1. Session 4: Infant and Young Child Feeding and HIV
Nutrition Management with HIV and AIDS: Practical Tools for Health Workers
Session 4 should take approximately 4 hours
Step 1: Overview, Session Objectives and Policy Recommendations (Slides 1-7) minutes
Step 2: Advantages and Disadvantages of Feeding Options (Slides 8-13) – 10 minutes
Step 3: Exclusive Replacement Feeding and AFASS (Slides 14-20) – 30 minutes
Step 4: Exclusive Breastfeeding and Feeding Management (Slides 21-27) – 15 minutes
Step 5: DNA PCR Testing (Slide 28) – 5 minutes
Step 6: Counselling and Implementation of Guidelines (Slide 29-33) – 20 minutes
Step 7: Group Questions (Slide 34) – 30 minutes
Step 8: Young Child Nutrition (Slides 35-41) – 15 minutes
Step 9: Maternal Nutrition (Slide 42) – 5 minutes
Step 10: Role Play (Slide 43) – 45 minutes
Step 11: Case Study (Slide 44) – 45 minutes
Step 12: Key Points (Slide 45) – 5 minutes
Before beginning, ask who has gone through PMTCT training. Ask them to review how HIV is transmitted to an infant and what are the ways to prevent transmission.
In this session we will review all points related to infant and young child feeding in the context of HIV. Ask participants who has had breastfeeding management training recently. This may determine how smoothly this session goes since prior breastfeeding management training would be useful for this session.

2. Objectives
Define infant feeding options for all mothers (HIV-negative or positive)
Explain advantages and disadvantages of feeding options
Discuss barriers and your concerns about teaching exclusive breastfeed, no mixed feeding, replacement and complementary feedings
List appropriate, locally available, and easy-to-prepare complementary foods to give an infant from 6 months onwards
Explain the importance of nutrition for pregnant or lactating women
Step 1: Objectives, Overview, Policy, and Counselling (Slides 1-11) minutes
Review the objectives for this session.

3. Namibia National Policy on Infant and Young Child Feeding
As a general principle, in all populations, irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted and supported
Recommend exclusive breastfeeding for first 6 months of life, followed by introduction of complementary foods and continued breastfeeding up to 2 years or more
Breast milk provides best nutrition for all babies
Statement taken from the national policy on IYCF.
Before discussing infant feeding and HIV, we need to know the Namibian National Policy on Infant and Young Child Feeding for the general populations.
Breastfeeding will continue to be protected, promoted, and supported irrespective of HIV rates in Namibia
All HIV-negative women and those with unknown HIV status are recommended to give exclusive breastfeeding for first 6 months of life, followed by introduction of complementary foods and continued breastfeeding up to 2 years or more
This is because breast milk provides the best nutrition for all babies.

4. HIV and Infant Feeding: The Dilemma
In light of all that is known about MTCT of HIV through breast milk, this area continues to present with many questions.
Should HIV-positive mothers breastfeed their infants? Are the risks of the child dying from misuse of infant formula greater than the risk of transmitting HIV to the infant?
In the end, the appropriate decision will depend on the individual mother, the family and community, and available household resources.

5. Mother-to-Child Transmission (MTCT) of HIV
Modes of Mother-to-Child Transmission of HIV:
Pregnancy
Labor and delivery
Breastfeeding
Three ways for child to contract HIV from the mother. We are focusing on the last one - Breastfeeding

6. Risk of HIV Transmission without PMTCT Interventions
300 HIV + pregnant women
Approximately 100/300 mothers (30%) will transmit HIV to infant
16 through pregnancy
50 through labour and delivery
34 through breastfeeding
When looking at the risk of HIV transmission from mother to child, approximately 30% (100/300) of HIV+ mothers will transmit the virus, without any type of PMTCT intervention (ART, formula, etc). Of these 100 mothers, approximately 16 transmit the virus through pregnancy, 50 through labour and delivery and 34 through breastfeeding, however this number can decrease with shortened duration of exclusive breastfeeding.
Reference: Government of the Republic of Namibia, Ministry of Health and Social Services, December Guidelines for the Prevention of Mother-to-Child Transmission of HIV, Windhoek, Namibia.

7. Factors Affecting MTCT through Breastfeeding
Exclusive breastfeeding vs. mixed feeding
Duration of breastfeeding
Mother’s overall health
Recent infection or co-infection in mother
Breast condition: sores or cracked nipples
Condition of baby’s mouth (i.e. cuts or sores)
There are several factors that affect mother to child transmission of HIV through breastfeeding. Primarily, introduction of any foods or drinks (including water) with breastmilk, called “mixed feeding”. This will be discussed in more detail in later Slides.
Duration of breastfeeding can also affect MTCT. In Namibia, our policy states that if a mother chooses to breastfeed or infant formula is not recommended (due to unsafe/unsanitary conditions/inconsistent supply), the mother should breastfeed exclusively for 4 months then switch to alternative feeding options (which will be discussed later).
Other factors that affect MTCT include the mother’s health – if the mother has AIDS, a low CD4 count, and/or any type of infection, she is more likely to pass the virus to the baby.
Similarly, if the baby has sores or cuts in the mouth and the mother develops cracked nipples, the virus can be more easily passed.
These are extremely important factors to consider when providing infant feeding counselling to a mother and her partner/family.

8. Feeding Options for HIV-positive Mothers and Their Partners: OPTION 1
Exclusively replacement feed if formula is acceptable, feasible, affordable, safe, and sustainable (AFASS)
Mother should not breastfeed at all during this time
Step 2: Advantages and Disadvantages of Feeding Options (Slides 8-13) – 10 minutes
Briefly discuss the feeding options on this Slide and the next and explain that these will be discussed in detail throughout this session.
For HIV-positive mothers, the first recommended option for infant feeding is to exclusively provide replacement feeding. This will ensure that the virus will not be passed to the baby in the postnatal period. However, there are 5 critical conditions that must be met by the mother and her home situation in order for replacement feeding to be safe for the infant. These 5 conditions, acceptable, feasible, affordable, safe, and sustainable (AFASS), will be discussed further in this session.
It is critical to remember that a mother who chooses replacement feeding must not breastfeed at all during this time.

9. Feeding Options for HIV-positive Mothers and Their Partners: OPTION 1
Exclusively breastfeed for 4 months, followed by early cessation and switch to replacement feedings
If even one of the 5 critical criteria (AFASS) for replacement feeding cannot be met, then the second option for infant feeding is to exclusively breastfeed for 4 months with abrupt cessation and switch to replacement feeding.
This is stated as the policy reads, however, the purpose now is to provide you with training on how to implement this. Not all mothers will be able to stop breastfeeding at 4 months. Some may be able to stop before 4 months if replacement feeding is AFASS. Some may need to continue breastfeeding after 4 months because replacement feeding is not AFASS.
These are important considerations for health workers and counsellors to know when providing all information to mothers and their partners.
Before going through Slides 10-13, ask participants what the advantages and disadvantages of each option are and list these on a flip chart.
Once all have been listed, review Slides and point out advantages or disadvantages not mentioned.

10. Exclusive Replacement Milk
Advantage
No risk of HIV transmission to the baby
Because Namibia is a country with a high infant mortality rate, largely due to malnutrition, the only true advantage to replacement feeding is that there is no risk of HIV transmission to the baby if replacement milk is exclusive.

11. Exclusive Replacement Milk
Disadvantages
Risk of diarrhoea, malnutrition, and infant death if formula not prepared correct
Less bonding between mother and baby
Lack of antibodies found in breast milk leading to more infections
More stigma if replacement feeding is associated with HIV status
Replacement milk has many disadvantages, particularly in countries with a high under-five mortality rate.

12. Exclusive Breastfeeding
Advantages
Promotes bonding of mother and baby
Provides best nutrition
Easy, affordable, safe, always available
Less risk of diarrhoea, malnutrition
Promotes brain development and growth
There are several advantages to exclusive breastfeeding for both the baby and the mother.
Breastfeeding promotes bonding between the mother and baby, thereby reducing the chances of child neglect or abuse later in life.
Breastfeeding is also the most ideal and complete nutrition for the baby for the first six months of life. It is easy to provide, affordable, safe and readily available.
Due to the antibodies in breastmilk, the baby will have a lower risk of developing diarrhoea or malnutrition, which are both very high among children under 5 in Namibia.
Breastmilk also promotes brain development and growth for the baby

13. Exclusive Breastfeeding
Disadvantage
Risk of HIV transmission to the baby
Note that not all HIV positive mothers who breastfeed will transmit the virus to the baby. This is important to know and understand when providing counselling on feeding options.
As discussed earlier, the risk of HIV transmission from mother to child is approximately 30% and of those, approximately 34% will transmit the virus through breastmilk. Therefore of the 300 HIV positive pregnant women, only 11% will pass the virus to the baby through breast milk (34 out of 300 equals 11%). This 11% can actually be reduced with exclusive breastfeeding, shortened duration of breastfeeding, and management of breast conditions and sores in the baby.

14. Exclusive Replacement Milk
Infant formula or modified animal’s milk
When giving animal’s milk, baby will need a daily multi-vitamin and mineral supplement
Cup feed only
Give no breastmilk or other non-milk foods (i.e. porridge drinks) before 6 months
Baby may need water to prevent constipation
Step 3: Exclusive Replacement Feeding and AFASS (Slides 14-20) – 30 minutes
Refer participants to Handouts for use in this step and throughout this session
Replacement from birth to six months should always be milk-based since the baby’s GI tract cannot adequately absorb or use any other food. Replacement feedings that are recommended and used in Namibia are either infant formula or modified animal’s milk. When given animal’s milk, baby will need a daily multivitamin
Infants should be fed by a cup instead of a bottle. This is recommended for sanitary reasons, and to prevent the baby from developing mouth sores from artificial teats and nipples.
Exclusive replacement feeding means the baby is not given any breastmilk or other non-milk based foods such as porridge drinks. The baby can receive water when given replacement feeding.

15. Replacement Milk Assess home and community situation: Acceptable
Feasible
Affordable
Sustainable
Safe
Present the criteria and explain that the participants will brainstorm the meaning of these criteria in small groups.
All of these conditions must be met before the mother can safely choose replacement feeding. If one or more cannot be met, the mother should be advised and supported to exclusively breastfeed for the health of the baby.
ACTIVITY: allow 15 minutes for this activity
Break participants into 5 groups – for time sake, group people sitting next to each other. Assign one of the criteria to each group and have participants brainstorm how they understand the term.
Allow 5-10 minutes for groups to brainstorm.
Bring the groups back together and allow 5-10 for groups to present their discussion.
Conclude the activity. Present Slides and only touch on points not mentioned by participants. During this time, refer participants to Handout 4.3.

16. Acceptable
Social and cultural factors involved with infant feeding, particularly breastfeeding
Assess if community/home will accept the use of replacement milk without stigmatising or isolating the mother
The term acceptable means to consider the social and cultural factors involved with infant feeding, particularly breastfeeding
Assess if community/home will accept the use of replacement milk without stigmatising or isolating the mother

17. Feasible (Possible)
Help the mother/partner consider the economic, behavioral, psycho-social aspects around replacement milk
Resources and skills are required with this option
Formula must be prepared before every feed, day and night
Feasible or possible means to help the mother/partner consider the economic, behavioral, psycho-social aspects around replacement milk
Extra resources and skills are required with replacement milk, such as formula must be prepared before every feed, especially if no refrigeration available

18. Affordable
Assess if the mother/partner has enough money to purchase formula or milk to prepare at home for up to 1 year
Household needs access to fuel, utensils to boil water and feed the baby, and soap to clean all utensils and cups
Assess if the mother/partner is able to afford formula or milk to prepare at home for up to 1 year
Household needs access to fuel, utensils to boil water and feed the baby, and soap to clean all utensils and cups
We also need to assess here the dynamics of the household and the mother’s power in the family to take money to purchase soap, utensils, formula, etc.

19. Sustainable Milk must be prepared for each feed every day and night
Need continuous, uninterrupted supply of formula or milk, utensils, fuel, water, and detergents for up to 1 year
Replacement milk should be exclusive over first 6 months (no breast milk or other foods given)
Replacement milk must be sustainable, meaning that the mother or family can prepare milk for each feed every day and night
The mother/family needs a continuous, uninterrupted supply of formula, utensils, fuel, water, and detergents for up to 1 year
Replacement milk should be exclusive over first 6 months, meaning that the mother will not feel pressured or any desires to breastfeed. This would introduce mixed feeding and put the baby at risk for HIV transmission, as well as other illnesses from disrupting the GI tract

20. Safe
Need clean water and detergent (soap) to clean utensils before and after every feed
Safe preparation of formula – not over or under-diluted, according to instructions on formula tin
Need to check expiry date of infant formula and fresh animal’s milk
Replacement milk should be safe, meaning the mother/family needs a steady supply of clean water and detergent (soap) to clean utensils before and after every feed
Formula or milk is prepared safely, meaning it is not over or under-diluted. Sometimes if formula or milk supply is not adequate, mothers may dilute the formula or milk to make it last longer. This is very dangerous and can lead to malnutrition and death of the infant.

21. Exclusive Breastfeeding
Must be exclusive (only breast milk)
No water, tea or porridge
Stop breastfeeding abruptly, when replacement milk acceptable, feasible, affordable, sustainable, and safe (AFASS)
Step 4: Exclusive Breastfeeding and Feeding Management (Slides 21-27) – 15 minutes
Refer participants to Handouts for use in this step and throughout this session
If mother chooses to breastfeed, considerations:
Exclusive breastfeeding means the baby is fed only breastmilk without other foods or liquids, including water.
To best prevent HIV transmission, but also considering risks of replacement milk, the mother should be counselled on early cessation of breastfeeding with abrupt stopping and switch to replacement milk when replacement milk becomes AFASS.

22. “Mixed Breast Feeding”
When an infant is fed breast milk with other foods or liquids, even water, before 6 months
Increases risk of HIV transmission and other illnesses/diseases
Should be avoided for ALL babies before 6 months, regardless of HIV status of mother
As discussed earlier, the term “mixed feeding” refers to giving any other foods or liquids (even water) to a baby who is receiving breastmilk. This is particularly dangerous for the infant as introduction of other foods or liquids with breastmilk can disrupt the infants gut and allow particles, such as HIV, to pass through into the blood stream. Mixed feeding is dangerous for all babies due to increased risks of infections and other diseases, but particularly important when preventing HIV transmission.

23. Breastfeeding Management
Show the mother:
Correct positioning
Correct attachment
Management of sore or cracked nipples, blocked ducts, mastitis, or breast abscess
Follow-up to check progress
Stress exclusive breastfeeding
When counselling a mother on how best to breastfeed and reduce the risk of HIV transmission, breastfeeding management should be discussed.
Show the mother:
Correct positioning
Correct attachment
Management of sore or cracked nipples, blocked ducts, mastitis, or breast abscess
Always follow-up to check progress
Stress exclusive breastfeeding

24. Breastfeeding and HIV Counsel on abrupt stopping at 4 months
How to transition to replacement feeding
If replacement feeding is not AFASS at 4 months
Mothers and their partners need counselling on how to abruptly stop breastfeeding to avoid any mixed feeding.
Ask participants to share how they would counsel a mother on abrupt stopping of breastfeeding and transition to replacement feeding – what is the process that a mother needs to know in order to effectively stop breastfeeding and transition?
If a mother cannot or does not want to stop breastfeeding at 4 months, then she can be counselled on continuing until she is ready to stop and replacement milk is AFASS. During this time breastfeeding should still be exclusive. At 6 months, the baby can be transitioned to replacement milk or unmodified milk and complementary foods, as will be discussed in the coming Slides.

25. Counselling on Abrupt Stopping at 4 Months
ASSESS prior to stopping
Acceptance and support from partner, family and/or community
Available, regular and appropriate supply of breast milk substitute
Ability to safely prepare breast milk substitute
Ability to cup feed
Importance of continued physical contact with baby
Strategies to prevent engorgement
The following are critical to assess before the mother stops breastfeeding and should be addressed as early as possible to avoid mixed feeding.
Acceptance and support from partner, family and/or community
Available, regular and appropriate supply of breast milk substitute
Ability to safely prepare breast milk substitute
Ability to cup feed – the family has a cup that can be used to feed the baby, and are able to keep all utensils clean
Importance of continued physical contact with baby
Strategies to prevent engorgement for the mother. She should express just enough milk to relieve swelling, but not too much as to stimulate more milk production.
Before discussing Slide 25, Transition from EBF to ERF, ask participants how they currently counsel mothers on this transition. Gather information from the participants on how this is currently done and what information mothers have on how to transition without mix feeding.
After participants have discussed this, go through the Slide step-by-step to thoroughly explain this transition method. This information is important for participants to bring back to their work and teach other health workers and mothers/partners.

26. Transitioning
Steps for successful transition from breastfeeding to replacement milk:
Express breast milk and provide feedings by cup between regular feeds
As the infant begins to accept cup feeding, replace breast feedings with cup feedings one feed at a time
Once all breast milk feeds are accepted by cup, begin feeding only breast milk substitutes (formula or modified cow’s or goat’s milk)
Mother should provide extra comfort to the baby during this time
Support mother as baby may cry and fuss
The following are steps for successful transition from breastfeeding to replacement milk:
Express breast milk and provide feedings by cup between regular feeds
As the infant begins to accept cup feeding, replace breast feedings with cup feedings one feed at a time
Once all breast milk feeds are accepted by cup, begin feeding only breast milk substitutes (formula or modified cow’s or goat’s milk)
Provide extra comfort to the baby during this time, such as swaddle, sing to the baby, rock, carry/hold, etc.
Support mother as baby may cry and fuss during this time

27. If Replacement Milk is Not AFASS at 4 Months
If the mother is healthy
If she is exclusively breastfeeding
Then continue until replacement milk is AFASS or infant is 6 months and can tolerate unmodified milk and solid foods
It is important to consider that each mother’s situation is different and many mothers may not be able to stop breastfeeding or may not want to stop breastfeeding at 4 months. These factors should be considered and mothers should be counselled appropriately so she can make a decision with her partner or family.
If the mother is healthy, meaning she has a good CD4 count (>200), and she is still able to breastfeed exclusively, then breastfeeding can continue until six months when the baby can begin taking unmodified milk and complementary foods. Breastfeeding still needs to stop abruptly whenever the mother is able to stop.

28. HIV Testing for Infant HIV DNA PCR testing to be introduced
Test infants from 6 weeks
Discuss infant feeding options before infant receives test
Re-evaluate infant feeding based on test result
Continue to advise against mixed feeding
HIV-infected babies should continue breastfeeding as per National Breastfeeding Policy
Step 5: DNA PCR Testing (Slide 28) – 5 minutes
Since HIV DNA PCR test, can detect HIV in an infant while the infant is potentially still exposed to HIV (if the mother is breastfeeding), health workers need guidance on how to counsel mothers based on the infant’s diagnosis.
This test is currently rolling-out throughout the country.
Infants are tested at 6 weeks, and the results are given at the 10 week follow-up visit. This tests looks at the antigen of the virus instead of the antibodies so it is more accurate for infants under 18 months of age.
Counselling on infant feeding should be done before the baby is tested so that the mother/partner can consider options before they receive results. It is critical that mothers who continue breastfeeding an HIV-negative baby are urged to continue exclusive breastfeeding and are followed up regularly.
HIV-infected babies should continue breastfeeding as per National Breastfeeding Policy

29. Counselling Provide all information on options
Allow mother and partner to choose
Discuss home situation, family and community/village support
Partner involvement
Support and counselling
Follow-up
Step 6: Counselling and Implementation of Guidelines (Slide 29-33) – 20 minutes
Refer participants to Handout 4.6 for use during this step.
It is very important for health workers to gain skills in counselling on infant feeding. Mothers should be provided information on both options and, after all information is given, be allowed to make the choice on how to feed her baby.
Health workers and counsellors can help in discussing the mother’s home situation, insisting on partner involvement in the decision, and providing ongoing support and follow-up.
The last two bullets are particularly important, and possibly the most challenging to achieve.
Facilitator: take this opportunity to ask participants about follow-up and how they follow clients after they have given birth.

30. Use the flowchart (Handout 4
Use the flowchart (Handout 4.6) to explain how to use the guidelines and policies on infant and young child feeding.

31. Infant Feeding Risk-Benefit of feeding options must be considered
Discuss all risks and benefits of each option with mother and her partner
Diarrhoea
Pneumonia
HIV
Breastfeeding in the context of HIV poses a major public health dilemma as far as child survival is concerned. We know that breastmilk transmits the virus but we also know that infants who do not breast feed in the developing world are at risk of death from diarrhea pneumonia and malnutrition. Infant feeding recommendations have to somehow balance these competing risks none of which are trivial.
This tension where on the one hand breastmilk transmits HIV and on the other hand lack of breastfeeding puts infants at risk of infectious disease mortality is reflected in the current recommendations regarding infant feeding in the context of HIV. Where rather than just saying that women should or should not breastfeed, certain conditions have to be met such as acceptability to the women and her family, feasibility and affordability of using alternatives to breastmilk and safety i.e the woman understands how to prepare the formula and has a safe water supply.
Mothers and their partners need to receive adequate counselling and support in making these decision for the best interest of their baby.

32. Challenges and Barriers for Health Workers
What challenges or barriers do you expect to have in implementing infant feeding recommendations?
How do you think these challenges can be resolved?
Discuss challenges and barriers that health workers may face. Generate discussion, as time allows, on what participants feel are barriers to implementing these guidelines.

33. Challenges to Effective Implementation of Infant Feeding Guidelines
Provider’s prejudice given in counseling
Health services inability to deliver appropriate of infant feeding counseling
Common infant feeding practice
Client’s own knowledge and choices
Support from the partner, family, and/or community
Ever-changing recommendations and research on infant feeding and HIV
Among the many challenges in effectively implementing infant feeding and HIV guidelines, the following should be considered by all implementers:
Provider’s prejudice given in counseling. Health workers should not allow their own personal feelings on infant feeding sway their counselling. Rather, they need to give all information to the mother/partner and allow them the right to make an informed decision.
Health services inability to deliver appropriate of infant feeding counseling – an increase in health worker training and support in providing counselling is needed.
Common infant feeding practice – we must consider the cultural practices in each community and how they could influence infant feeding decisions
Client’s own knowledge and choices
Support from the partner, family, and/or community – it is critical to start involving the partners, family members, and community. We, as health workers and counsellors, need to mobilize the community to recognize the issues and challenges around infant feeding and HIV.
Dynamism of infant feeding – infant feeding challenges vary from community to community and house to house, therefore these issues need to be addressed on an individual as well as community wide level to spread consistent messages.
There is currently a great deal of confusion around infant feeding practices and recommendations, but if we can start to spread the same and correct messages throughout our health facilities and the communities, perhaps we can begin to see an improvement in care and eventually less HIV transmission and malnutrition in babies.

34. Group Questions
Group 1: If I breastfeed, I will need to eat more food myself to make good milk. I can’t afford this extra food. Would it be better to use formula for the baby instead?
Group 2: If I breastfeed and I have HIV, then my baby may get HIV from the milk. If the baby gets other milk, the baby may get sick and die. How can I decide what to do?
Step 7: Group Questions (Slide 34) – 30 minutes
Present Slide 34 and refer participants to Worksheet 4.1 for these group questions.
Divide the class in either 2 or 4 groups (depending on size of class). Groups should not be more than 5 people. Assign one question to each group. Ask groups to brainstorm their assigned question.
Allow 15 minutes for group work. Allow another 15 minutes for each group to present their answers and class discussion.
Worksheet 4.1 in the Facilitator Guide contains discussion points for the facilitator.
Summarise the discussion and activity

35. Introduction of Complementary Foods
When? 6 months
What? Household staple energy foods and locally available foods plus 2 cups of milk per day
How? Gradually by spoon, feed liquids with a cup
Step 8: Young Child Nutrition (Slides 35-41) – 15 minutes
For all infants, complementary foods should start to be introduced at 6 months. For infants of HIV-positive mothers who are being breastfed still, the breastfeeding should stop abruptly then complementary foods and drinks can be given. We still want to avoid mixed feeding for HIV-exposed infants.
For infants of HIV-negative mothers or those who do not know their status, Namibian recommendations are to continue breastfeeding up to 2 years and beyond with introduction of nutritious complementary foods at 6 months.
Begin introduction of complementary foods with household staple foods, which are high in energy and locally available. These are foods such as porridge, mashed pumpkin or other vegetable, or mashed fruit like banana, guava, or paw-paw. When providing counselling on introduction of complementary foods, it is critical to discuss locally available foods.
Foods should be introduced either with a spoon or cup for liquids.

36. Complementary Foods: How Often and How Much?
One to two teaspoons twice a day; gradually increase amount and frequency
One food at a time to avoid confusion
Introduce well-mashed vegetable and fruits, one spoon of one food at a time
Add other food e.g. soft meat, fish, chicken and egg (only yellow) and enrich staple food with oil, fats and nuts at 9 months
Include 2 cups of milk per day
Complementary foods should be introduced one to two teaspoons twice per day and gradually increased in amount and frequency.
Infants tend to accept one food at a time, so take one week to introduce one food, then another week to introduce a different food.
In addition to staple foods such as porridge, introduce mashed vegetables and fruits to ensure the child receives all essential nutrients to grow and develop well.
As the infant begins to grow and accept other foods, introduce protein foods like soft meats, fish, chicken and egg (only yellow) and enrich staple foods with fats or groundnuts at 9 months.
If child needs extra nutrients and short supply of infant formula is available, sprinkle formula on porridge or vegetables. Also, can sprinkle un-sifted maize/millet flour on porridge or vegetables.

37. Examples of Appropriate Complementary Foods
Soft porridge
Fortify with baobab fruit (powder), mashed beans, pounded dried fish (sift to remove all bones), 1 egg, milk powder, infant formula (add scoop to porridge), or other locally available foods
Mashed vegetables – examples: pumpkin, potato, sweet potato, carrots, well-cooked greens (spinach)
Soft fruits – examples: mango, papaya (paw-paw), banana, guava
Porridge is a staple and is usually readily available to families, but it can lack many nutrients that are necessary for a child. To fortify porridge with locally available foods use the following suggestions:
Fortify with baobab fruit (powder), pounded or well cooked dried fish (sift to make sure powder does not have bones left), 1 egg, milk powder or infant formula (add scoop to porridge)
Mashed vegetables – pumpkin, potato, sweet potato, carrots, well-cooked greens (spinach)
Soft fruits – papaya (paw-paw), banana, guava

38. Strategies to Prevent Malnutrition and Promote Good Nutrition
Nutritious complementary foods and drinks with locally available foods
Ensure adequate nutrient intake
Growth monitoring at each follow-up visit
Referral to hospital if severe acute malnutrition
Prompt treatment and nutrition management for infections (e.g. oral ulcers)
Provide appropriate and hands-on information for preparation of nutritious complementary foods using locally available foods.
Ensure adequate nutrient intake. The child should eat a variety of foods several times a day to ensure he/she is getting all the necessary nutrients.
Monitor growth of child by measuring height or length, weight, and head circumference at each follow-up visit.
Promote adequate health and nutritional status of women and other care-takers of infants and young children
Prompt treatment and nutrition management for infections (e.g oral ulcers)

39. Nutritional Issues in the HIV Infected Child
Poor nutrition weakens the immune system, increasing the child’s risk for common infections
HIV infected children are at increased risk of malnutrition because of:
Weaker immune systems due to infection
Inappropriate feeding practices
Household food insecurity
Orphan or vulnerable status
Continue breastfeeding to protect the baby from other infections and prevent malnutrition
For HIV-positive children, nutrition is even more important to prevent malnutrition and maintain a strong immune system because the child may be at greater risk of developing infections.
Discuss the factors involved in a high risk of malnutrition listed
Point out that their immune systems are weaker due to the infection therefore they may not be able to fight infections or maintain their weight as easily.
Continue breastfeeding to protect the baby from other infections and prevent malnutrition. Remember that once a baby is HIV-infected, we are no longer trying to prevent HIV transmission; therefore, the safest feeding for the baby is to continue receiving breastmilk (if mother is breastfeeding) up to 2 years.

40. Feeding a Child During Illness
Encourage caregiver to be patient with child
Encourage (not force) the child to eat, even if not hungry
Continue feeding the child during illness
Feed extra foods once the child has recovered from the illness until she/he has regained lost weight and is continuing to grow at a normal pace
Refer participants to Handout 4.7 for reference on this topic.
As with adults, children who are ill still need food, and often times, they need more food than normal. It is important, though, not to force a child to eat, rather be patient and nurturing.
Counsel the mother on trying creative ways to encourage the child to eat and make foods high energy and nutrient-dense to make up for eating less.
During recovery, continue to give extra foods until she/he has regained lost weight and is continuing to grow at a normal pace.

41. Goals of Infant and Young Child Feeding
Provide optimal nutrition for infants and children
Reduce HIV transmission through breast milk
Keep babies healthy, alive, and HIV free
For HIV-infected babies, continue providing extra nutrition care and support
Our goals in infant and young child feeding are to:
Provide optimal nutrition for infants and children
Reduce HIV transmission through breast milk
Keep babies healthy, alive, and HIV free
For HIV-infected babies, continue providing extra nutrition care and support

42. Maternal Health and Nutrition
Good maternal nutrition is important for
Infant growth and development
Prevention of MTCT
Promotes adequate milk supply if breastfeeding
Benefits household
Stress family planning and continued safer sex practices
Step 9: Maternal Nutrition (Slide 42) – 5 minutes
Equally important to infant and young child feeding are maternal health and nutrition. If a mother is not healthy, then there is a risk that the baby may not grow and develop well.
Maternal health is also important for PMTCT in terms of the risk of HIV transmission to the baby.
Good maternal nutrition can ensure that a breastfeeding mother will produce enough milk supply to feed the baby.
Maternal nutrition also benefits the entire household as well as the community as women are an equal part of society, yet are often marginalized by gender bias.
Women also need counselling on family planning and safer sex practices.
In terms of nutrition, lactating mothers need to increase their energy intake from food by about 10 percent. To achieve this, health workers or counsellors can encourage mothers to add high-energy local foods to staple food, such as an egg to porridge or 1-2 teaspoons of oil.

43. Role Play Step 10: Role Play (Slide 43) – 45 minutes
Follow the instructions in Worksheet 4.2 to conduct the role play

44. Case Study Step 11: Case Study (Slide 44) – 45 minutes
Follow the instructions in Worksheet 4.3 to conduct the case study

45. Key Points
Counsel and support mothers and their partners on infant feeding options
If choice is replacement feeding,
Stress exclusive, give no breast milk during this time
Must be AFASS
If choice is breastfeeding,
Stress exclusive
Abruptly stop at 4 months or when AFASS
Add complementary foods at 6 months
Stress good maternal nutrition through pregnancy and after birth
Step 12: Key Points (Slide 45) – 5 minutes
Review the key points as listed on the Slide.