|Guidelines for Training Community Health Workers in Nutrition (WHO, 1986, 128 p.)|
After studying this chapter, taking part in the discussions and doing the exercises, a community health worker should be able to:
· Find out how mothers feed their young children and what are their beliefs about various foods.
· Find out what foods available in the area are suitable for feeding to children.
· Find out how the availability and prices of foods vary with different seasons.
· Prepare and mix local foods so they can be suitable for giving to young children.
· Prepare an appropriate diet for young children, and know when, how often, and how much they should eat.
· Give feeding advice convincingly to parents.
Finding out how mothers feed young children and what are their beliefs about various foods
In most tropical and developing countries mothers breast-feed their babies. Breast milk is an excellent food and this feeding should be encouraged. However, after 4-5 months, breast milk alone is not enough to make an infant grow well. Other foods are also needed. To help mothers feed their babies, it is important to know first what foods mothers in the area give their young children, and what are their beliefs about these foods. Most feeding practices are part of the customs and traditions in any community. They are passed down from one generation to the next. Religious beliefs influence feeding practices. Feeding practices may also vary among different social groups, castes, etc.
When finding out about children's diets one should be sensitive about the mothers' feelings. Read again the comments at the beginning of Module 3. A friendly and sympathetic manner is important when asking questions or observing. Information should be collected systematically. Questionnaires may be useful.
Information about feeding of young children
A community health worker needs to know the answers to the following questions:
· At what age is the first food other than breast milk given to children?
· What are these foods?
· How are the foods for young children prepared?
· Are there ceremonial, religious, or other reasons for giving these foods to children?
· How many times per day and in what amounts are children given food at different ages?
· What foods are generally forbidden for children, and why?
· Is there a communal dish from which young children must compete for food? How much food does a young child actually get? (Observe the family group at meals.)
Local foods suitable for young children
Find out which foods are grown in the area and which others are available in shops and markets. What are the prices of these foods? Many foods are seasonal. At certain times of the year it may not be possible to grow or buy certain things. The prices will go up and down because of variations in climate, availability, and demand. It will be useful to make lists of the foods available and of their prices at different seasons, e.g., lists of foods that are the cheapest source of energy, animal protein, iron, or vitamin A, and so on, in a particular region, village, or community.
Some foods are better than others for the growth and health of young children. As they grow older, children need mixtures of foods. The most important groups of food in most communities are listed below.
Important groups of foods in most communities
· Cereal grains: wheat, rice, maize, millet, etc.
· Legumes or pulses: peas, beans, and lentils.
· Leafy green or coloured vegetables or fruits: spinach, carrots, tomatoes, pumpkin, papaya, mangoes.
· Foods from animals: meat, eggs, fish, and milk.
· Oils and sugar: vegetable oils, animal fats, sugar, molasses.
Cereals are the largest part of the diet in most areas. In some places where cereals are not easily available, people eat cassava, potatoes, or plantain. These foods are not as good as cereals for growing children. Cereals and legumes cooked properly make an excellent food combination for infants.
All young children should gradually be given food from the first three groups listed above. If it is culturally acceptable, and if parents can afford it, small amounts of the animal foods can also be given, though these are not essential. Some oil added to food or cooked with it is especially useful because it gives much energy and also makes food soft and tasty. Remember to have as many varieties of food in the diet as possible. This increases the nutritional value of the diet.
Preparing and mixing local foods for children
Before preparing food, before eating it and before feeding children, the hands should be washed with soap and water. Germs that cannot be seen on dirty hands can be passed on to the food. These germs will be eaten with the food and may cause diarrhoea and other illnesses. Cooking kills most germs. After cooking, handle food as little as possible and keep it in a covered container.
Food for infants up to 6 months of age
A baby has no teeth and since he is only used to breast milk, the first foods given to him should be soft and should not have a strong spicy flavour (e.g., curry). If a certain cereal is the staple diet of the community, it should be used to make the first food for an infant. Corn and rice starch powders, sold in markets in many countries, should not be used for this purpose. The cereal should be well cooked and mashed so that it is soft. Cereal or cereal flour can be made into porridge or made very soft by adding water. In the beginning this porridge may be very thin, but as the child grows older, the porridge should be made thicker. If much water is added, the porridge will not provide much energy to the child. A thick porridge is more nourishing than a thin watery gruel.
If the cereal is cooked in oil, or if oil is added, it will increase the amount of energy the food can provide. Sugar, either white or brown, will also increase the energy in the food, but it is not as good as oil. Sweet foods are bad for the teeth.
Food for children 6 months to 1 year old
In the second half of the first year of life a child can take a more varied diet. Once a child is eating the cereal porridge well, cooked leguminous and other vegetables can be mixed with cereal or given separately. New items should be added to the diet one at a time. Only small amounts should be given at first. Gradually increase the quantity but do not force the child to eat more than he accepts. The vegetables should be very soft, without fibre, and mashed.
If a family eats animal foods and can afford to buy them, these
can also be given. Meat or fish should be minced or finely chopped. A lightly
boiled egg can be mixed with the porridge or given by itself. Milk from animals
should be boiled before it is given to children. Curd is an acceptable food for
children in many cultures. None of these animal foods is essential for growth
and health so long as adequate amounts and mixtures of vegetable foods are
given. After introducing a new food,
it is good to wait for a few days before introducing another food.
Food after the first year
After the first year, a child is usually able to eat the food prepared for the family. In other words, he starts sharing the family diet. It is good to separate a little food on to a separate plate for a young child; care should be taken to include at least three kinds of food. In that way it is possible to see how much the child is given and how much he eats. During cooking, it may be necessary to remove a portion for a young child before adding strong spices.
The stools of a child will change when he starts eating a mixed diet. The mother should be warned about this. A healthy breast-fed child has soft yellow stools. When a child eats other foods the colour, smell, and shape of stools will change. Stools will become more like adult stools. Some mothers who breast-feed may say that their babies have diarrhoea, when actually the stools are normal-soft in consistency. It is better to demonstrate to them the difference between a breast-fed baby's soft stools and the adult type of stools of babies fed on other foods (including formula milk).
Feeding young children: how, when, and how often
To feed a young baby a mother should have patience and simple knowledge about the foods that are available and can help her baby grow to be healthy and well. Most mothers have the love and patience, but they may need to learn how to use available foods for their babies.
At what age should food (other than breast milk) first be given to an infant?
Start solid food at about 4 or 5 months of age. Until then breast milk of most mothers supplies all the nourishment a young child needs.
When the baby is 4-6 months old, breast milk alone is not sufficient-start solid foods.
How many times a day should a young child be fed?
At first, when the baby is still being breastfed, give cereal porridge, 1-2 small spoonfuls twice a day. The amount of food and the number of feeds per day should be increased gradually. By 6-9 months of age a child should be fed 3-4 times a day in addition to breast-feeds.
How should the meals be timed in relation to the breast-feeds?
At first, when a child is learning to take new foods, give the food when the child is hungry before breast-feeds. When the child is taking the porridge or mixtures well, give the breast-feed first, or between other meals. In this way the baby will suck the breast hard because he will be hungry. This will encourage a continued supply of breast milk. Remember, breast-feeding should continue for 2 full years if possible (see Module 3).
How much food should a child take at one meal?
If he is just starting to eat, or if a new food is being introduced, 2 small spoonfuls may be enough. Once he is used to the new food and flavour, he should be given at least 3 large spoonfuls (tablespoons) of food for each meal. If he can take more, more should be given. If he is unwilling to take this amount it may be necessary to divide the amount into 2 smaller meals. If this is done, the amount kept for the second small meal should be carefully protected from flies and dust in a covered container. It should be kept in as cool a place as possible for not more than 4 hours.
By the time the child is 1 year old, he or she should be sharing the family diet, with four or five varieties of food.
Feeding small children should be a priority within the family
Feed the young child first because he eats slowly and cannot compete with older children and adults for the limited amount of food prepared for a meal. Feed the girls as much and as frequently as the boys. By the time a child is 2 years old he or she should eat half as much as an adult. It is good for a small child to have his own plate and portion of food. When a child is ill, he still needs nourishment. He may lose his appetite and often refuses to eat, but he needs strength to get better from the illness. Time and care must be taken to help an ill child eat enough food. Even if small amounts of foods are eaten, this will help, if such feeding is repeated as often as possible.
A time-chart for the feeding of children
The chart shown in Fig. 28 gives you an idea of how to feed children from birth up to 2 years of age. It need not be followed too rigidly.
Teaching and convincing mothers about correct feeding
In order to teach effectively, a community health worker must not only know about the correct methods of infant feeding, she must also really believe in them. A friendly relationship with people is important in teaching about feeding. Some mothers may feel insulted or threatened if another person starts teaching them about feeding their children. Make friends with mothers before teaching them. Show a loving concern for mothers and their families in other ways also. The best way to learn is from a friend.
Fig. 28. A time-chart for the feeding of children
Once some women have learnt about feeding and start to feed their children in the way you have taught them, others will copy the same methods when they see children growing up healthily. The messages about successful feeding can thus spread within the community. Some mothers are good teachers.
How do you know if a child is getting enough food?
Weigh him regularly and plot the weights on a growth chart (Module 2). With sufficient food of good quality, the child's weight will continue to increase within the two reference lines
on the growth chart. The use of the growth chart can be a very useful way of teaching the mother to find out for herself whether she is feeding her child properly.
1. Lecture: Training content.
2. Practical work and demonstration: Preparing a meal for a small child.
3. Community survey: Observing diets and feeding problems of small children.
4. Group discussion: Results of the community survey.
Exercise 1. Observing a child's diet
Ask trainees to make friends with mothers who have babies between the ages of 12 and 18 months. These mothers should not be from wealthy families. The trainees should ask their permission to "observe" the babies for a whole day. The trainees should base their observations on the questions given below:
· How many times is the child put to the breast?
· How many other feeds are given during the day?
· What foods are given?
· How much food is given each time?
· Who gives the food?
· How are hands and utensils cleaned before feeding the child?
· How are the foods prepared and stored?
On the next day ask the trainees to discuss what they observed. After the discussion, they will have a better understanding of feeding practices and problems in that area. They will be able to plan how to help and teach mothers more effectively.
Exercise 2. Preparing food for small children
In this exercise the trainees work together to prepare a meal for about 10 children between the ages of 6 and 9 months. At least two types of food should be used.
The trainees should first plan the meal and then go and buy the necessary materials. They should be given some money for this purpose. The meal should be prepared in an ordinary home in the community. The trainees should invite about 10 mothers with children between the ages of 6 and 9 months. Once the meal is ready the trainees should help the mothers to feed the babies. After the meal they should have a discussion with the mothers on the cost of food, method of preparation, suitability of the food, and difficulties in feeding young children.
This exercise should be repeated for children between the ages of 1 and 1½ years of age. This exercise provides a teaching and learning situation both for the trainees and for the mothers. If the class is too large, the trainees can be divided into two or more groups.
Exercise 3. Feeding problems
The trainees can ask the mothers of small children what difficulties they have had in feeding children. They can find out why mothers ask for the help of older women in the community when they have feeding problems. These "advisers" can be asked about their advice. Later the trainees can meet together and discuss what they learnt from the older women. This will help them to understand and teach mothers more effectively about feeding problems.
Exercise 4. Storing food
Mothers are very busy people. They only have time to cook food once or twice a day. Small children need to eat 4-6 times a day. It is important to be able to store food safely for short periods. In tropical countries, if food is not prepared cleanly and stored safely, it will soon spoil. Dirty or spoilt food can cause diseases such as diarrhoea.
The trainees should find out how food is stored in homes. They should discuss together and with their supervisors if these methods are safe. They should consider how storing of food can be improved using only the utensils found in ordinary homes. The most important points to remember are to keep the food cool and properly covered so that flies and dust cannot reach it. Hands should be washed properly before handling food.