat, eggs, or fish.
(You may have included examples of good complementary foods in your local area.)
2. a. No tick. This comment would make the mother feel guilty. You might find out if she
would be interested in resuming breastfeeding at night, and if so, refer her to a breastfeeding
counsellor.
b. √
c. √
d. No tick. The feeding recommendations say that a non-breastfed 8-month-old child should
be given complementary foods 5 times per day. This child is being given 5 formula feedings
plus 3 cereal feedings per day, which is a total of 8 feedings and is plenty for her age.
e. √
3. a. √
b. √
c. No tick. This comment may make the mother feel guilty. It is better to state this as in "d"
below.
d. √
e. √
4. 1st row: What kinds of thick, nutritious foods will you give? What are some examples of
foods you will give?
2nd row: How will you know when your baby is ready for these foods? What signs will you
look for?

Answers to Short Answer Questions, Page 35
1. Follow-up: 2 days
Return immediately if:

- Not able to drink (since child is 3 years old, there is no need to say "or breastfeed")
- Becomes sicker
- Develops a fever
2. Follow-up: 2 days for dysentery

- Not able to drink or breastfeed
- Becomes sicker
- Drinking poorly
Since the child already has a fever and blood in the stool, these signs are not listed. You may
have combined the signs, "not able to drink or breastfeed" and "drinking poorly."
Additional follow-up: 5 days for ear infection
3. F/up: 5 days for feeding problem

- Not able to drink or breastfeed
- Becomes sicker
- Develops a fever
- Blood in stool
- Drinking poorly
You may have combined the signs, "not able to drink or breastfeed" and "drinking poorly."
Additional follow-up: 14 days for pallor, 28 days for very low weight.

Contact Address
Federal Ministry of Health
Health Promotion and Disease Prevention General Directorate
E-mail: moh@ethionet.et
Tel: +251-11-515 99 78; +251-11-515 0407
Fax: 552 45 49
P.O.Box: 1234

Module 5 Counsel Nov 2011

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Integrated Management of

Newborn and Childhood Illness

Counsel the Mother

COUNSEL THE MOTHER

Learning Objectives ............................................................................................................. 1

Feeding Recommendations ................................................................................................ 2

1.0 Assess the child's feeding ..................................................................................... 13

2.0 Identify feeding problems..................................................................................... 15

3.0 Counsel the mother about feeding problems ........................................................ 18

3.1 Give relevant advice ................................................................................ 18

3.2 Use good communication skills ............................................................... 26

3.3 Use a mother's card .................................................................................. 29

4.0 Advise the mother to increase fluid during illness ............................................... 33

5.0 Advise the mother when to return to a health worker .......................................... 33

6.0 Counsel the mother about HIV testing ................................................................. 40

8.0 Counsel the mother about her own health ............................................................ 41

Annex: Family Health Card .............................................................................................. 44

Answers to short answer exercises.................................................................................... 45

Counsel the Mother i

* assessing the child's feeding practice

* identifying feeding problems

* counselling the mother about feeding problems

* advising the mother to increase food and fluid during illness

* advising the mother:

In practising these tasks, you will focus on:

* giving relevant advice to each mother

Counsel the Mother 1

RECOMMENDATIONS FOR AGES UP TO 6 MONTHS

Some of the advantages of breastmilk

Counsel the Mother 2

RECOMMENDATIONS FOR AGES 6 MONTHS UP TO 12 MONTHS

It is important to actively feed the child. Active

Counsel the Mother 3

 Breastfeeding is not enough for a child over 6 months of age.

 A variety of thick, nutritious foods are needed to prevent malnutrition.

Counsel the Mother 4

Counsel the Mother 5

2 Years and Older

SPECIAL RECOMMENDATIONS FOR CHILDREN WITH

Feeding recommendations for a child who has PERSISTENT DIARRHOEA

Continue other foods appropriate for the child's age.

Counsel the Mother 6

Amounts of RUTF to give:

Counsel the Mother 7

• Counseling and support on “safer breastfeeding practices” is an effective way to encourage

• Advise about risks of relactation [restarting breastfeeding after weaning] which is

• Lactating mother should be provided with nutritional support for herself.

Alternative Infant Feeding Option:

• For replacement feeding commercial infant formula should be used. Home-modified

• As mentioned above there should not be mixed feeding.

• Mother should be taught how to prepare replacement feeds hygienically.

Counsel the Mother 8

Promote good hygiene, proper food safety and handling.

Counsel the Mother 9

Up to 6 Months of Age 6 Months Up to 12 Months 12 Months Up to 2 Years 2 Years and Older

 Consider replacement feeding and discontinuation of • Discontinue breast feeding

Counsel the Mother 10

Counsel the Mother 11

___ a. Children should be given fewer feedings during illness.

2. When should complementary foods be added to the child's diet?

3. List 5 locally available, nutritious complementary foods:

4. Samuel is 15 months old. He has PERSISTENT DIARRHOEA and NO

When should Samuel return for a follow-up visit?