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close this book Community Nutrition Action for Child Survival
close this folder Part I - Community nutrition problems and interventions
close this folder Unit 2: Measuring and monitoring growth in young children
View the document Session 1: Measuring growth
View the document Session 2: Arm circumference
View the document Session 3: The road to health chart
View the document Session 4: The thinness chart
View the document Session 6: Counseling, referral and follow-up of malnourished children

Session 6: Counseling, referral and follow-up of malnourished children


In this session, trainees practice explaining the significance of children's growth measurements to their parents. Actions that should be taken in cases of severe malnutrition and early growth failure are discussed.

Time: 2 hours


- Role Plays - containing growth charts and mother's instructions for three situations (In this exercise, trainees use the Road to Health Chart as the tool for assessing the nutrition status of several children. Arm circumference measures or measures from the Thinness Chart can be substituted.)

- Handout - "Community Action with Malnourished Children" (This should be developed locally. An example is included.)


1. Introduce the session with a discussion of the critical role parents play in monitoring and taking action to improve the growth of their children.

2. Divide into work groups of three people. Work groups will conduct three role plays each. The characters in the role plays are a "community nutrition worker," the "mother" of a malnourished child and an "observer." Work group members will rotate the roles so that each member plays all three roles.

3. Give group members different situation sheets and instruct them to remove the " Instructions to the Mother" for their own reference. In each situation, the "mothers brings her child's Road to Health Chart to the Community nutrition worker." The "worker's" job is to:

- explain the Road to Health Chart and the child's growth curve to the "mother";

- discover the causes of growth failure by asking the questions about the health, eating habits, etc., of the child;

- help the "mother" plan what to do to improve the growth of her child.

The "observer" should note how the "worker" uses the Road to Health Chart to explain the child's situation and the need for action.

Allow about five minutes per role play situation.

4. Discuss the role plays by asking trainees to answer the following questions based on their experience in the roles of "mother," and "community nutrition worker" and


- How did the "community nutrition worker" use the Road to Health Chart to explain a child's nutrition status? - What questions did you ask to find out why the child had stopped growing?

- Did the "community nutrition workers" tell the "mothers" what they should do, or did they plan together how to improve the child's growth? Which do you think is more effective?

5. Counseling and education of parents are two community interventions to improve the nutrition of children identified during growth monitoring activities. Ask participants: "What other actions can/should be taken in the community with "high risk" children?" Write their responses on the flipchart.

6. Distribute the Handout - "What to Do When Children are Malnourished." Explain that each community nutrition program must decide what the community/clinic or agency will do for the malnourished children identified in growth monitoring activities. This handout gives a basic list of appropriate community interventions. Review them with the trainees and encourage them to add others that they feel would be necessary and feasible.

7. Review the basic steps in measuring growth and taking action to improve the nutrition of "high risk" children:

- Measure and assess the growth of all children under five regularly.

- Counsel the parents of "high risk" children. Visit them at home if possible.

- Refer or treat malnourished and sick children for illness.

- Follow up and evaluate the progress of each child.


Situation #1

Situation #1

Instruction to the Mother:

You brought the baby to the weighing activity because she is sick and has gotten thin.

You stopped breastfeeding her in September, at 4 months, because she "didn't like" your milk.


Situation #2

Situation #2

Instruction to the Mother:

You work on a tea plantation all day and leave this child with your 8-year-old daughter. Your husband left in August to find a job in the city. You are breastfeeding in the morning and at night. During the day the baby eats rice from the morning meal.


Situation #3

Situation #3

Instruction to the Mother:

You stopped breastfeeding this child in August when he was 16 months old because you became pregnant again. He refused to eat much for the next few weeks. Then he got the measles in November. Since then he has had frequent diarrhea.



To the Trainer:

This handout should be developed by each program based on the nutrition assessment instruments they use, their resources and established guidelines for intervention.


In a CEDPA-supported nutrition program, Community Nutrition Volunteers use arm circumference and weight gain to identify "high risk" children.

If a child has:

The Community Nutrition Volunteer:

Yellow Arm Circumference
(>12.5 cm <13.5 cm)
No weight gain for two months

- Counsels the parent(s)
- Teaches the mother to make improved foods for child feeding
- Refers the child to the nearest clinic if he is sick
- Follows up after one month

Red Arm Circumference
(<12.5 cm)
No weight gain for three months

- Counsels the parent(s)
- Refers for immediate medical treatment
- Gives food supplement
- Visits home one week later to teach mother how to make improved foods and how to treat diarrhea with ORS
- Follows up monthly until arm circumference is green

All children

- Teaches the mother to prepare improved weaning foods
- Teaches the mother how to make and give ORS to treat diarrhea
- Discusses the importance of and methods for child spacing



American Public Health Association. Growth Monitoring. 1981.

Morley, D. and Woodland, M. See How They Grow Monitoring Child Growth for Appropriate Health Care in Developing Countries. Oxford University Press, New York, 1979.

Nabarro, D., Verney, J. and Wijga, A. The Weight-for-Height Chart Project. Evaluation Report. 1982-1984.

World Health Organization. Guidelines for Training Community

Health Workers in Nutrition. WHO Offset Publication No. 59. Geneva, 1981.