CAPLOWs project Saving Children

Lives at Rehri Goth

Counseling material for Community
Health Worker
Materials to take on a home visit
Married Woman Surveillance (13-49
years) visit
Greet the family
Tell the purpose of visit
Take verbal consent
Ask the status of Married
woman
Ask the status children
under five years
Discuss the problem
Thank the family
Tell that you will visit
again according to the
schedule
Pregnant Women Identification
Ask the woman whether she is
pregnant or not
Probe the woman well ask about
missed period and LMP
Early pregnancy detection and
identification is very important for
pregnant woman and her child
identify the pregnant woman within
12-16 weeks of gestation
Once pregnant woman identified
VERBAL CONSENT WILL BE TAKEN
AND FILL CASE REPORT FORM 1
First Pregnancy Visit: Promote
Antenatal Care
GREET THE FAMILY. Explain that you are visiting to talk
about care during pregnancy.
Ask & Listen: Do you have other children? (If yes) Did you
attend antenatal clinic in previous pregnancies? In this
pregnancy?
Understand the situation and adapt your advice
accordingly.
Give relevant information: Ask the family what they see in
the pictures and listen to their answers.
Check understanding and discuss what the family will do.
Will the pregnant woman go for four antenatal care visits?
If yes, praise them. If no, ask why not and try to solve any
problems
Tell the story of Ayesha, who had a healthy baby:
Story of Ayesha
Ayesha went for the first
antenatal check up as soon as
she knew she was pregnant.
She knew this was important to:
be examined to make sure she
was healthy (Picture 1-3),
get injections to protect against
tetanus (Picture 3),
receive iron and folic acid tablets
to prevent anemia or weak
blood (Picture 4),
get tested so she could receive
appropriate care and reduce the
risk (Picture 5).
Ayesha went for antenatal check
ups four times during her
pregnancy.
1
2
3
4
5
First ANC visit will be done between
24 to 28 weeks of pregnancy.
Topics covered :
Birth preparedness
Nutrition counseling
Folic acid and iron supplementation
Immunization (TT)

FILL CASE REPORT FORM 1A
First Pregnancy Visit: Prepare for Birth
in a Health Facility
Ask & Listen: (If the woman has other children) Where
did you give birth? (If not) Where did other
women in your family give birth?
Understand the situation and adapt your advice
accordingly.
Give relevant information: Ask the family what they
see in the pictures and listen to their answers.
Check understanding and discuss what the family will
do. Will the family plan for birth in a facility. If yes,
praise them. If no, ask why not and try to solve any
problems
Tell the story of Ayesha, who had a healthy baby.
Story of Ayesha
Ayesha and her family:
Chose to have the birth in a health
facility (Picture 1) because they knew
that complications can happen to any
woman and these can be prevented
and treated immediately in a health
facility.
Identified transport to get to the
health facility when labour started,
either during the day or night
Saved money for transport and other
expenses for birth at health facility
(Picture 2)
Collected supplies (towels for drying
and wrapping the baby and clothes
for the baby) (Picture 3) and planned
who will care for the household when
the woman is in the facility for
childbirth
Went to health facility early in labour
(Picture 4)
1
2
3 4
Pregnant Woman Registration at
Koohi Goth Hospital for delivery
Why?
Trained and experience staff for delivery
Clean environment and clean delivery
Prevention of any complication during delivery
Near to Rehri Goth
New born will be save

Trained midwife is far better than traditional
birth attendant save your child

Pregnant Woman Registration at
Koohi Goth Hospital for delivery
How?
Registration in first to early second trimester is
very important to identify any risk and avoid any
complication
Lab test (Blood and urine)
Ultrasound
Antennal visit at Koohi Goth Hospital Midwives,
sitting at Rehri Goth Center


Pregnant Woman Registration at
Koohi Goth Hospital for delivery
How we can help pregnant woman?
Providing transport
Facilitating and helping pregnant woman to get
register at Koohi Goth Hospital
Free lab test
Free ultrasound



Pregnant Woman Registration at
Koohi Goth Hospital for delivery
What we want for woman and her family?
Provide us with the time
Listen to the advice of Community health worker
Listen to the advice of Koohi Goth health team
Get register and visit for Antenatal care at Koohi
Goth clinic
Deliver at Koohi Goth Hospital
Be patient with the procedure as we are working
for the best of pregnant woman and her child


First Pregnancy visit: Home Care for
the Pregnant Woman
Ask & Listen: What care do you think women
need during pregnancy?
Understand the situation and adapt your advice
accordingly.
Give relevant information: Ask the family what
they see in the pictures on the next page
Check understanding and discuss what the
family will do. Can the pregnant woman care for
herself like Ayesha? If yes, praise them. If no, ask
why not and try to solve any problems and tell
the story; Ayesha:
Story of Ayesha
Ayesha ate more than
usual during pregnancy to
help the baby grow
(Picture 1)
Avoided heavy work and
rested more, to help her
and the baby stay healthy
(Picture 2)
Took iron-folic acid
tablets and followed
other advice given at the
antenatal clinic (Picture 3)
Health Nutrition for Pregnant Woman
What makes a Pregnant Women
Healthy
Water
8-10 glass of water daily is very important to
drink for the pregnant woman
Clean and boil drinking is important
Iron and Folic Acid Supplement or
related items
Very important for the baby to deliver healthy
Prevent the birth defects and other danger
illness
Prevent complications related to blood

Prevention of Anemia
Women should know the signs of anemia
anemia is very dangerous but very easy to
prevent by Ferrous Sulphate tablet
Tiredness
Weakness
Headache
Whitening of skin below eye and nails
Sleep disturbance
Increase heart beat and fast breathing




When to start Folic acid and Ferrous
Sulphate
Folic acid should be given 1 tablet per day, as
soon as pregnancy is confirmed
Ferrous Sulphate should be given 1 tablet
twice daily, as soon as pregnancy is confirmed
Both tablet should be taking with food to
avoid stomach upset
Other source of Folic acid and Ferrous
Sulpate
We may provide you biscuit for pregnant
woman this will help you to prevent
nutritional deficiency
CHW will provide you 42 biscuit for 1 week
duration to the pregnant woman and woman
has to consume 6 biscuits per day
Identification of Malnourished woman
Community health worker will identify
malnourished pregnant woman at the time of
registration or during ANC visit
The MUAC will be used to identify whether
the pregnant woman is malnourished or not
not.

Types of Malnutrition
Criteria Classification Treatment / care
MUAC less than 19 cm

Severe acute malnutrition
(SAM) with complication
(fever, hypothermia, severe
anemia or dehydration,
vomiting, bilateral edema
+++) or no appetite
Referral to the hospital

Ask the coordinator for further
plan
SAM with appetite and no
complication
High energy biscuits or Super
cereal CSB plus
Weight loss or no weight gain
MUAC greater than or equal to 19
and less than or equal to 23.5 cm
Moderate/mild malnutrition High energy biscuits or Super
cereal CSB plus
MUAC > 23.5 cm Normal Nutritional advice + High energy
biscuit supplies as micronutrient
High Energy Biscuit for Malnourished
pregnant woman
We may provide you biscuit for pregnant woman
this will help you to fulfill the nutritional
requirements deficiency
CHW will provide you 42 biscuit for 1 week duration
to the pregnant woman and woman has to consume
6 biscuits per day for whole pregnancy period and 6
months after delivery
CHW will follow you every 15 days and assess our
nutritional status by taking your MUAC and weight.
What else pregnant woman need to
eat apart from High Energy Biscuit
1 egg per day with high energy biscuits
1 glass of milk
AND
Routine meals of three times

High energy biscuits special instructions
Woman has to consumed 6 biscuits per day as
guided by the CHW
Drink plenty of water
These biscuits are specially made to fulfill the
nutritional requirements of pregnant woman
other family member should not use them
Tetanus prevention
Tetanus is a serious disease cause by germ
that affects your:
nervous system,
leading to painful muscle contractions, particularly
of your jaw and neck muscles.
Tetanus can interfere with your ability to breathe
and, ultimately, threaten the life.
Tetanus is commonly known as
"lockjaw, and majorly fits occur.

What is the source of tetanus disease?
And what is Maternal and Neonatal
Tetanus?
Maternal tetanus occurs in the woman when she
was exposed to dirty tools is used during
childbirth.
Neonatal tetanus is a form of that occurs in
newborns.
A newborn baby may become infected:
if the knife, razor, or other instrument used to cut its
umbilical cord is dirty,
if dirty material is used to dress the cord, or
if the hands of the person delivering the baby are not
clean.
Symptoms usually appear after 3
rd
day.
Do you know the symptoms of tetanus in
mother and baby?
We have discussed this earlier as well but now we tell
you again.
muscular stiffness in the jaw
stiffness in the neck,
difficulty swallowing,
stiffness in the stomach muscles,
muscle spasms,
sweating,
and fever
Newborn babies who are normal at birth, but stop
sucking between three and 28 days after birth


How is tetanus disease prevented?
Clean practices when a mother is
delivering a child, even if she has been
immunized use of A complete
delivery kit with disposable sheet,
clean and sterile blade, thread, cord
clamp, soap, gauze piece and swabs
Neonatal tetanus can be prevented by
immunizing women of childbearing age
with tetanus toxoid, either during
pregnancy or outside of pregnancy.
Immunizing infants and children with
hexavalent vaccine
How many doses and at what interval
in woman of childbearing age?
Dose When
How long it will
give you projection
First dose 1. As soon as girl reach the age of 13 years or
2. As soon as woman got married or
3. Woman got pregnant at 5
th
month or
4. Any one has deep wound
No protection
Second dose Four weeks after first dose 3 years
Third dose 6 months after second dose 5 years
Fourth dose One year after third dose 10 years
Fifth dose One year after fourth dose

30 years (through
out reproductive
age)
Ask the woman can you tell the
difference between these two pictures?
The difference between these two
pictures?
And the difference between these two
pictures?
Special note for pregnant woman
If the mother comes later, then she could be
given two doses but the 2nd dose must be
given one month before the Expected date of
delivery.
If two injections have been given in the
previous pregnancy, then only one is required.
This can be given at any time during the
pregnancy.
So what we learnt from last 6 picture?
What do you think is the better woman?
The one who was sick, and unconscious OR the one
which is health after child birth and enjoying with her
baby
What do you think is the best delivery?
The one by trained staff like midwife, nurse or doctor,
under hygienic condition OR the one by Daai under
unhygienic condition.
What do you think is the better child?
The one who was sick, OR the one who is health
Arrangement of Transport
In case of labour pain or any
other related emergency,
pregnant woman or the
family member need to
inform our community health
worker in Rehri Goth
Woman should tell the health
worker about close address of
household
The health worker will
arrange AMAN ambulance for
transportation
Please call at
number


Important things to remember in
case of home delivery
Important precautions for woman during
pregnancy
Important precautions for woman
during pregnancy
Important precautions for woman during
pregnancy
Danger signs during Pregnancy

Vaginal bleeding


Severe Abdominal
pain


Fits


Severe headache


High grade fever


Fast or difficult
breathing

Second pregnancy visit: Review Home
Care for the Pregnant Woman and
Preparation for Birth
GREET THE FAMILY. Explain that you are visiting to talk about
preparations for birth and care of the newborn after birth.
Ask, listen and discuss what the family will do: (use the pictures to
reinforce advice, if needed)
Has the pregnant woman attended antenatal clinic?
If she has, praise her and the family.
If not, ask why not and try to solve any problems they may have.
How has the woman been caring for herself?
If the woman has been able to eat and rest more, and take iron folic acid
tablets, praise her and the family.
If not, ask why not and try to solve any problems they may have.
How are the preparations for birth going?
If they have decided on health facility birth and are saving money, have
identified transport and are collecting supplies, praise them.
If not, ask why not and try to solve any problems they may have.
Second pregnancy visit: prepare for birth
at home (for use if the family thinks
facility birth might not be possible)
Encourage the woman and family that safest place of delivery is
good facility
There are important points which need to be remember in case
of home delivery
Identified a midwife to assist at birth. They also identified an additional
person (her mother-in-law) to help the birth attendant care for the baby
immediately after birth
Knew that it is an emergency if labour lasts longer than 12 hours, there is
heavy bleeding, the placenta is not delivered, or the baby has difficulty
breathing
Saved money and identified transport to go the health facility in case of
an emergency
Collected clean towels to dry and wrap the baby, and a hat, socks and
clothes to keep the baby warm
Cleaned the room for birth and had soap and water available for the
birth attendant and her helper to wash hands
Second pregnancy visit: advise on
immediate newborn care
Care of mother
Care of New born
Breastfeeding
Childhood immunization
Care of mother
Eating of multani mitti,
paan, gutka , niswar,
biddi ,chalia, sopari and
other addicted drugs like
heroin and related drug
are very dangerous for
the child - must be
absolutely discouraged.
Also ask to limit their
consumption of tea and
coffee to 2-3 cups in 24
hours.
Care of mother
Anxiety or depression is a common occurrence in
pregnant women especially in first pregnancy.
Mothers if sad, stressed or depressed must be
counseled to stay happy and stress free by sharing
their worries with the husband or family members
and friends.
Mothers are also asked to have some rest during
day time and appropriate sleep during night hours.
They are encouraged to identify their causes of
stress and help them to overcome by counseling.
Encourage the pregnant woman to continue
routine light work during pregnancy like cooking,
washing, cleaning, etc. but avoiding heavy work,
e.g. washing clothes, fetching water, moving heavy
Second pregnancy visit: Advise on
immediate newborn care
Ask & Listen: What care do you think a baby should
receive right after birth?
Understand the situation and adapt your advice
accordingly.
Give relevant information: Ask the family what they
see in the pictures and listen to their answers.
Check understanding and discuss what the family will
do. Can they care for the baby in the same way as in
the story? If yes, praise them. If no, ask why not and try
to solve any problems.
Tell the story of the care that Ayeshas baby received
immediately after birth.
Ayeshas story
The birth attendant dried the baby
immediately after birth (Picture 1), placed
the baby skin to skin on Ayeshas tummy, and
covered them with a blanket to keep the
baby warm (Picture 2)
The birth attendant cut the cord with a new
blade, Ayeshas mother-in-law put hat and
socks on the baby, put him skin to skin
between Ayeshas breasts and covered
mother and baby (Picture 3)
In a few minutes, when the baby was ready,
Ayesha put the baby to the breast to help
the milk come in, reduce Ayeshas bleeding,
and protect the baby from disease (Picture
4)
The baby was allowed to suckle as long as he
wanted and kept in skin to skin contact with
Ayesha for one hour after birth, and then
wrapped well and kept close to her to make
sure the baby stayed warm, the family
delayed bathing until the next day
Postnatal visit: Assess feeding, danger
signs and weight
GREET THE FAMILY. Ask and Listen: How are the mother and baby doing? IF THE MOTHER HAS HEAVY BLEEDING,
FEVER, FITS, SEVERE HEADACHE, DIFFICULT BREATHING, OR SEVERE ABDOMINAL PAIN, REFER URGENTLY TO
HOSPITAL. If not, ask if the mother has put the baby to the breast. If yes, praise the family. If no, encourage her
to do so now.
Understand the situation: WASH your hands. OBSERVE the mother breastfeed. Is the baby well attached
(CHIN TOUCHING BREAST? MOUTH WIDE OPEN? LOWER LIP TURNED OUTWARD? MORE AREOLA VISIBLE ABOVE
THAN BELOW THE MOUTH?) and suckling effectively? If not, help the mother to improve positioning and
attachment.
Ask the family if you can check the baby use the pictures to explain what you will do. ASSESS the baby
for these DANGER SIGNS:
NOT ABLE TO FEED SINCE BIRTH, OR STOPPED FEEDING WELL
CONVULSED OR FITTED SINCE BIRTH
FAST BREATHING: 60 BREATHS OR MORE IN ONE MINUTE (TWO COUNTS)
CHEST INDRAWING
HIGH TEMPERATURE: 38C OR MORE
VERY LOW TEMPERATURE: 35.5C OR LESS
ONLY MOVES WHEN STIMULATED, OR DOES NOT MOVE EVEN ON STIMULATION
YELLOW SOLES
SIGNS OF LOCAL INFECTION: UMBILICUS RED OR DRAINING PUS, SKIN BOILS AND EYES DRAINING PUS.
WEIGH THE BABY, record the weight

CRF 2 for outcome information and CRF 3 for baby registration will
be filled

Breastfeeding - What do mother need
to know?
Breast milk provides all the food and water
that your baby needs during the first 6
months of life.
Make sure you feed your baby the first
yellowish milk known as colostrum.
Colostrum protects your baby from many
diseases.
Exclusive breastfeeding means giving
breast milk only, and nothing else (no
other milks, foods or liquids, not even sips
of water), except for medicines prescribed
by a doctor or nurse.
Feeding your baby both breast milk and
other foods or liquids, including infant
formula, animal milks, or water (called
mixed feeding) before 6 months reduces
the amount of milk that you produce and
can make your baby sick.
Help baby attach to your breast
Good attachment helps you to produce a good
supply of breast milk.
Put the baby to your breast within the first hour of
birth.
Good attachment helps to ensure that your baby
suckles well.
Good attachment helps to prevent sore and
cracked nipples.
To make sure your baby is attached well:
Touch babys lips with your nipple
Wait until your babys mouth opens wide
Quickly bring onto your breast from below,
aiming your nipple up towards the roof of the
babys mouth
Baby should take a big mouthful of breast
The 4 signs of good attachment are:
1. Babys mouth is wide open
2. You can see more of the darker skin (areola)
above the babys mouth than below
3. Babys lower lip is turned outwards
4. Babys chin is touching your breast
Your baby should take slow deep sucks while
breastfeeding, sometimes pausing.
How often should I breastfeed?
Breastfeed your baby on demand,
both day and night, at least 8 to 12
times each day.
Frequent feeding will help your
body to produce breast milk.
Continue to feed until your baby
finishes the breast and comes off
on his or her own. Offer the other
breast and let your baby decide if
he or she wants more or not.
You will know if your baby is taking
enough breast milk if he or she
passes light-coloured urine at least
6 times a day and is gaining weight.
Things to remember
Breast milk is the best food for babies.
Breast milk also protects against infections, which are the most common causes of
illnesses and deaths in newborn infants.
Breastfeed the baby within the first hour after birth to promote milk production
and to give the baby the benefits of colostrum, the first yellowish milk that is
secreted initially.
Colostrum is a natural vaccine that protects the baby from illnesses. Do not throw
it away; give it to your newborn baby.
Immediate breastfeeding also helps with the delivery of the placenta and reduces
bleeding in the mother.
While breastfeeding, wait until the baby spontaneously lets go of the nipple before
switching to the other breast. In this way, the baby is more likely to receive the fat
rich milk that comes out near the end of a feed as the breast gets emptied.
Breastfeed day and night on demand whenever the baby wants milk. This will
promote milk production; it will also prevent painful breast engorgement
Exclusive breastfeeding is essential during the first six months. This means giving
only breast milk; no water, teas, other liquids, herbs, or foods. During this period,
breast milk is a complete food and contains all the water a baby needs, even in hot
climates.
Good and Poor Attachment
Good positioning
Feeding twin babies

Breastfeeding
the remarkable first hour of life
The mothers body helps to keep the baby
appropriately warm, which is especially important for
small and low birth weight babies.
The baby is less stressed, calmer and has stable
breathing and heart rates.
The baby is exposed first to the bacteria from the
mother which are mostly harmless, or against which
the mothers milk contains protective factors
The mothers bacteria helps to prevent infection in her
baby by colonizing the babys gut and skin; as well as
competing with more harmful bacteria from health
providers and the environment.

Colostrum for the first feeds

Colostrum is rich in immunologically active cells, antibodies and
other protective proteins. Thus it serves as the babys first
immunization and protects against many infections. It helps to
regulate the babys own developing immune system
Colostrum contains growth factors, which help the infants
intestine to mature and function effectively. This makes it more
difficult for micro-organisms and allergens to get into the
babys body.
Colostrum is rich in Vitamin A, which helps protect the eyes
and reduce infection.
Colostrum stimulates the baby to have bowel movements so
that meconium is cleared quickly from the gut. This will help
reduce jaundice in the baby.
Colostrum comes in small volumes, just right for the new baby.

Importance of Breastfeeding for the
Infant/Young Child
Saves infants lives.
Is a whole food for the infant, contains balanced proportions and sufficient
quantity of all the needed nutrients for the first 6 months.
Promotes adequate growth and development, thus preventing stunting.
Is always clean.
Contains antibodies that protect against diseases, especially against diarrhea and
respiratory infections.
Is always ready and at the right temperature.
Is easy to digest. Nutrients are well absorbed.
Protects against allergies. Breastmilk antibodies protect the babys gut preventing
harmful substances to pass into the blood.
Contains enough water for the babys needs (87% of water and minerals).
Helps jaw and teeth development; suckling develops facial muscles.
Frequent skin-to-skin contact between mother and infant lead to better
psychomotor, affective and social development of the infant.
The infant benefits from the colostrum, which protects him/her from diseases.
The amount is perfect for newborn stomach size.
Promotes brain development;

Importance of Breastfeeding for the
Mother
Putting the baby to the breast immediately after
birth facilitates the expulsion of placenta because
the babys suckling stimulates uterine contractions.
Reduces risks of bleeding after delivery.
When the baby is immediately breastfed after
birth, breastmilk production is stimulated.
Breastfeeding is more than 98% effective as a
contraceptive method during the first 6 months
provided that breastfeeding is exclusive and
amenorrhea persists.
Immediate and frequent suckling prevents
engorgement.

Care of the Low Birth Weight (LBW)
infant
The low birth weight newborn is very fragile. It is important to take good
care of him/her to promote good health.
Avoid a dangerous drop in the babys body temperature, especially soon
after birth:
Dry the baby with a clean cloth, discard the wet cloth. Wrap the body,
including the head, with a fresh dry cloth or several cloths as required.
Ask the mother and another family member to practice continuous skin
to skin- contact, also known as kangaroo mother care
Do not bath the baby until the end of the first week.
Practice exclusive breastfeeding, day and night, at least 10 to 12 times a
day.
Wash your hands with clean water and soap every time before touching a
low birth weight baby, in order to protect him/her from infections.
Visit the health center and get your baby weighed once a week to make
sure he/she is growing well.
Key points for counseling mothers and
families
Much of the care of the small or low birth weight baby is similar to
that required by normal newborns, but these vulnerable babies
require extra support.
To avoid a dangerous drop in the babys body temperature,
especially soon after birth:
Dry the baby quickly with a clean cloth and discard the wet cloth.
Wrap the body, including the head, with a fresh dry cloth or several
cloths/blanket as required to keep the baby warm.
Check the temperature of the baby. Place your hand on the babys
tummy and compare its temperature with that of the hands and feet.
The tummy, hands, and feet all should be warm, not too hot and not
too cold.
Ask the mother and/or another family member to practice continuous
skin-to-skin contact, also known as kangaroo mother care. Find out
more details of this component from your facility health care provider
or supervisor if this is being practiced in your area.
Do not bathe the baby until the end of the first week.
Recommended breastfeeding practices
Recommended
Breastfeeding Practice
Possible Points of Discussion for Counseling (choose most relevant to mothers
situation)
Put infant skin-to-skin with
mother immediately after
birth
Skin-to-skin with mother keeps newborn warm
Skin-to-skin with mother helps stimulate brain development
Initiate breastfeeding within
the first hour of birth

This first milk local word is called colostrum. It is yellow and full of antibodies
which help protect your baby
Colostrum provides the first immunization against
many diseases.
Breastfeeding from birth helps the milk come in and ensures plenty of breastmilk
Exclusively breastfeed (no
other
food or drink) for 6 months
Breastmilk is all the infant needs for the first 6 months
Do not give anything else to the infant before 6 months, not even water
Giving water will fill the infant and cause less suckling; less breastmilk will be
produced
Breastfeed frequently, day
and night
Breastfeed the baby often, at least 8-12 times for a newborn, and 8 or more times
after breastfeeding is well-established, day and night, to produce lots of breastmilk
More suckling (with good attachment) makes more breastmilk
Breastfeed on demand (or
cue) every time the baby
asks to breastfeed
Crying is a late sign of hunger.
Early signs that baby wants to breastfeed:
Restlessness
Opening mouth and turning head from side to side
Putting tongue in and out
Sucking on fingers or fists
Postnatal newborn follow-ups
Postnatal follow-ups will be perform on day 2,
6, 13, 20, 27, 34, 41, 48 and 49
CRF 4 will be filled on each follow-up

Danger sign: Not able to feed since
birth, or stopped feeding well

If the baby is not able to suckle at the breast
even when the mother has tried to put the baby
to the breast several times over a few hours, this
indicates the baby may have a severe illness, and
is therefore a danger sign. You have already
observed the baby at the breast while trying to
help the mother initiate and sustain
breastfeeding.
If the mother tells you that the baby was feeding
well after birth but has stopped feeding well now,
this indicates that the baby may have a severe
infection. This is also a danger sign.
A baby with a danger sign should be referred to a
health facility immediately. If the CHW finds a
danger sign, there is no need to spend time to
complete the rest of the assessment; instead the
CHW should make urgent arrangements for
referral.

Danger sign: Convulsions or fits

A convulsion or fit indicates severe
illness in the baby and is therefore a
danger sign.
During a fit, the baby's arms and legs
may become stiff. The baby may stop
breathing and become blue. Many
times there may only be a recurring
movement of a part of the body, such
as twitching of the mouth or blinking
of eyes.
When you ask the mother "Has the
baby convulsed or fitted since birth?"
and she says yes, this is a danger
sign. If she does not understand what
a fit is, explain. If she says the baby
did not have a fit, do not ask any
further questions.
Danger signs: Fast breathing
Fast breathing: Counting breaths the newborn
takes in one minute
What is a full breath?
Breathing is taking air in and out of the body
through the mouth or nose. Breaths can be counted
by looking at the breathing movements. The chest
and abdomen move out when we breathe in, and
move in when we breathe out. One outward and
inward movement of the chest and abdomen
together makes one breath.
What is fast breathing in a newborn
If the breathing rate of a newborn is 60 per minute
or more the first time, the
CHW should repeat the count.
If the second count is still 60 breaths per minute or
more, the newborn has "fast breathing", which is a
danger sign. A baby with fast breathing should be
REFERRED to a hospital.
How to count breathing rate in a
newborn?
Wait for the newborn to be calm (or
sleeping). Do not count when the baby
is breastfeeding.
Make sure that there is enough light to
see the breathing movements.
Gently lift the baby's shirt so you can
see breathing movements. The chest
and abdomen rising and falling once
makes one breath.
Watch a few breaths until you are sure
when the baby is breathing in and out.
Start the timer and count the breaths
for one full minute (until the final beep,
which is at the end of one minute).
Record the number of breaths.
If there are 60 breaths per minute or
more, repeat the count and record the
number of breaths counted the second
time
What are the common errors in counting
breaths?
Counting when the baby is not calm or is breastfeeding
Generating your own rhythm of respiratory movements
and not actually observing the abdomen of the baby
Counting for less than a minute and multiplying the result.
It does not take account of irregular breathing which is
normal in newborn babies
Counting breaths loud and slower than the actual
movement of the abdomen
Counting up and down movements of chest and abdomen
as 2 breaths instead of one.
Not repeating the count when the first count is 60 or more.
Danger signs:
Chest in drawing
Normally the abdomen and chest move
out when the baby breathes in. Both
the upper and lower part of the chest
move out when the baby breathes in.
When the baby has a problem with his
lungs, the LOWER chest wall goes IN
when the child breathes IN. At the
same time, the upper chest and
abdomen move out. You can therefore
see a groove forming between the
chest and abdomen. Chest indrawing is
a danger sign. A newborn with chest
indrawing should be referred urgently
to a hospital.
why should the baby be calm and not
breastfeeding when you look for chest
indrawing

Even normal babies can seem to have chest
indrawing when they are breastfeeding or are
crying. The baby should therefore be calm and
not breastfeeding when you look for chest
indrawing

How to look for chest indrawing
:
Steps in looking for chest indrawing
To look for chest indrawing, the child must be calm. The
child should not be breastfeeding.
Ask the caregiver to raise the childs clothing above the
chest just like while counting breaths.
Look at the lower chest wall when the child breathes IN.
For chest indrawing to be present, it must be clearly visible
and present at every breath.
If you see chest indrawing only when the baby is crying or
feeding, the baby does not have chest indrawing. If you are
unsure, decide that the baby does not have chest
indrawing.
Danger signs: High or very low
temperature
WHY SHOULD A CHW MEASURE TEMPERATURE OF A NEWBORN?
In a previous unit, you learnt about the importance of keeping babies
warm. If a baby gets cold, he has problems in suckling at the breast, can
get sick easily and is more likely to die.
A well baby is neither hot nor too cold. When a newborn has a serious
infection, his body can become very cold. In some cases, the baby may
have fever instead. Thus, both very low temperature and high
temperature are danger signs indicating severe illness in a baby.
It can be difficult to tell whether the baby is too hot or too cold just by
touching them. The best way to knowing is to use a thermometer to
measure temperature.
Measuring temperature
Take thermometer out of the box, hold at broad end
Wash the area from the tip of the thermometer extending 4 cm
(the length of half a finger), with warm (not hot) soapy water. Air
dry thoroughly before using.
Press the "on" button once to turn the thermometer on.
Hold the thermometer upward and place the shining tip in the
centre of the armpit. Press the arm against the side of the baby. Do
not change the position.
When you hear 3 short beeps, and the numbers stop changing,
remove the thermometer (this will take a few minutes).
Remove the thermometer and read the number in the display
window. Record the temperature reading.
Turn the thermometer off; clean the shining tip with warm soapy
water, air dry, and place it in the storage case.
Common errors in temperature
measurement
Thermometer not properly placed in the armpit
so that the tip juts out at the other end of the
armpit of the baby.
Thermometer not held firmly in the armpit of the
baby.
Removing the thermometer from the armpit
without hearing the three beeps, because you
think it has been there for a long time.
Not recording the temperature immediately after
measuring it.

How to interpret temperature?

If a baby's temperature is:
38
0
C or more: the baby has high
temperature (fever) -- this is a
danger sign and the baby should be
URGENTLY referred to a hospital for
treatment and care.
35.5
0
C or less: the baby has very
low temperature and this is a danger
sign and the baby should be
URGENTLY referred to a hospital for
treatment and care.
A baby with temperature between
35.60C and 37.90C does NOT have a
danger sign. However, the family of a
baby with temperature between
35.60C and 37.40C should be
specially counseled on keeping the
baby warm.
38.5
Babies often sleep most of the time, and this is not a
sign of illness. Observe the baby's movements while
you do the assessment. If a baby does not wake up
during the assessment, ask the mother to wake
him/her.
A baby who is awake will normally move his/her arms
or legs or turn his/her head several times in a minute if
you watch him closely. If you see the baby moving on
his/her own, he/she does not have the danger sign
"Movement only on stimulation or no movement even
on stimulation".
If the baby is awake but does not move on his own,
gently stimulate the baby by tapping or flicking the
sole. If the baby moves only when stimulated and then
stops moving, he/she has a danger sign.
If the baby does not move at all even after stimulation,
this is also a danger sign. A baby who cannot be woken
up even after several efforts to wake him/her up also
has this danger sign.
A baby who moves only on stimulation or does not
move at all should be
URGENTLY taken to a hospital for care.
Danger signs: Movement
Danger sign: signs of local infection
Most common local infections occur on
skin, umbilicus and eyes. Pus and
redness are signs of local infection. You
should therefore look at the:
Umbilicus: Is there pus coming out of
umbilical stump? Is the skin around the
umbilical stump red?
Skin: Are there skin boils filled with
pus? Look at the whole body including
the back, armpits and groin area.
Eyes: Is pus coming out from the eyes?
Look at both the eyes.
A baby with any local infection needs
treatment because local infection may
progress to a severe infection if it is not
treated. Refer a baby with a local
infection to a health facility.
Some important to remember for
newborn
Hand washing
Hands should be washed by the mother and
members of the family before handling the baby,
at least after using the toilet, after changing the
babys diaper/napkin and after cleaning the
house.
Hands should be washed even more frequently
before handling the low birthweight/preterm
baby who is much more susceptible to infections.
The community health worker/volunteer must
wash his/her hands before entering the
house/room where there is a newborn baby,
particularly because it is good for the worker to
review the baby for the status and presence of
danger signs with the mother. After washing,
hands are best air-dried. If a cloth or towel is
used, it must be clean.
Since health workers need to see and touch
newborn babies, it is best that their nails are
short and clean to decrease germs under the
nails.
Parents Guide to Childhood
Immunizations
As parents, we all want our children to grow up
healthy and free from the effects of serious
disease.
One of the easiest and most effective steps we
can take to help achieve this goal is to make
sure that our children receive all the
recommended childhood immunizations
It is strongly recommended that immunizing all
healthy children against the 10 vaccine-
preventable childhood diseases.
Children who are immunized are not the only
ones to benefit from the protection these
vaccinations give. Immunizations also
contribute to the well-being of everyone by
reducing the chance for diseases to spread.
Why should my child be immunized?
Children need immunizations (shots) to protect them from
dangerous childhood diseases.
These diseases have serious complications and can even kill
children.
Newborn babies have antibodies from their mothers and
are immune to many diseases.
However, this immunity does not last and quickly wears off
in the first year of life.
By immunizing children at the recommended times, you
give their immune systems a chance to make protective
antibodies that help fight against disease and illness.
Children who are not immunized run the risk of being
exposed to germs too strong for them to fight.
Are these diseases very serious?
Today we might not think of these diseases as
being very serious because, thanks to vaccines,
we don't see them as often as we used to.
But the fact is they still exist and may lead to
pneumonia, choking, brain damage, heart
problems, blindness and death in children who
are not protected.
What diseases do vaccines prevent?
Immunizations protect children against
Diphtheria
Tetanus (Lockjaw)
Pertussis (Whooping cough)
Polio
Measles
Mumps
Rubella (German measles)
Haemophilus Influenzae Type B (Hib)
Hepatitis B
Pneumococcal infections
How many shots does my child need?
The following vaccinations are recommended by
age 5 and can be given in five visits to a doctor or
public health clinic:
1 vaccination against BCG
15 times 2 polio drops
3 vaccinations against Hib
3 vaccinations against diphtheria, tetanus and
pertussis (DTP)
3 vaccinations against hepatitis B
3 vaccination against Pneumococcal
2 vaccination against measles/mumps/rubella (MMR)
Can my child receive many
vaccinations at the same time?
Vaccines are as useful when combined with other
vaccines as they are alone and carry no greater risk for
harmful side effects.
In addition to being safe, there are two reasons for
giving children multiple vaccinations during the same
visit.
First, we want to immunize children early to protect
them at a time when they are more likely to become
sick.
Second, giving several vaccinations at one time means
fewer trips to your health care provider and may be
less traumatic for your child.
Can my child be immunized if he or
she is sick?
Even if your child has a slight fever, cold or runny
nose, upset stomach, ear infection, or is taking
antibiotics, he or she can still be immunized
safely.
There is no greater risk of harmful events when
immunizations are given during a minor illness.
However, if a fever or other symptoms suggest a
moderate or serious illness, your child should not
be vaccinated until the symptoms improve.
Are the vaccines safe?
Yes, very safe. But, like any medicine, they can
occasionally cause mild reactions for example, a
slight fever, a sore arm or a mild rash that don't last
long.
Serious reactions are rare, but they can happen.
Overall, vaccines are among our safest and most
effective medicines, and most medical experts agree
that, for almost all children, the benefits of complete
immunization far outweigh the risks.
There are rare circumstances under which a child
should not receive certain vaccines, or should have
vaccinations delayed. Your doctor will discuss these
circumstances with you before giving the shots.
What will happen if my child doesn't
get the shots?
Maybe nothing, if your child is never exposed to
disease.
But children are often exposed to diseases. All
but one of these diseases (tetanus) are spread
easily from person to person.
If your child has not had her shots and she is
around someone who has measles, whooping
cough or one of the other childhood diseases, she
will probably get sick, too.
We are here to vaccinate the child, if your child is
not vaccinated
Is it important to keep a record of my
child's immunizations?
An immunization record helps you and
your health care provider keep your
child on schedule by reminding you
when his next immunizations are due.
A record should be started when your
child gets his first shot and updated
each time he receives an immunization.
This information will be helpful if you
move or change health care providers,
and will be needed when your child
starts day care or school.
Your child's immunization record should
be treated like a birth certificate or any
other important paper, stored in a safe
place where you can find it easily.
Have you heard that vaccine causes any
side effects, are they serious?
Possible side effects Is that serious?
Soreness, redness, or swelling at
the site of the injection
No, it will resolve with in few days and it is very
mild
Fever No, only occur in very few women and it will
resolve with in few days and it is very mild
Headache or body aches No, very rare and mild
Fatigue No, very rare and mild
All side effects are mild and reversible they
occur very rarely
RATHER
Any of the disease has very serious
consequences - death
Any myths related to vaccine?
Myth
What do
you think,
is it right
or wrong
Why not true?
Better hygiene and
sanitation will make
diseases disappear
vaccines are not
necessary?
Wrong
If we do not vaccinate our woman and children, the disease
will attack them - better hygiene, hand washing and clean
water help protect people from infectious diseases, many
infections can spread regardless of how clean we are.
Vaccine cause infertility,
children or woman who
are vaccinated are not
able to give birth to the
child?
Wrong
None of the vaccine has this side effects, many of you sitting
here and may be your family members, e may have received
the vaccine doses, you all have kid.
Have you heard of population of China, India and even Pakistan
if vaccine has this effect, than there were not so populated
Vaccine is against Islam
or religion?
Wrong

Vaccine is not prohibited in any religion. All Islamic clerics and
scholars around the world, urged in the Fatwa that vaccine is
safe and it should be give to prevent the dangerous diseases.
Are immunizations costly?
Local health departments provides
vaccinations for children at no cost or very low
cost
And will not deny childhood vaccinations for
those who cannot pay.
Care of Infants and Children
Infant and child follow-up
Form 4a will be used to register all children
between age 3-59 months, in the project
Child aged between 60 days to 6 months will
be followed every 15 days and CRF 5 will be
filled
Child aged between 6 months to 59 months
will be followed every 2 months and CRF 6 will
be filled

History of illness in infants and children
CHW will ask the mother about history of any illness is last
few days for which care was sought
The illnesses include
Not feeding well/unable to feed
Convulsions
Lethargy/unconscious
Vomit everything
Cough Cold/running nose
Fast breathing
Fever
Hypothermia
Skin pustules
Ear pain or discharge
Sore Throat
Diarrhea
Irritability
Urgent referral if the child has any
problem
Physician will fill CRF 7 after assessment of the child whether self referral or
referred by any CHW
Recommended complementary
feeding practices
Age Frequency
(per day)

Amount of food an average
child will usually eat at each
serving (in addition to
breastmilk)
Texture
(thickness/
consistency)

Variety

6 - 8
months
2 - 3 times
food
2 - 3 tablespoons Tastes up to
cup (250 ml)
Thick
porridge/pap
Mashed/
pureed
family foods
Breastfeeding
+
Staples (porridge, other local
examples) Legumes (local
examples) Vegetables/
Fruits (local examples)
Animal foods (local examples)
9-11 months 4 times
foods and
snacks
cup/bowl (250 ml) Finely chopped
Family foods
Finger foods
Sliced foods
12-23 months 5 times
foods and
snacks
-1 cup/bowl (250 ml) Finely chopped
Family foods
Finger foods
Sliced foods
Note: If baby is
Not breastfed
Add 1-2 extra times
food and snacks
Add 1-2 cups of milk per day
Responsive/Active feeding Be patient and actively encourage your baby to eat
Hygiene Feed your baby using a clean cup and spoon, never a bottle as this is difficult to clean and
may cause your baby to get diarrhoea.
Wash your hands with soap and water before preparing food, before eating, and before
feeding young children.