Facilitators Guide for Training on Kangaroo Mother Care

Facilitators Guide for Training

on Kangaroo Mother Care

This facilitator’s guide was prepared by Tedbabe D. Hailegebriel UNICEF HQ.

Christabel Nyange as part of consultancy with UNICEF HQ (New York) with

support from the Bill and Melinda Gates Foundation developed the lesson plan.

Dr. Julieta Villenga Rosales reviewed and provided input. Overall guidance and

direction provided by Nabila Zaka (UNICEF HQ), Kimberly Harding (Nutrition

International) and Stella Abwao for reviewing/providing comments and project

support by Seun Oyedele (UNICEF HQ).

This publication has used training materials, technical presentations, inpatient

record forms, and monitoring tools from the American Academy of Pediatrics

and South African Medical Research Council Unit for Maternal and Infant

Health Care Strategies at the University of Pretoria, University of Pretoria,

WHO and Save the Children. The Do No Harm Technical Series was prepared

by a team led by Jim Litch and Judith Robb-McCord (Every Preemie–SCALE)

and Lily Kak (USAID).

Find all presentations and key documents here.

ACKNOWLEDGEMENTS

Cover Photo: © UNICEF/UN0135391/Selaam

Background: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Planning and Organizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Facilitators’ Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Your Role as Facilitator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Training plan by each day (agenda) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Introduction to key resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Lesson Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Knowledge Check (Pre-and post-test) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Answer to Knowledge Check (Pre and post-test) . . . . . . . . . . . . . . . . . . . . . . 33

Skill Assesment Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Discussion guides for group works/templates . . . . . . . . . . . . . . . . . . . . . . . . . 36

Template for SWOT ANALYSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Template for Follow-up monitoring and national scale-up plan . . . . . . . . . . . 37

Template for Prioritising Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Tips for facilitators for Crinkle-Free Workshop . . . . . . . . . . . . . . . . . . . . . . . . . 38

Administrative note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Introduction to workshop participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Team building at the beginning and introductions . . . . . . . . . . . . . . . . . . . 38

Ice breakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Facilitator meetings: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Sample Budget for the KMC training . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Workshop Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

CONTENTS

The global neonatal mortality rate fell from 37 (36, 38) deaths per 1,000 live births in

1990 to 19 (18, 20) in 2016, and 2.6 (2.5, 2.8) million children died in the ﬁrst month of

life in 2016 – approximately 7,000 newborn deaths every day – most of which occurred

in the ﬁrst week, with about 1 million dying on the ﬁrst day and close to 1 million dying

within the next six days

. Complication related to preterm births is the leading cause

of death among children under ﬁve. Three-quarters of all neonatal deaths occur during

the ﬁrst week of life, 25–45% in the ﬁrst 24 hours

2,3

globally, nearly 1 million babies die

each year from complications of premature birth and preterm birth is one of the leading

causes of newborn morbidity and mortality globally.

Low coverage of proven interventions and large disparities in coverage across population,

particularly in the postnatal and childhood periods, result in millions of preventable deaths

of newborns. Despite strong evidence regarding the improved health outcomes among

preterm or low birth weight infants receiving KMC, including a recent recommendation

by the World Health Organization that KMC should be routine care for newborns

weighing less than 2000 g

, only modest KMC coverage has been achieved globally.

Millions of LBW babies still do not have access to KMC and other essential neonatal care

interventions, such as those to prevent and cure infections and ensure adequate nutrition.

A previous systematic review identiﬁed barriers to health system adoption of KMC and

noted that families play an important role in KMC adoption

. Further, the review noted

that family interactions with the health system were critical to KMC adoption. Caregivers

(e.g. mothers, fathers, and families) are key implementers and beneﬁciaries of KMC.

Health system and social barriers for KMC implementation includes lack of awareness

on the beneﬁts of KMC, expectation that KMC could be done with no or little instruction,

lack of social support, caregivers’ medical concern including the clinical conditions of the

mother and the baby, lack of space for privacy and KMC resources and lack of money

for transportation

. Studies have shown that strategies that can improve the presence

of staff, supplies, and space for KMC is a prerequisite for quality implementation of

KMC as well as the qualityof key components of KMC—skin–to–skin care, exclusive

breastfeeding and discharge and outpatient follow-up care—is also needed to achieve

meaningful process evaluation and scale–up of this life–saving intervention

1 UNICEF UN Inter-agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality.

New York: UNICEF, 2017 report

2 Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet, 2005, 365:891–900.

3 Born Too Soon: The Global Action Report on Preterm Birth. World Health Organization. Geneva: World Health.

Organization Geneva, 2012. Available: www.who.int/pmnch/media/news/2012/preterm_birth_report/en/.

4 WHO. WHO recommendations on interventions to improve preterm birth outcomes. In. Geneva:

World Health Organization. (2015).

5 Chan GJ, Labar AS, Wall S, Atun R. Kangaroo mother care: a systematic review of barriers and enablers.

Bull World Health Organ. 2016; 94(2):130–41J.

6 Emily R. Smith, Ilana Bergelson, Stacie Constantian, Bina Valsangkar and Grace J. Chan. Barriers and enablers of health

system adoption of kangaroo mother care: a systematic review of caregiver perspectives. BMC Pediatrics 2017 17:35

DOI: 10.1186/s12887-016-0769-5

7 Kondwani Chavula , Dyson Likomwa, Bina Valsangkar, Richard Luhanga, Lydia Chimtembo, Queen Dube, Wasihun

Andualem Gobezie, Tanya Guenther. Readiness of hospitals to provide Kangaroo Mother Care (KMC) and documentation

of KMC service delivery: Analysis of Malawi 2014 Emergency Obstetric and Newborn Care (EmONC) survey data.

www.jogh.org • doi: 10.7189/jogh.07.020802

BACKGROUND

This Facilitator’s Manual originally designed for a ﬁve-day training course on Kangaroo

Mother Care (KMC) clinical skills and program planning, monitoring and evaluation,

maternal, perinatal death audits and surveillance (MPDSR) and Infection Prevention

and Control(IPC). It was pretested in four trainings in Beirut for MENA region, in Nepal

and Pakistan for ROSA and South Africa for ESARO and WCAR. Participants in these

trainings pointed out that time was not sufﬁcient to adequately cover the MPDSR and

IPC components and the need to include health workers who are responsible for these

activities who may not be represented by participants selected for the KMC training.

The current revision includes three and half day training on KMC while two modules on

IPC and MPDSR are developed and will soon be pretested. By applying the knowledge

and skills acquired at the workshop; participants are expected to change their facilities’

ability to address newborn health issues speciﬁcally the provision of quality care for

management of LBW/preterm infants and ensure better outcomes.

How should this document be used?

The workshop intends to equip participants with knowledge and skill to manage Low

Birth Weight/preterm baby and provide essential newborn care, train health workers, plan

and implement KMC at scale, monitor and analyze data related to ENC, LBW/preterm

and KMC, and follow-up at home while caring for the LBW/preterm infants. This capacity

building workshop is designed to support the roll-out of the 2015 WHO recommendations

on Interventions to Improve Preterm Birth Outcomes. If you have comments or

suggestion for improving this document contact Dr. Tedbabe at thailegebriel@unicef.org

What is to be taught and how?

• There is a need to have a training schedule or agenda

• The agenda should contain date, time, and sessions/topics to be covered

and responsible persons, tea/coffee and lunch breaks

• The agenda should also include the objectives of the training program,

introduction of participants and of the training program, and methods of evaluation

Who is responsible for what?

• A training program needs a course coordinator, ﬁve facilitators with relevant

skills and experience, administrative and support staff

• Facilitators should divide tasks among themselves before hand and be well

prepared on the tasks they are going perform

• The course coordinator organizes the training program and coordinates activities

• Facilitators provide information, organize learning tasks, demonstrate and

supervise skill practice, evaluate the progress of participants and provide feedback

• Administrative and support staff provide administrative, secretarial, logistics

and other services for the training

Powerpoint slides for lectures.

The facilitators can use all the slides or select based on the need and capacity

of the participants. There are video demonstrations of key clinical skills. Show

each video demonstrations of skills in plenary, let facilitators demonstrate on

each table followed by practice among pair of participants.

A successful training needs good planning and preparation ahead of time.

The concept note for the training should include these three points

1) Background information that highlights why topic is important to prospective

audience; 2) What the attendee can expect to happen? How will the learning

objectives be achieved? and 3) What the attendee can expect to take away?

-knowledge and/or skills as well as tangibles (resource material, handouts).

It is important to stress the interactive portions of the workshop. In planning

a training course, the facilitator needs to answer the following questions:

Aim

This facilitators guide was developed as a reference to guide health workers

responsible for the training of health care providers at primary and district level

health facilities. The aim is to standardize the knowledge of health professionals

in the management of preterm and/or low birth weight infants through essential

newborn care, to train health professionals in the implementation of two

components of KMC; kangaroo position and nutrition and feeding strategies

for preterm and low birth infants, and to sensitize health care providers on the

importance of early discharge with outpatient follow-up and the relevance and

impact of prematurity and low birth weight on newborn mortality.

Who is the intended audience?

The organization that is planning the

training need to identify the skills level

of the learner/participant, and since

health workers have different training

backgrounds and functions, it is best

to establish aims and tailor the training

accordingly. This workshop is intended

for doctors, nurses and midwives who

provide care for preterm and low birth

weight infants and who are responsible

for planning and managing newborn

health programs in health facilities and

the Ministry of Health. Trainees should

possess basic competences in maternal

and newborn care. Their knowledge and

basic experience in caring for preterm

and low birth weight infants can be

strengthened under the concepts of

Kangaroo Mother Care, as expressed

through its three components: kangaroo

position, kangaroo nutrition and early

discharge with outpatient follow-up.

PLANNING AND ORGANIZING

What skills will be acquired?

• Providing essential newborn care for

preterm and low birth weight babies

• Routinely assessing the baby and mother

• To counsel and support mother initiate

breast feeding

• To identify, prevent and mange

hypothermia

• To use interpersonal communication to

counsel and support mother to put baby

in KMC position in the facility and at

home after discharge

• To teach mothers to express breast

milk, to cup, syringe or dropper feed

the baby, to feed baby through naso

gastric tube

• To teach and support mothers in home

care for the baby and to recognize

danger signs and ask her to promptly

seek care when concerned

• To provide follow-up care

• To mobilize institutional support, plan,

implement and monitor KMC program

How many participants will be in the training course?

The training requires extensive practical skills and should accommodate a

number that is easy to manage. The number should not exceed 25 to 30

participants per class.

What is to be taught and how?

• There is a need to have a training schedule or agenda

• The agenda should contain date, time, and sessions/topics to be covered

and responsible persons, tea/coffee and lunch breaks

• The agenda should also include the objectives of the training

program, introduction of participants and of the training program,

and methods of evaluation

• A training program needs a course coordinator, ﬁve facilitators with

relevant skills and experience, administrative and support staff with

following clear delineation of responsibilities:

• Facilitators should divide tasks among themselves before hand

and be well prepared on the tasks to be performed

• The course coordinator organizes the training program

and coordinates activities

• Facilitators provide information, organize learning tasks, supervise skill

practice, evaluate the progress of participants and provide feedback

• Administrative and support staff provide administrative, secretarial, logistics

and other services for the training

How many facilitators are needed and what

qualiﬁcations should they have?

• The number of facilitators should be determined based on the number of

staff and trained facilitators available. It is good to have up to 5 facilitators

conducting a training program. Ensuring that facilitators have relevant

skills and experience is key, maximum facilitator to trainee ratio

should be 1:6

• Facilitators should know the content of the training modules and be

skilled in the aspects they teach

• Facilitators should be well versed in pedagogical techniques and

imparting skills as stipulated in the training guides

• Facilitators should be KMC experts. A KMC expert is a health

professional with practical (i.e. has worked in a certiﬁed Kangaroo

Mother Care Program) and theoretical expertise in all three components

of Kangaroo Mother Care, and is able to train and show others how to

properly apply the Kangaroo Mother Care Method and has the capacity

to evaluate the functioning of a Kangaroo Mother Care Program.

What facilities/preparations are needed?

Administrative Notes for the training event.

Administrative note should include essential information on dates, visa,

venue, security, etc is sent at least 4-6 week ahead of the workshop date.

Similarly, the lead facilitator need to inform participants about necessary

preparations, documents or data they need to bringso participants come

prepared. It is crucial to follow-up and compile list of participants with

their responsibility, past training experience on the topic and current role in

newborn care.

Venue

When selecting a venue consider a place that allows the intended number

of patcipants to attend and is suitable for the educational objectives.

A large room with chairs and tables) is required in which all participants

can sit comfortably. The room also needs to have provisions for video

demonstration in plenary.

Participants will be organized in

groups of 6 per facilitator. Each

group will need to refer to an

Action Plan and a Facilitator Flip

Chart. Each participant will need

a Provider Guide and recording

sheets for the Knowledge Check

(multiple choice questions)

and Objective Structured

Clinical Evaluations (OSCE A

and B). Each pair or group of

3 participants will work with a

small baby simulator, manikin or

doll and additional equipment.

A premature newborn simulator is available for insertion of a nasogastric

tube, and a breast model can be used for training manual expression of milk.

Visit to KMC Facilities

A visit to a functioning KMC service should be a mandatory component

of this training. The course coordinator should write an ofﬁcial paper to

the health facility. It is necessary to assign a focal person who selects

and keeps sick children for the participants according to a given schedule.

Encourage participants to observe and learn from the visit, adhere to the

facilities SOP and share their learning which they could use in their facility.

Powerpoint slides for lectures.

The faciltators can use all the slides or selct based on the need and

capacity of the partcipants.

Essential Equipment and Materials

No Description Quantity

1. Action Plan one for six participants

2. Flip Chart one for six participants

3. Provider Guide one for each participant

4. Parent Guide one for each participant

5. Small baby simulator, manikin or doll in which a

nasogastric tube can be placed

one for two participants

6. Breast model (if available) one for two participants

7. Alcohol-based hand rub or soap and water one for six participants

8. Bag/mask device, small and premature masks (if available) one for two participants

9. Head covering, diaper and socks one for two participants

10. Extra blankets one for two participants

11. Scale (if available) one for six participants

12. Support binder for skin-to-skin care one for each participant

13. Thermometer one for two participants

14. Stethoscope one for two participants

15. Weighing scale, measuring tape and torch one of each per table

16. Water to simulate breast milk one for two participants

17. Cup, or paladai for feeding one for two participants

18.

Measuring container for collecting breast milk one for two participants

19. Clean nasogastric tube (5 or 6 French) one for two participants

20. 20 mL syringe one for two participants

21. Tape to secure nasogastric tube one for two participants

22.

Table to calculate collected breast milk one for two participants

23. Growth chart (optional) one for two participants

24. Mother’s Observation Form (in Provider Guide) one for each participant

25. Newborn Assessment Form (in Provider Guide) one for each participant

26. Newborn Referral Form (in Provider Guide) one for each participant

27. Pen, and paper one for each participant

28. Course Registration Form 1 per room

29. ICD forms

30. Stickit notes (two to three colors) 1 per table

Facilitators need to review the ﬁve sections of each Flip Chart page

1. Explain and demonstrate – Emphasize key points and be practical.

2. Invite discussions – Suggest questions that will provoke discussion

among the providers about the local context of care. These questions will

also help participants identify changes to improve care.

3. Facilitate practice – guidance about how providers should practice skills

required for each action.

4. Background – a summary of details about the action which will help you

answer questions.

5. Educational advice – advice that will assist you in creating the ideal

learning experience. You will need to collect and familiarize yourself with

national and facility guidelines for such practices as eye care, cord care,

and immunizations.

There are four exercises that combine a series of actions to help the learner

integrate the steps of aspect of care. They also focus on how to communicate

with the mother and teach her some of the skills. Familiarize yourself with

exercises and evaluations in the Flip Chart

1. The Knowledge Check can be given as both a pre- and post-course

evaluation if desired.

2. OSCE A and B evaluate knowledge, skills, and decision-making.

3. Review the four sections of each Provider Guide page

4. Review Key Knowledge – a summary of important facts.

Review and prepare for the “Practice Key Skills” section. It is a section to guide

practice during and after the workshop and includes what to monitor - some

key indicators that can be used for data collection as part of efforts to improve

quality of care as well as quality improvement. Conduct demonstration using

videos from the global health media at the indicates session timing in the

lesson plan. (https://globalhealthmedia.org/videos/smallbaby/). The videos on

follow up can be downloaded from www.fundacioncanguro.co after registering

and creating an account. To avoid connection issues; it is recommended to

download the videos ahead of the session.

FACILITATORS’ PREPARATION

Explain to participants that, as facilitator your role throughout this course will

be to guide them through the course activities, answer questions as they arise

or ﬁnd the answer if you do not know, clarify information they ﬁnd confusing,

give individual feedback on exercises where indicated lead group discussions,

demonstrations on mannequins, video demonstration and role plays, help them

learn skills.

Remember adults learn what they need or want to learn – unlike children who

like to learn almost everything. As facilitator; you should continually relate

course content to the “real world” of the adult learner. Due to the many

pressures adults face whether family, business, or social etc. Adults must feel

that attending and participating in a course gives them information they can

use. Establish relevance for learners by asking them to list their expectations

for the course and paste the expectations on a ﬂipchart. At end of the course,

review the list of the participants’ objectives. Determine if each has been

met by the workshop. Explain how to resolve any issues that have not been

addressed in class.

The adult learner comes to class with a wide variety of experiences, both

personal and professional. The facilitator should respect the learner’s life

experiences and relate the learning topics to those experiences. You can show

respect by asking participants’ opinions, allowing participants to answer, and

offering positive responses when the learner shares experiences. A component

of respect is inclusion. Adults need to feel included as an equal in the group.

You can accomplish this by drawing each learner into discussions, rotating

volunteers and attempting to give each participant equal attention. Consider that

students generally remember:

• 50% of what they hear and see;

• 70% of what they say and

• 90% of what they do and talk about.

Active participation in the learning process ensures that participants gain and

retain the most information from class.

YOUR ROLE AS FACILITATOR

This agenda is illustrative for four and half to ﬁve days training. When you

organize the training, you can adapt the time based on partcipants experience

and available time. For daily recap session, select and inform one or two

participants in advance. Encourage them to use participatory methods.

Type of Activity Time

Day One

Section 1: Introduction 8:30-9:55am

Ac tivit y 1.1 Registration of participants 10 mins

Activity 1.2 Introduction of participants 15 mins

Activity 1.3 Lay ground rules and announce any administrative arrangements 10 mins

Activity 1.4 Pre-test assessment 30 mins

Activity 1.5 Expectations 20 mins

Activity 1.6 Presentation on workshop rationale, leaning objective and methods 15 mins

Section 2: KMC Clinical Knowledge and Skills 9:55am-1:00pm

Ac tivit y 2 .1 Presentation on essential newborn care 30 mins

TEA BREAK at 9.55am 15 mins

Activity 2.2

Preparing for the birth ofLBW/preterm and essential care

for small babies

40 mins

Activity 2.3 Classify the LBW/preterm 30 mins

Activity 2.4 Presentation on KMC physiologic mechanism of effect 40 mins

LUNCH BREAK at 12.20-3:00 pm 60 mins

Activity 2.5 Maintaining thermal care for the LBW/preterm 90 mins

Day Two 8:30am-5:00pm

Activity 2.6 Recap of day two and administrative announcements 30 mins

Activity 2.7 Feeding the LBW/preterm babies-support breast feeding 80 mins

TEA BREAK at 10:00am 10 mins

Activity 2.8

Support feeding the LBW/preterm-feeding by cup, inserting NGT

and feeding NGT

145 mins

LUNCH BREAK at 1:00pm

60 mins

Activity 2.9

Explain and demonstrate assessing sings of readiness of

breastfeeding when using alternative feeding methods

50 mins

Ac tivit y 2 .10

Routine assessment of LBW/preterm babies for change of

care or referral

60 mins

TRAINING PLAN BY EACH DAY (AGENDA)

Type of Activity Time

Day Two 8:30am-5:00pm (cont’d)

TEA BREAK at 3:00pm 10 mins

Ac tivit y 2 .11 Routine assessment of LBW/preterm babies 120 mins

Day Three 8:30am-5:00pm

Ac tivit y 2 .12 Recap of day two and administrative announcements 30 mins

Ac tivit y 2 .13 Prompt referral and stabilization 60 mins

Ac tivit y 2 .14 Planning for successful discharge and home care 20 mins

TEA BREAK at 10:00am 10 mins

Ac tivit y 2 .15 Practice on counseling the mother and other caregivers for home care 60 mins

Ac tivit y 2 .16 Proper hygiene and preventing infection 90 mins

Ac tivit y 2 .17 Conduct OSCE B 60 mins

LUNCH BREAK at 1:00pm 45 mins

Section 3: KMC Implementation Experiences, Challenges and Possible Solutions

Ac tivit y 3.1

Introduction to KMC implementation and scale-up

Learners start to think about what they will include in their action plans

40 mins

Activity 3.2

Quality of care and supportive supervision

Learners work in country or facility teams to document ideas to

include in country/facility action plans

30 mins

TEA BREAK at 3:00pm 10 mins

Activity 3.3 Multidisciplinary care and teamwork in KMC

30 mins

Activity 3.4

Mobilizing support for KMC

(national level, health facilities and community)

40 mins

Day Four 8:30am-5:00pm

Activity 3.6 Recap of day three and administrative announcements 30 mins

Activity 3.7 Documentation for monitoring and evaluation 60 mins

TEA BREAK at 10am 15 mins

Activity 3.8 Action planning for KMC implementation and scale-up 180 mins

Activity 5.5 Orientation to resource materials 30 mins

Activity 5.6 Post-sessions self-assessment and Course Evaluation and closing 60 min

This resource package is compiled from different sources and this brief

description is intended to aid the user to smoothly navigate and use as needed

for clinical care as well as to plan and execute trainings.

1. Helping Babies Survive, Essential Care for Every Baby:

Helping Babies Survive (HBS) is an

initiative of the American Academy

of Paediatrics (AAP), developed

in collaboration with WHO, and

supported by the US Agency for

International Development (USAID),

Save the Children, Latter-day Saint

Charities, Laerdal Global Health,

Johnson & Johnson, and a number

of other global health partners. The

Neo-Natalie mannequin in a size

of preterm infant has a “stomach”

that allows skills practice for Naso- Gastric Tube (NGT) insertion, feedings

and NGT removal. The breast Mama Breast Simulator is used for hands on

practice on expressing breast milk. Laerdal is the provider of these materials

and AAP has the copy right. Prior approval is needed for translation and

adaption of the materials in the event you can not have the mannequins;

locally develop dolls/models can be used to practice skills.

2. Early Childhood Devlopment(ECD): includes an article on A

Guide for Monitoring Child Development in Low and Middle-Income

Countries, glossary of terms use in ECD, UNICEF document on

standards for ECD programming. The aim of this document is to guide

practitioners interested in early childhood development through a set of

recommended standards for parenting programmes. The standards cover

a range of good practices that

programmes could offer to

parents and key caregivers.

These standards provide

statements of expectations

of what programmes should

offer to parents and, in doing

so, support them in raising

their children. The poster on

recomndation for care for

child devlopment covers from

for ﬁrst two years of child’s

live and could be translated

and adapted to local context.

Contents of ECSB Training Materials

• PremieNatalie newborn simulator

• MamaBreast

• Nifty feeding cup

• HBS ECSB Facilitator Set that

includes: 1 action plan wall poster,

ﬂip chart, OSCEs, provider and

parent guide

•

Give your child aection and show your love

•

Be aware of your child’s interests and respond to them

•

Praise your child for trying to learn new skills

Your baby learns

from birth

PLAY Provide ways for

your baby to see, hear, move

arms and legs freely, and

touch you. Gently soothe,

stroke and hold your child.

Skin to skin is good.

COMMUNICATE

Look into baby’s eyes and

talk to your baby. When you

are breastfeeding is a good

time. Even a newborn baby

sees your face and hears

your voice.

PLAY Provide ways for

your child to see, hear, feel,

move freely, and touch

you. Slowly move colourful

things for your child to see

and reach for. Sample toys:

shaker rattle, big ring on a

string.

COMMUNICATE

Smile and laugh with your

child. Talk to your child. Get

a conversation going by

copying your child’s sounds

or gestures.

PLAY Give your child

clean, safe household

things to handle, bang,

and drop. Sample toys:

containers with lids, metal

pot and spoon.

COMMUNICATE

Respond to your child’s

sounds and interests. Call

the child’s name, and see

your child respond.

PLAY Hide a child’s

favourite toy under a cloth

or box. See if the child can

ﬁnd it. Play peek-a-boo.

COMMUNICATE

Tell your child the names

of things and people.

Show your child how to

say things with hands, like

“bye bye”. Sample toy: doll

with face.

PLAY Give your child

things to stack up, and to put

into containers and take

out. Sample toys: Nesting and

stacking objects, container and

clothes clips.

COMMUNICATE

Ask your child simple

questions. Respond to your

child’s attempts to talk.

Show and talk about nature,

pictures and things.

PLAY Help your child

count, name and compare

things. Make simple toys

for your child. Sample toys:

Objects of dierent colours

and shapes to sort, stick or

chalk board, puzzle.

COMMUNICATE

Encourage your child to

talk and answer your child’s

questions. Teach your

child stories, songs and

games. Talk about pictures

or books. Sample toy: book

with pictures

NEWBORN,

BIRTH UP TO 1 WEEK

1 WEEK UP

TO 6 MONTHS

6 MONTHS

UP TO 9 MONTHS

9 MONTHS

UP TO 12 MONTHS

12 MONTHS

UP TO 2 YEARS

2 YEARS

AND OLDER

Recommendations for

Care for Child Development

INTRODUCTION TO KEY RESOURCES

3. Lessons Plan: Executing competency based training session’s entails

a clear plan, expected skill acquisitions, how they are measured and

evaluated. This becomes even more important when the capacity

building activity is expected to be delivered at scale, concurrently by

different trainers than as a small-scale initiative. The competency based

training on care of small babies is run by ﬁve facilitators in one session

for 30 participants. Having one lessons plan allows coherent session

ﬂow for facilitators. In addition, the plan guides facilitators in the

preparation required for each session. The lesson plan guide facilitators

in step by step process and indicates the pages in the ﬂip chart for the

speciﬁc session. The videos are meant to enhance skill demonstration

and are best delivered in plenary. If the venue does not allow for video

demonstration in plenary session, this could be done in each of the ﬁve

small groups. For organising and executing such a training for the ﬁrst

time; the lesson plan helps organisers in determining the number of

facilitators, supplies and venue required.

4. Technical Presentations: The training is competency based and there

is a minimal number of presentations or theoretical discussions. The

selected few presentations provide important background information

on history of kangaroo mother care, its immediate and long-term

beneﬁt, physiologic mechanism of skin to skin contact, importance of

infection prevention and control and KMC program implementation.

Faciltators are adviced to select the relevant slides for their audience.

a. On history, mechanism of action, immediate and long term beneﬁt

of kangaroo mother care: This presentation provides background

information on the beginning of KMC in Colombia and its start in South

Africa. The presentation has a break point to allow delivering of the

presentation a brief 15-20 minutes’ presentation. Indicative grouping of

the slides is included in the session plan. You as a faciliator can determine

which slides to include and number in each presentation. For example, if

particpants are aware of the information; you can skip this presentation.

The physiologic mechanisms of skin to skin contact in maintaining baby’s

temperature include stimulating breathing, neurophysiologic outcomes

fostering bonding of mother and infant, physiological stress, effects on

stress, nosocomial infections and mortality reduction, brain development

and epigenetics, early intervention and developmental outcomes. This up-

to-date information with current evidence provides learner the knowledge

they need to understand the importance of KMC in the care of preterm

and low birth weight infants. The current evidence on brain development

provides knowledge on the importance of early childhood development

and KMC’s role in the early stimulation, nurturing care and follow-up to

prevent, promptly identify and provide care for disabilities associated with

preterm birth. All presentations and different tools and templates can be

accessed here.

b. Implementation, monitoring and evaluation of kangaroo mother

care program There are six sessions on the agenda devoted to the

implementation of a KMC program. Much of the materials that are provided

serve as hints and reminders for facilitators and are not necessarily

presentations that you can repeat as is with workshop participants. All the

handouts serve as examples of activities that can be included in working

sessions for brainstorming and compiling plans of action.

5. Technical Briefs: The technical briefs

by Every Preemie-SCALE highlights

the safe and effective use of speciﬁc

inpatient newborn care interventions.

Central to this series of technical

briefs is the guiding principle of “Do

No Harm”. The briefs are designed to

provide stakeholders with evidence-

based information regarding safe and

effective inpatient care in low resource

settings as an important step to avoid

harm and improve health outcomes for

newborns. The series covers:

• Current evidence based

recommendations on safe

and effective use of oxygen,

• Infection prevention,

• Thermal protection and

• Human milk for inpatient newborn care.

They can be translated to local language if needed and can be accessed

www.everypreemie.org/resources/

6. Guidelines: The clinical guidelines are from Kalafong Hospital KMC unit

in South Africa. The guidelines are standard operating procedures of the

KMC unit. To provide guidelines and compliance requirements regarding

admission, transfer and discharge procedures. They are intended to serve

as an example and each health facility may adapt them to the speciﬁc

situation and need.

a. Feeding: infant feeding policy of the hospital is clearly deﬁned to be breast

milk. The policy indicated the choice and volume of feeds, caloric requirement

of premature infants, and use of breast milk fortiﬁers, method of feeding and

management of breast milk bank. The resource also includes a guide to daily

feeding requirements by weight and age, cup feeding procedures and protocol

and method of use of breast milk fortiﬁer.

DO NO HARM TECHNICAL BRIEF

Safe and Effective Oxygen Use for

Inpatient Care of Newborns

How can unsafe oxygen use cause

harm?

Oxygen is fundamental for sustaining life, but it is also toxic.

Unique developmental vulnerabilities of newborns put them at a

greater risk of injury from oxygen use than adults. Injury may occur

from high levels of oxygen in the blood, regardless of the

administered oxygen concentration, and from exposure of the lungs

to high concentrations of oxygen. The two main complications of

oxygen use with newborns are retinopathy of prematurity (ROP) and

lung injury. The historical success of improving survival of

premature infants was tempered by blindness in some survivors

that was caused by low, but unmonitored, oxygen exposure. Even

with low concentrations of administered oxygen, levels in the blood

can rise far above normal. ROP is the abnormal development of

blood vessels in the retina of the eye. In its most severe form, ROP

can result in blindness. Exposure to supplemental oxygen also

produces complications from direct oxygen toxicity to lung tissue.

Chronic lung disease (also known as bronchopulmonary dysplasia)

is a serious consequence in extremely preterm infants, but

cumulative oxygen exposure also leads to lung problems in infancy

among moderately preterm babies.

There are multiple ways in which inadequately regulated oxygen

use can cause harm. In the special care of newborns the most

common include:

• 100% oxygen administration

• Unmonitored oxygen saturation during any supplemental oxygen

administration

• “Prophylactic” administration of oxygen to sick or at-risk

newborns without clinical indication

• Environmental enrichment with oxygen (i.e. oxygen in

incubator)

• Use of non-rebreathing mask or funnel to deliver oxygen

• Interrupted oxygen administration (rotating allocation of

available oxygen)

What are current WHO

recommendations for oxygen

therapy?

Current WHO recommendations and clinical guidelines address

several aspects of oxygen therapy (Table 1).

Clinical indications for oxygen use include resuscitation of preterm

infants and advanced resuscitation of term infants as well as the

full spectrum of respiratory illness from mild hypoxemia to

moderate/severe respiratory distress and respiratory failure.

Routine resuscitation of term and moderate-to-late preterm infants

begins with bag-and-mask ventilation using room air. However,

preterm infants < 32 weeks should receive ventilation beginning

with 30% oxygen or air if blended oxygen is not available (rather

than 100% oxygen). Oxygen concentration should be guided by

blood oxygen saturation levels. Titrating the concentration of

oxygen to meet time-specific saturation targets (Table 2). The

adjustment of the concentration of oxygen levels should be by 10%

(FiO2=0.1) per 30 seconds and must be guided by oxygen

saturation levels reached.

Oxygen is important in the care of newborn infants because many conditions that affect babies in the first days of life

can result in low levels of oxygen in the body. Hypoxemia, or low level of oxygen in the blood, is a life-threatening

condition that results in increased mortality and morbidity. Prematurity and respiratory distress syndrome (surfactant

deficiency), pneumonia and other severe infections, asphyxia and difficulties in the transition from fetal to neonatal

life can all result in hypoxemia. Supplemental oxygen is an essential lifesaving treatment.

Why is Safe Oxygen Use Important?

Access to appropriate oxygen therapy has been demonstrated to reduce death from childhood pneumonia and neonatal

respiratory distress. Improved detection of hypoxemia and the safe administration of oxygen has resulted in a 35%

reduction in the risk of death from childhood pneumonia in high-burden settings.

Historically, the administration and

delivery of oxygen with pressure that helps maintain lung inflation has resulted in a dramatic improvement in survival

of premature infants.

Oxygen therapy remains an essential element in the treatment of newborn respiratory distress,

with specialized delivery methods being increasingly used in low and middle-income countries.

3;4

b. For doctors: Clinical guideline for doctors include neonatal jaundice

management ﬂow chart, admission and discharge criteria that includes

clinical conditions of both the infant and the mother as well as the social

circumstances of as well. Similarly, the ward protocol describes detailed

roles and responsibilities of doctors, work organization and allocation among

different teams, discharge arrangements and procedures, and routine care and

clinical rounds in the unit.

c. For nurses: includes standard operating procedures of the unit,

clear instruction for weighing the infant and recoding it regularly and

clearly, KMC unit checklist that describes admission producers, routine

investigation and treatment, discharge procedure and documentation.

7. Ward documents: are useful guides in using different equipment and tools

in the care of the premature infants. It includes how to care and correctly

use electronic or mechanical baby scales to maintain their precision,

postnatal daily checklist, admission book, information brochure for mothers

and monthly statistics from. Recommended standards for described

essential care, environmental design, infection prevention, levels of newborn

care in the facility and human resource requirements.

8. Key WHO Guidelines:

Pregnancy, Childbirth,

Postpartum and Newborn

Care: A guide for essential

practice’ (PCPNC) has

been updated to include

recommendations from

recently approved WHO

guidelines relevant to

maternal and perinatal

health. These include pre-

eclampsia & eclampsia;

postpartum haemorrhage;

postnatal care for the mother and baby; newborn resuscitation;

prevention of mother-to- child transmission of HIV; HIV and infant

feeding; malaria in pregnancy, tobacco use and second-hand exposure

in pregnancy, post-partum depression, post-partum family planning and

post abortion care. This revised guide brings a full range of updated

evidence – based norms and standards that enable health care providers

at the ﬁrst health care level to provide high-quality, integrated care during

pregnancy and childbirth and after birth, both for mothers and babies.

All recommendations are for skilled attendants working at the primary

level of health care, either at the facility or in the community. WHO

recommendations on interventions to improve preterm birth outcomes

NEWBORN CARE

EXAMINE THE NEWBORN

Use this chart to assess the newborn after birth, classify and treat, possibly around an hour; for discharge (not before 24 hours); and during the first week of life at

routine, follow-up, or sick newborn visit. Record the findings on the postnatal record

and home-based record.

Always examine the baby in the presence of the mother.

ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS CLASSIFY TREAT AND ADVISE

Check maternal and newborn record

or ask the mother:



How old is the baby?



Preterm (less than 37 weeks

or 1 month or more early)?



Breech birth?



Difficult birth?



Resuscitated at birth?



Has baby had convulsions?

Ask the mother:



Do you have concerns?



How is the baby feeding?

Is the mother very ill or transferred?



Assess breathing (baby must

be calm)

→listen for grunting

→count breaths: are they 30-60

per minute? Repeat the count

if elevated

→look at the chest

for in-drawing.



Look at the movements: are they

normal and symmetrical?



Look at the presenting part —

is there swelling and bruises?



Look at abdomen for pallor.



Look for malformations.



Feel the tone: is it normal?



Feel for warmth. If cold, or

very warm, measure temperature.



Weigh the baby.



Body temperature

35.5ºC-36.4ºC.

MILD

HYPOTHERMIA



Re-warm the baby skin-to-skin



If temperature not rising after 2 hours, reassess

the baby.



Mother not able to breastfeed

due to receiving special

treatment.



Mother transferred.

MOTHER NOT ABLE

TO TAKE CARE FOR BABY



Help the mother express breast milk



Consider alternative feeding methods until mother is

well

K5-K6



Provide care for the baby, ensure warmth



Ensure mother can see the baby regularly.



Transfer the baby with the mother if possible.



Ensure care for the baby at home.



Normal temperature:

36.5ºC-37.5ºC.



Normal weight baby

(2500 g or more).



Feeding well — suckling effectively

8 times in 24 hours,

day and night.



No danger signs.



No special treatment needs or

treatment completed.



Small baby, feeding well and

gaining weight adequately.

WELL BABY If first examination:



Breastfeeding counseling

K2-K3



Give vitamin K

K12



Ensure care for the newborn

J10



Examine again for discharge.

If pre-discharge examination:



Immunize if due

K13



Advise on baby care

K9-K10



Advise on routine postnatal contacts at age

3-7days

K14



Advise on when to return if danger signs

K14



Breastfeeding counselling

K2-K3



Record in home-based record.



If further visits, repeat advices.

Next: If preterm, birth weight <2500 g or twin

NEWBORN CARE

Examine the newborn

EXAMINE THE NEWBORN

IF PRETERM, BIRTH WEIGHT <2500-G OR TWIN

ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS CLASSIFY TREAT AND ADVISE



Baby just born.



Birth weight

→<1500 g

→1500 g to <2500 g.



Preterm

→<32 weeks

→33-36 weeks.



Twin.



If this is repeated visit,

assess weight gain



Birth weight <1500 g.



Very preterm <32 weeks

or >2 months early).

VERY SMALL BABY



Refer baby urgently to hospital

K14



Ensure extra warmth during referral.



Birth weight 1500 g-<2500 g.



Preterm baby (32-36 weeks

or 1-2 months early).



Several days old and

weight gain inadequate.



Feeding difficulty.

SMALL BABY



Provide as close to continuous Kangaroo mother

care as possible.



Give special support to breastfeed the small

baby



Ensure additional care for a small baby

J11



Reassess daily

J11



Do not discharge before feeding well, gaining weight

and body temperature stable.



If feeding difficulties persist for 3 days and

otherwise well, refer for breastfeeding counselling.



Twin TWIN



Give special support to the mother to breastfeed

twins



Do not discharge until both twins can go home.

Next: Assess breastfeeding

NEWBORN CARE

If preterm, birth weight <2500‑g or twin

IF PRETERM,

BIRTH WEIGHT <2500 G OR TWIN

ASSESS BREASTFEEDING

Assess breastfeeding in every baby as part of the examination.

If mother is complaining of nipple or breast pain, also assess the mother’s breasts

ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS CLASSIFY TREAT AND ADVISE

Ask the mother



How is the breastfeeding going?



Has your baby fed in the

previous hour?



Is there any difficulty?



Is your baby satisfied with the feed?



Have you fed your baby any other

foods or drinks?



How do your breasts feel?



Do you have any concerns?

If baby more than one day old:



How many times has your baby fed

in 24 hours?

Observe a breastfeed.

If the baby has not fed in the

previous hour, ask the mother to put

the baby on her breasts and observe

breastfeeding for about 5 minutes.

Look



Is the baby able to

attach correctly?



Is the baby well-positioned?



Is the baby suckling effectively?

If mother has fed in the last hour,

ask her to tell you when her baby is

willing to feed again.



Not suckling (after 6 hours

of age).



Stopped feeding.

NOT ABLE TO FEED



Refer baby urgently to hospital

K14



Not yet breastfed (first hours

of life).



Not well attached.



Not suckling effectively.



Breastfeeding less than 8 times

per 24 hours.



Receiving other foods or drinks.



Several days old and inadequate

weight gain.

FEEDING DIFFICULTY



Support exclusive breastfeeding

K2-K3



Help the mother to initiate breastfeeding

K3-K4



Teach correct positioning and attachment

K3-K4



Advise to feed more frequently, day and night.

Reassure her that she has enough milk.



Advise the mother to stop feeding the baby other

foods or drinks.



Reassess at the next feed or follow-up visit in

2 days.



Suckling effectively.



Breastfeeding 8 times in 24 hours

on demand day and night

FEEDING WELL



Encourage the mother to continue breastfeeding on

demand



To assess replacement feeding see

J12

Check for special treatment needs

NEWBORN CARE

Assess breastfeeding

ASSESS BREASTFEEDING

CHECK FOR SPECIAL TREATMENT NEEDS

ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS CLASSIFY TREAT AND ADVISE

Check record for

special treatment needs



Has the mother had

within 2 days of delivery:

→fever >38ºC?

→infection treated with antibiotics?



Membranes ruptured >18 hours

before delivery?



Mother tested RPR-positive?



Mother tested HIV-infected?

→is or has been on ARV

→has she received

infant feeding counselling?



Is the mother receiving TB treatment

which began <2 months ago?



Baby <1 day old and

membranes ruptured >18 hours

before delivery,



Mother being treated with

antibiotics for infection,



Mother has fever >38ºC.

RISK OF

BACTERIAL INFECTION



Give baby 2 IM antibiotics for 5 days

K12



Assess baby daily

J2-J7



Mother tested RPR-positive. RISK OF

CONGENITAL SYPHILIS



Give baby single dose of benzathine penicillin

K12



Ensure mother and partner are treated



Follow up in 2 weeks.



Mother known to be HIV-infected.



Mother has not been

counselled on infant feeding.



Mother chose breastfeeding.



Mother chose

replacement feeding.

RISK OF HIV TRANSMISSION



Give ARV to the newborn

G12



Teach mother to give ARV to her baby

G12

K13



Counsel on infant feeding options



Give special counselling to mother who is breast

feeding



Teach the mother safe replacement feeding.



Follow up in 2 weeks



Mother started TB treatment

<2 months before delivery.

RISK OF TUBERCULOSIS



Give baby isoniazid propylaxis for 6 months

K13



Give BCG vaccination to the baby only when baby’s

treatment completed.



Follow up in 2 weeks.

Next: Look for signs of jaundice and local infection

NEWBORN CARE

Check for special treatment needs

CHECK FOR SPECIAL

TREATMENT NEEDS

LOOK FOR SIGNS OF JAUNDICE AND LOCAL INFECTION

ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS CLASSIFY TREAT AND ADVISE



What has been applied to

the umbilicus?



Look at the skin, is it yellow?

→if baby is less than 24 hours

old, look at skin on the face

→if baby is 24 hours old or

more, look at palms and soles.



Look at the eyes. Are they swollen

and draining pus?



Look at the skin, especially

around the neck, armpits,

inguinal area:

→Are there skin pustules?

→Is there swelling, hardness or

large bullae?



Look at the umbilicus:

→Is it red?

→Draining pus?

→Does redness extend to

the skin?



Yellow skin on face and

only <24 hours old.



Yellow palms and soles and

≥24 hours old.

SEVERE JAUNDICE



Refer baby urgently to hospital

K14



Encourage breastfeeding on the way.



If feeding difficulty, give expressed breast milk by

cup



Eyes swollen and draining pus. GONOCOCCAL

EYE INFECTION



Give single dose of appropriate antibiotic for eye

infection

K12



Teach mother to treat eyes

K13



Follow up in 2 days. If no improvement or worse,

refer urgently to hospital.



Assess and treat mother and her partner for

possible gonorrhea



Red umbilicus or skin around it. LOCAL

UMBILICAL INFECTION



Teach mother to treat umbilical infection

K13



If no improvement in 2 days, or if worse, refer

urgently to hospital.



Less than 10 pustules. LOCAL SKIN INFECTION



Teach mother to treat skin infection

K13



Follow up in 2 days.



If no improvement of pustules in 2 days or more,

refer urgently to hospital.

Next: If danger signs

NEWBORN CARE

Look for signs of jaundice and local infection

LOOK FOR SIGNS OF JAUNDICE

AND LOCAL INFECTION

IF DANGER SIGNS

SIGNS CLASSIFY TREAT AND ADVISE

Any of the following signs:



Fast breathing

(more than 60 breaths

per minute).



Slow breathing or gasping

(less than 30 breaths

per minute).



Severe chest in-drawing.



Not feeding well.



Grunting.



Convulsions.



Floppy or stiff.



No spontaneous movement,

floppy or stiff.



Temperature>37.5ºC.



Temperature <35.5ºC or not

rising after rewarming.



Umbilicus draining pus or

umbilical redness and swelling

extending to skin.



More than 10 skin pustules

or bullae, or swelling, redness,

hardness of skin.



Bleeding from stump or cut.



Pallor.

POSSIBLE

SERIOUS ILLNESS



Give first dose of 2 IM antibiotics

K12



Refer baby urgently to hospital

K14

In addition:



Re-warm and keep warm during referral



Treat local umbilical infection before referral

K13



Treat skin infection before referral

K13



Stop the bleeding.

Next: If swelling, bruises or malformation

NEWBORN CARE

If danger signs

IF DANGER SIGNS

IF SWELLING, BRUISES OR MALFORMATION

SIGNS CLASSIFY TREAT AND ADVISE



Bruises, swelling on buttocks.



Swollen head — bump on

one or both sides.



Abnormal position of legs

(after breech presentation).



Asymmetrical arm movement,

arm does not move.

BIRTH INJURY



Explain to parents that it does not hurt the baby,

it will disappear in a week or two and no special

treatment is needed.



DO NOT force legs into a different position.



Gently handle the limb that is not moving,

do not pull.



Club foot



Cleft palate or lip



Odd looking, unusual appearance



Open tissue on head,

abdomen or back

MALFORMATION



Refer for special treatment if available.



Help mother to breastfeed. If not successful,

teach her alternative feeding methods

K5-K6

Plan to follow up.



Advise on surgical correction at age of

several months.



Refer for special evaluation.



Cover with sterile tissues soaked with

sterile saline solution before referral.



Refer for special treatment if available.



Other abnormal appearance. SEVERE MALFORMATION



Manage according to national guidelines.

Next: Assess the mother’s breasts if complaining of nipple or breast pain

NEWBORN CARE

If swelling, bruises or malformation

IF SWELLING, BRUISES

OR MALFORMATION

ASSESS THE MOTHER’S BREASTS IF COMPLAINING OF NIPPLE OR BREAST PAIN

ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS CLASSIFY TREAT AND ADVISE



How do your breasts feel?



Look at the nipple for fissure



Look at the breasts for:

→swelling

→shininess

→redness.



Feel gently for painful part of

the breast.



Measure temperature.



Observe a breastfeed

if not yet done



Nipple sore or fissured.



Baby not well attached.

NIPPLE SORENESS

OR FISSURE



Encourage the mother to continue breastfeeding.



Teach correct positioning and attachment



Reassess after 2 feeds (or 1 day). If not better, teach the mother

how to express breast milk from the affected breast and feed

baby by cup, and continue breastfeeding on the healthy side.



Both breasts are swollen,

shiny and patchy red.



Temperature <38ºC.



Baby not well attached.



Not yet breastfeeding.

BREAST

ENGORGEMENT



Encourage the mother to continue breastfeeding.



Teach correct positioning and attachment



Advise to feed more frequently.



Reassess after 2 feeds (1 day). If not better, teach mother

how to express enough breast milk before the feed to relieve

discomfort



Part of breast is painful,

swollen and red.



Temperature >38ºC.



Feels ill.

MASTITIS



Encourage mother to continue breastfeeding.



Teach correct positioning and attachment



Give cloxacillin for 10 days



Reassess in 2 days. If no improvement or worse, refer to hospital.



If mother is HIV-infected let her breastfeed on the healthy breast.

Express milk from the affected

breast and discard until no fever



If severe pain, give paracetamol



No swelling, redness

or tenderness.



Normal body temperature.



Nipple not sore and no

fissure visible.



Baby well attached.

BREASTS HEALTHY



Reassure the mother.

Next: Return to

and complete the classification, then go to

J10

NEWBORN CARE

Assess the mother’s breasts if complaining of nipple or breast pain

ASSESS THE MOTHER’S BREASTS

IF COMPLAINING OF NIPPLE OR

BREAST PAIN

CARE OF THE NEWBORN

Use this chart for care of all babies until discharge.

CARE AND MONITORING RESPOND TO ABNORMAL FINDINGS



Ensure the room is warm (not less than 25ºC and no draught).



Keep the baby in the room with the mother, in her bed or within easy reach.



Let the mother and baby sleep under a bednet.



If the baby is in a cot, ensure baby is dressed or wrapped and covered by a blanket.

Cover the head with a hat.



Support exclusive breastfeeding on demand day and night.



Ask the mother to alert you if breastfeeding difficulty.



Assess breastfeeding in every baby before planning for discharge.



DO NOT discharge if baby is not yet feeding well.



If mother reports breastfeeding difficulty, assess breastfeeding and help the mother with positioning

and attachment



Teach the mother how to care for the baby.

→Keep the baby warm

→Give cord care

K10

→Ensure hygiene

K10

DO NOT expose the baby in direct sun.

DO NOT put the baby on any cold surface.

DO NOT bath the baby before 6 hours.



If the mother is unable to take care of the baby, provide care or teach the companion

K9-K10



Wash hands before and after handling the baby.



Ask the mother and companion to watch the baby and alert you if

→Feet cold.

→Breathing difficulty: grunting, fast or slow breathing, chest in-drawing.

→Any bleeding.



If feet are cold:

→Teach the mother to put the baby skin-to-skin

K13

→Reassess in 1 hour; if feet still cold, measure temperature and re-warm the baby



If bleeding from cord, check if tie is loose and retie the cord.



If other bleeding, assess the baby immediately

J2-J7



If breathing difficulty or mother reports any other abnormality, examine the baby as on

J2-J7



Give prescribed treatments according to the schedule

K12



Examine every baby before planning to discharge mother and baby

J2-J9

DO NOT discharge before baby is 24 hours old.

Additional care of a small baby (or twin)

NEWBORN CARE

J10

Care of the newborn

J10

CARE OF THE NEWBORN

ADDITIONAL CARE OF A SMALL BABY (OR TWIN)

Use this chart for additional care of a small baby: preterm, 1-2 months early or weighing 1500 g-<2500 g. Refer to hospital a very small baby: >2 months early, weighing <1500 g

CARE AND MONITORING RESPOND TO ABNORMAL FINDINGS



Plan to keep the small baby longer before discharging.



Allow visits to the mother and baby.



Give special support for breastfeeding the small baby (or twins)

→Encourage the mother to breastfeed every 2-3 hours.

→Assess breastfeeding daily: attachment, suckling, duration and frequency of feeds, and baby

satisfaction with the feed

→If alternative feeding method is used, assess the total daily amount of milk given.

→Weigh daily and assess weight gain



If the small baby is not suckling effectively and does not have other danger signs, consider

alternative feeding methods

K5-K6

→Teach the mother how to hand express breast milk directly into the baby’s mouth

→Teach the mother to express breast milk and cup feed the baby

K5-K6

→Determine appropriate amount for daily feeds by age



If feeding difficulty persists for 3 days, or weight loss greater than 10% of birth weight and

no other problems, refer for breastfeeding counselling and management.



Ensure additional warmth for the small baby

→Ensure the room is very warm (25º–28ºC).

→Teach the mother how to keep the small baby warm in skin-to-skin contact.

→Provide extra blankets for mother and baby.



Ensure hygiene

K10

DO NOT bath the small baby. Wash as needed.



Assess the small baby daily:

→Measure temperature

→Assess breathing (baby must be quiet, not crying): listen for grunting; count breaths per minute,

repeat the count if >60 or <30; look for chest in-drawing

→Look for jaundice (first 10 days of life): first 24 hours on the abdomen, then on palms and soles.



If difficult to keep body temperature within the normal range (36.5ºC to 37.5ºC):

→Keep the baby in skin-to-skin contact with the mother as much as possible

→If body temperature below 36.5ºC persists for 2 hours despite skin-to-skin contact with mother,

assess the baby

J2-J8



If breathing difficulty, assess the baby

J2-J8



If jaundice, refer the baby for phototherapy.



If any maternal concern, assess the baby and respond to the mother

J2-J8



Plan to discharge when:

→Breastfeeding well

→Gaining weight adequately on 3 consecutive days

→Body temperature between 36.5º and 37.5ºC on 3 consecutive days

→Mother able and confident in caring for the baby

→No maternal concerns.



Assess the baby for discharge.



If the mother and baby are not able to stay, ensure daily (home) visits or send to hospital.

NEWBORN CARE

J11

Additional care of a small baby (or twin)

J11

ADDITIONAL CARE OF A

SMALL BABY (OR TWIN)

ASSESS REPLACEMENT FEEDING

If mother chose replacement feeding assess the feeding in every baby as part of the examination.

Advise the mother on how to relieve engorgement

. If mother is complaining of breast pain, also assess the mother’s breasts

ASK, CHECK RECORD LOOK, LISTEN, FEEL SIGNS CLASSIFY TREAT AND ADVISE

Ask the mother



What are you feeding the baby?



How are you feeding your baby?



Has your baby fed in the

previous hour?



Is there any difficulty?



How much milk is baby taking

per feed?



Is your baby satisfied with the feed?



Have you fed your baby any other

foods or drinks?



Do you have any concerns?

If baby more than one day old:



How many times has your baby fed

in 24 hours?



How much milk is baby taking

per day?



How do your breasts feel?

Observe a feed



If the baby has not fed in the

previous hour, ask the mother

to feed the baby and observe

feeding for about 5 minutes.

Ask her to prepare the feed.

Look



Is she holding the cup to the

baby’s lips?



Is the baby alert, opens eyes

and mouth?



Is the baby sucking and

swallowing the milk effectively,

spilling little?

If mother has fed in the last hour,

ask her to tell you when her baby is

willing to feed again.



Not sucking (after 6 hours

of age).



Stopped feeding.

NOT ABLE TO FEED



Refer baby urgently to hospital

K14



Not yet fed (first 6 hours of life).



Not fed by cup.



Not sucking and swallowing

effectively, spilling



Not feeding adequate amount

per day.



Feeding less than 8 times per

24 hours.



Receiving other foods or drinks.



Several days old and inadequate

weight gain.

FEEDING DIFFICULTY



Teach the mother replacement feeding



Teach the mother cup feeding



Advise to feed more frequently, on demand,

day and night.



Advise the mother to stop feeding the baby other

foods or drinks or by bottle.



Reassess at the next feed or follow-up visit in

2 days.



Sucking and swallowing adequate

amount of milk, spilling little.



Feeding 8 times in 24 hours on

demand day and night.

FEEDING WELL



Encourage the mother to continue feeding by cup on

demand

NEWBORN CARE

J12

Assess replacement feeding

J12

ASSESS REPLACEMENT FEEDING



Examinine routinely all babies around an hour of birth,

for discharge, at routine and follow-up postnatal visits in the

first weeks of life, and when the provider or mother observes

danger signs.



Use the chart Assess the mother’s breasts if the mother is

complaining of nipple or breast pain



During the stay at the facility, use the Care of the newborn chart

J10

. If the baby is small but does not need referral, also use the

Additional care for a small baby or twin chart

J11



Use the Breastfeeding, care, preventive measures and treatment

for the newborn sections for details of care, resuscitation and

treatments

K1-K13



Use Advise on when to return with the baby

K14

for advising the

mother when to return with the baby for routine and follow-up

visits and to seek care or return if baby has danger signs.

Use information and counselling sheets

M5-M6



For care at birth and during the first hours of life, use Labour

and delivery

D19

ALSO SEE:



Counsel on choices of infant feeding and HIV-related

issues

G7-G8



Equipment, supplies and drugs

L1-L5



Records

N1-N7



Baby dead

D24

NEWBORN CARE

Newborn care

useful to those directly providing care to pregnant women and

preterm infants, such as obstetricians, paediatricians, midwives,

nurses and general practitioners. The information in this guideline

will be useful for developing job aids and tools for pre- and in-

service training of health workers to enhance their delivery of

maternal and neonatal care relating to preterm birth. In includes list

of the nine-evidence based maternal and newborn interventions

to improve health outcomes for the preterm infants. The ﬁle also

includes the new WHO IPC guideline. It is the core components

of IPC programmes form a key part of WHO strategies to prevent

current and future threats, strengthen health service resilience and

help combat antimicrobial resistance (AMR). The guide is useful

to develop protocols for IPC and AMR action plans and to support

health care facilities as they develop or strengthen their own

approaches to IPC.

9. Training Supplies: The list contains essential supplies required

to organise in- services capacity building and training on Kangaroo

Mother Care (KMC). The list assumes that participants have skills

on essential newborn care and helping babies breathe/resuscitation.

The supply is for one session for 30 participants and ﬁve facilitators.

10. Articles: Born Too Soon, the Global Action Report on Preterm

Birth, published in 2012. It reports the magnitude of the problem,

evidence based interventions and delivery platforms, global action

agenda for research and advocates for increased resource and

accelerated progress. The 2010 Plos article describes new strategies

that can prevent, diagnose, and treat neonates with sepsis are

needed in both low- and high-income settings. The review of

neonatal sepsis gives an overview of the burden of bacterial sepsis

and meningitis in the newborn population in developing countries.

It is focused on the pathogens mostly implicated, their antibiotic

susceptibility patterns, and management. The 2005 Lancet paper

on hospital acquired neonatal infection in developing countries

reviewed the burden of hospital-acquired bacterial infections, the

range of neonatal pathogens and antimicrobial resistance, potentially

modiﬁable intrapartum and postnatal risk factors for infection,

and low-cost quality improvement, infection prevention strategies

for resource constrained settings and further research needs. In

Journal of Hospital Infection, 2008, authors describe strategies for

the prevention of nosocomial infections to include hand hygiene

practices, prevention of central venous catheter (CVC)-related

bloodstream infections (CRBSIs), judicious use of antimicrobials for

therapy and chemoprophylaxis, enhancement of host defenses, skin

care and early enteral feeding with human milk.

Facilitators

Learning Objectives

At the end of the sessions, participants will be able to acquire knowledge and skills

to manage LBW/preterm babies and counsel and support mothers and caregivers with

LBW/preterm babies

• Preparation and/or anticipating for birth of LBW/preterm newborns

and Essential newborn care

• Maintaining thermal care for the LBW/preterm and KMC positioning

• Feeding LBW/preterm babies

• Routine assessment of LBW/preterm babies for change of care or referral

• Referral, discharge, re-admission and follow-up of LBW/preterm babies

• KMC Implementation Experiences, challenges and Possible Solutions

• Increasing KMC support, and Action Planning for Implementation and Scale-up

• Perinatal Death Reviews using WHO guidelines

• IPC (Infection Prevention & Control) in Health Care Facilities (HCF)

Sitting arrangement/ Resources/Preparation required

Sitting arrangement

One facilitator per table

3 pairs of two Participants per table

Resources

• Facilitator Agenda

• ECSB Action Plan (on wall, or easel)

• ECSB Flipchart

• ECSB Kit

• PowerPoint presentation

• Videos

• Participant Agenda (1 per person)

• ECSB Provider Guide (1 per person)

• ECSB Parent Guide (1 per person)

• PremieNatalie (1 per pair)

• MamaBreast (1 per pair)

Other resources per table

• Alcohol handrub for hand washing

• Thermometers (type used locally)

• Vials of antibiotics

• Vial to simulate eye drops

• Vial to simulate Vitamin K

• 1.0 mL Syringe for Vitamin K

• 1.0 mL Syringe for antibiotics

• Cloth binder for skin-to skin care

• Baby blanket, cap, socks and nappy

• Measuring container for breast milk

• Cup, spoon, for feeding baby

• Clean nasogastric tube (5 or 6 French)

• Clean 20ml syringe

• Weighing scale, measuring tape and torch

Preparation required

• Organise venue for PowerPoint presentation

• Translate to local language if needed

LESSON PLAN

WORKSHOP TITLE: Kangaroo Mother Care (KMC)

Timing Facilitator/ Participant Activities Resources/tools required

DAY 1

Objective 1: Preparation for birth of LBW newborns & essential care– 100 mins

mins

• Explain, counsel and demonstrate essential care for

small babies (ECSB ﬂip chart 1/1b)

• Explain on preparation for birth of LBW, and

coordination and collaboration among different teams

(ECSB ﬂip chart 2/2b)

• Explain and demonstrate essential newborn

care - show video (7 mins)

• Explain and demonstrate essential care of the

small baby at birth (ECSB ﬂip chart 3/3b) - show video

(7 mins)

• ECSB ﬂip chart

• Videos

• PremieNatalie

• Vitamin K vial

and syringe

• Antibiotics vial

and syringe

• Baby blanket

mins

• Participants practice preparing for birth of a small baby,

and communicating with the family

• Participants practice on identifying steps that keep a

small baby well and support breathing, warmth, feeding,

and preventing infection

• Using a manikin, participants practice on essential care

of the small baby at birth

mins

• Explain and demonstrate classifying LBW babies (ECSB

ﬂip chart 4/4b, 5/5b) –show video (6 mins)

mins

• Participants practice classifying the small baby

Objective 2: Maintaining thermal care for the LBW and KMC positioning – 90 mins

mins

• Explain and demonstrate assisting mothers to

provide skin-to-skin care for small babies in the ﬁrst

24 hours, checking the temperature, and wrapping the

baby when no longer using skin-to-skin care (ECSB ﬂip

chart 6/6b)

• Facilitator demonstrate interpersonal counseling skills

• Explain, counsel and demonstrate assessing a baby

during continuous skin-to-skin care for activity, breathing,

color and temperature (ECSB ﬂip chart 7/7b, 8/8b)

• PowerPoint presentation

(slides 1-28)

• ECSB ﬂip chart

• Videos

• PremieNatalie

• Cloth binder

• Thermometers

• Baby blanket

mins

• Show video (7 mins)

mins

• Using the manikin, participants practice continuous skin-

to-skin care, and assessing activity, breathing, color and

temperature (ECSB ﬂip chart 9/9b)

mins

• Participants practice recording feedings and wet or dirty

diapers on a simple form

Timing Facilitator/ Participant Activities Resources/tools required

DAY 2

Objective 3: Feeding LBW babies – 300 mins

mins

• Q & A session for Day 1 lessons

Participants get a chance to ask questions on day 1

sessions and clarify any issues

• Videos

• ECSB ﬂip chart

• PremieNatalie

• MamaBreast

• Measuring container for

breast milk

• Cup, spoon, for

feeding baby

• Clean NGT (5 or 6 French)

• Soap & water/Alcohol

hand rub

• Water to simulate milk

mins

• Explain, counsel and demonstrate supporting

breastfeeding and evaluating the baby’s effectiveness

at breastfeeding (ECSB ﬂip chart 10/10b)

mins

• Working in pairs, participants practice evaluating baby’s

effectiveness at breastfeeding using case scenario

(ECSB ﬂip chart 10b)

mins

• Explain, counsel and demonstrate expressing breastmilk,

and storing expressed milk (ECSB ﬂip chart 11/11b)

show video (7 mins)

mins

• Using MamaBreast, participants practice on expressing

breastmilk and correctly storing breast milk

mins

• Explain, counsel and demonstrate cup feeding (ECSB

ﬂip chart 12/12b)- show video (8.43 mins)

mins

• Participants practice feeding by cup, including proper/

thorough cleaning of cup/spoon before each feeding, and

assessing the baby’s ability to take cup or spoon feedings

mins

• Explain, counsel and demonstrate inserting and removing

a nasogastric tube (ECSB 13/13b)–show video (7 mins)

• Explain, counsel and demonstrate feeding with NGT

(ECSB ﬂip chart 15/15b)–show video (6.15 mins)

mins

• Using a manikin, participants practice inserting NGT,

feeding with a NGT, and safely removing NGT

mins

• Explain feeding options for babies with HIV+ mothers

mins

• Explain and demonstrate determining appropriate

volume of breastmilk (ECSB ﬂip chart 14/14b)

mins

• Participants discuss determining appropriate volume of

breastmilk using case scenarios (ECSB ﬂip chart 14b)

mins

• Explain and demonstrate assessing signs of readiness

for breastfeeding (ECSB ﬂip chart 16/16b)

https://globalhealthmedia.org/portfolio-items/

breastfeeding-the-small-baby/?portfolioID=5623(9)

(10.35 mins)

mins

• Participants discuss assessing breastfeeding readiness

using case scenarios (ECSB ﬂip chart 16b)

Timing Facilitator/ Participant Activities Resources/tools required

Objective 4: Routine assessment of LBW babies for change of care or referral – 120 mins

mins

• Explain and demonstrate on routine assessment

of LBW babies for change of care or referral

(ECSB ﬂip chart 18/18b)

• PowerPoint presentation

(slides 29-52)

• Daily weight follow-up,

ward observation

• Daily PNC check form

• Ward statistics forms

mins

• Participants work in groups of 3 (mother, provider,

colleague assuming care of the baby) practice case

scenario (ECSB ﬂip chart 18b)

mins

• Participants practice on ﬁlling daily follow-up of vital

signs, adequacy of feeding, weight gain, danger signs

and ﬁlling forms and clinical notes

• participants practice interpersonal counseling skills

DAY 3

Objective 5: Referral, discharge and re-admission of LBW babies – 240 mins

mins

• Q & A session for Day 2 lessons

Participants get a chance to ask questions on day 2

sessions and clarify any issues

• Power Point presentation

(slides 53-64)

• Referral form (provider

guide, pg 60)

mins

• Explain and demonstrate prompt referral, and

stabilization for transport when a baby needs advance

care (ECSB ﬂip chart 19/19b)

mins

• Participants work in pairs, discuss case scenarios

(ECSB ﬂip chart 19b)

• Power Point presentation

(slides 6 5 -111)

• Parent Guide or local

materials

• Soap and water/ Alcohol

hand rub

• Bag and mask (optional)

mins

• Explain and demonstrate on planning for successful

discharge and home care (ECSB ﬂip chart 20/20b)

mins

• Using parent guide or local materials, participants

practice on counselling the mother for home care

(ECSB ﬂip chart 20b)

mins

• Explain and demonstrate proper hygiene and preventing

infection (ECSB ﬂip chart 21/21b)

mins

• Discharge and outpatient high risk follow-up of preterm

and low birth weight infants

Note: The slides on neurological examination (Amiel Tison and

INFANIB exam) will be used when it is feasible. A pediatrician must

be available to provide mentoring support.

mins

• Participants practice on teaching the mother how to

wash hands

• Participants discuss hygiene practices and immunizations

given in the ﬁrst 6 months (ECSB ﬂip chart 21b)

mins

• Administer OSCE B to all participants • OSCE B

Timing Facilitator/ Participant Activities Resources/tools required

Objective 6: KMC Implementation Experiences, challenges

and Possible Solutions- 135 mins

40-60

mins

Introduction to KMC implementation and scale-up

• Expectations: what do learners want to be able to do at

the end of the workshop

• Learners share their own experience with KMC

implementation (if any) (a few short presentations or

discussion in group with plenary feedback)

Inform participants to include the following

key information:

• Total number of births (percentage of premature and

low birth weight infants)

• Neonatal mortality (percentage of deaths that are

attributed to prematurity or low birth weight)

• Place of birth (i.e. concentrated cities of the

country, number of births in the community VS.

institutional births)

• Basic description of the health system (i.e. different

levels of care, private institutions VS. public institutions

distribution, number of public hospitals, who pays for

health care in the government; health insurance,

out of pocket)

• Ethnic minorities and geographic distribution

• Current medical care that is being delivered to

premature and low birth weight infants and the cost of

providing such care

• Available data on screening and referral from lower

health facilities and follow-up babies monitored (in both

facility and community level)

• Nutrition proﬁle (TIBF, EBF, wasting, stunting)

• Available policies or guidelines on infant and neonatal

care (i.e. Has the country being sensitized to KMC? is

KMC included in policies and national guidelines?)

• Institutions that offer traditional neonatal care/

institutions that offer neonatal care and KMC

(if any)

• Learners are prepared for further disseminating

knowledge and skills through training, orientation,

on-the-job training, etc. appropriate to the context

• Discussion

• Short presentations by

participants

• PowerPoint presentation

to guide the session

• Use training slide table

as handout

• USAID/MCHIP KMC

implementation guide

mins

Quality of care and supportive supervision – short

presentation with group activities in between

• Learners work in country or facility teams to document

ideas to include in country/facility action plans

• Power Point presentation

• Activity handout

• Example supportive

supervision checklists

• USAID/MCHIP KMC

implementation guide

Timing Facilitator/ Participant Activities Resources/tools required

mins

Multidisciplinary care and teamwork in KMC – short

presentation with group activities in between

• Participants brainstorm on categories of health

services, professionals and other health workers

that should be involved in KMC at different levels

of the health system per what is available in their

country or health facility (Examples: nutritionists/

dieticians, speech-language therapists, psychologists,

occupational therapists, physiotherapists,

ophthalmologists, neurologists, community

health workers)

• Discussion on the need for multidisciplinary care

in KMC and role of KMC for early childhood

development

• PowerPoint presentation

• Activity handouts

mins

Mobilizing support for KMC – short presentation with

group activities in between (national level, health

facilities and community)

• Participants brainstorm on KMC sensitization and

mobilization at different levels (Who? What? Where?

When? How?)

• Participants brainstorm how to look beyond barriers

and transform barriers into enablers

• Power Point presentation

• Activity handouts

• USAID/MCHIP KMC

implementation guide

DAY 4

Objective 7: Increasing KMC support, and Action Planning for Implementation

and Scale-up – 180 mins

mins

• Q & A session for Day 3 lessons

Participants get a chance to ask questions on day 3

sessions and clarify any issues

mins

Documentation for monitoring and evaluation

• Rationale for the monitoring and evaluation of KMC

• Utilization of data for program improvement

and advocacy

• Documentation and record keeping – case scenarios and

learners practice ﬁlling or interpreting patient records

and collective registers and and reﬂect on the use of the

results of the analysis

Power Point presentation

(Presentations: 3.5 and 3.6

and handouts: 3.5)

• Facilitator(s)and

participant(s) share

experiences

• Completed stats form

and KMC register

for discussion and

interpretation

Timing Facilitator/ Participant Activities Resources/tools required

mins

Action planning for KMC implementation

and scale-up

• Different interpretations of KMC, stages of change, tools

for measuring change, deciding on an approach

for scale-up

• Power Point

presentation

(Presentations: 3.1

and 3.6 and

handouts: 3.6

mins

Learners work in country/facility teams to develop

short- and long-term action plans (immediate, 3, 6,

and 12 months) – use available templates or design

own template

• Facility level: implementation or quality improvement

• District or regional level

• National level

Working groups hand in a copy of their action plan to the

lead facilitator – if hand written, the facilitator could make

a photocopy or take a picture so that participants take the

original plan with them

• Design templates for

country brain storming

(action plans [stages

of change/simple/ PPT

template], prioritizing

activities)

40-60

mins

Learners report back to other country/facility teams on

their plans – what will be done immediately, what will

be done immediately, within 1month, within 3 months, 6

months and one year (Could also be done on the next day)

• Power Point

• Electronic copy to lead

facilitator

mins

• Participants take a post-test assessment for the course

and do course evaluation

mins

• Closing, and post-course remarks

Formative/Summative Assessment

• Q & A

• Making presentations/being able to provide feedback

• Multiple Choice Questions Examination (MCQ): a 30-item examination

pre-and-post training.

• Objective Structured Clinical Exams (OSCEs): two OSCEs.

• OSCE A to evaluate the skills of positioning, counseling and assessment

with skin-to-skin care.

– If time allows.

– If not conduct only B

• OSCE B to evaluate the skills of family counseling, NG placement

and NG feed administration.

Essential Care for Small Babies – Knowledge check

Select the best answer to each question or statement Circle the letter of the

correct answer

1. Which of the following statements correctly describes

a well small baby?

Feeds by cup, stays warm with skin-to-skin care, has convulsions

Feeds by cup, stays warm with skin-to-skin care, weighs 1600 grams

Breastfeeds poorly, breathes at 100 times per minute, maintains

temperature in an incubator

Feeds by cup, weighs 1200 grams, maintains temperature in an incubator

2. Which of the following is an important step in the care of

a small baby?

Teaching the mother to give a bath

Giving the small baby lots of time in the sunlight

Preventing infection by washing hands before touching the baby

Weighing the small baby ﬁve times a day

3. Which of the following statements describes preparation

for the birth of a small baby?

Identify a skilled helper, provide extra warmth in the area for delivery,

anticipate need to help the baby breathe at birth.

Prepare an area for the baby’s bath, check equipment,

review emergency plan.

Wash hands, prepare herbs for babies ﬁrst feeding.

Anticipate need to help baby breathe at birth, identify a skilled helper,

prepare an area for the baby’s bath.

KNOWLEDGE CHECK

(PRE-AND POST-TEST)

4. A 1700-gram baby has been placed skin-to-skin with the mother after birth.

What other care should be provided in the ﬁrst 90 minutes after birth?

Showing the baby to the extended family

Feeding the baby with a nasogastric tube

Monitoring breathing and measuring temperature

Bathing the baby

5. At 90 minutes after birth, an 1800-gram baby is placed skin-to-skin

with the mother and has a temperature of 36.7˚ C. What should you

do to help maintain the baby’s temperature?

Bathe the baby in warm water.

Place in direct sunlight.

Assist mother with continuous skin-to-skin care.

Place the baby on an open warmer set for high heat output.

6. Shortly after birth, a small baby is classiﬁed based on the temperature,

weight, and physical exam. The baby is 1400 grams, is breathing at 90

breaths per minute, and has a temperature of 35˚C. What should you do?

Put the baby to the breast to assess breastfeeding.

Continue to watch for improvement.

Place a nasogastric tube to administer a feeding.

Arrange a transfer for advanced care.

7. How many feedings should a small baby receive in a day?

Two to four

Five to six

Eight to twelve

Twenty-four

8. Which of the following techniques can help a mother to support

or improve a small baby’s latch?

Wrapping the breasts in tight clothing between feedings

Supporting the head of the baby so he is positioned to take the nipple

and surrounding area into an open mouth

Putting oils on the breast

Feeding ﬁrst with a bottle until sucking is strong

9. What is the skin temperature of a well small baby?

35.0-35.5˚C

35.5-36.5˚C

36.5-37.5˚C

37.0-38.0˚C

10. Shortly after birth, the temperature of an 1800-gram baby is 36˚C.

After placing the baby skin-to-skin, the baby’s temperature remains

the same. Which of the following actions should be taken?

Place the baby in direct sunlight.

Place warm stones around the baby.

Bathe the baby in warm water.

Remove wet diaper and cover the mother and the baby with a blanket.

11. A 1600-gram baby has been maintaining temperature with

continuous skin-to-skin care. The baby will not breastfeed or cup feed

and requires nasogastric feeding. What do you advise the mother

about skin-to-skin care?

The mother can continue skin-to-skin care even while the baby

is receiving nasogastric feedings.

The baby will need to be in an incubator while receiving nasogastric feeding.

The baby will need to be on a radiant warmer while receiving

nasogastric feeding.

The mother must stop skin-to-skin care during nasogastric feeding.

12. When a baby cannot feed directly from the breast after support is

provided, what should you advise a mother to do next?

Give the baby formula.

Keep trying to breastfeed the baby.

Express her breast milk to feed to the baby by a safe,

alternate feeding method.

Wait until the baby can feed directly from the breast.

13. When a mother expresses her breast milk, how can it be stored safely?

In a covered container in a cool place for up to 6 hours

In an open container in a shaded area

In an open container in direct sunlight

In a covered container heated in warm water until used

14. When breastfeeding is not effective, which of the following are safe

and recommended alternate feeding methods for a small baby?

Attempt cup feedings and if not successful, insert a nasogastric tube.

Use a syringe to pour milk directly into the baby’s mouth.

Dip ﬁnger or tongue depressor into milk and allow the baby to lick the milk.

Give bottle feedings and insert a nasogastric tube.

15. Which of the following best describes a 3-day-old 1800-gram baby

who needs nasogastric tube feeding?

The baby is breastfeeding 8-12 times per day.

The baby is gaining 15 grams/kilograms per day.

The baby shows feeding readiness cues every 2-4 hours.

The baby takes 5-10 mL by cup per feeding for 4 feedings.

16. What is the proper length for nasogastric tube insertion?

From the tip of the nose to earlobe to half way between the tip of

the breast bone and the umbilicus

From the mouth opening to the nipple to the umbilicus

From the earlobe to the umbilicus

From the tip of the nose to the chin to the bottom of the breast bone

17. You have just inserted a nasogastric tube into a small baby who cannot

breastfeed or receive cup feedings. Which of the following best describes

a method for conﬁrming proper placement of the nasogastric tube?

Measure the tube outside the nose.

Inject 2 mL of air while listening with a stethoscope for the sound of air

entering the stomach.

Administer 5 mL of a feeding and then withdraw it back to see if it is

mixed with gastric contents.

Evaluate the baby’s breathing.

18. What should a mother be taught to do before administering

a nasogastric feeding?

Wash her hands and reinsert the nasogastric tube.

Wash her hands and conﬁrm placement of the nasogastric tube by

checking that the mark on the tube is at the edge of the nose.

Wash her hands and conﬁrm placement of the nasogastric tube by

checking that the mark on the tube is at the sternum.

Wash her hands and inject 10 mL of air into the tube.

19. After initial weight loss, how much weight should a small baby

gain each day?

5 grams per kilogram per day on average

15 grams per kilogram per day on average

25 grams per kilogram per day on average

30 grams per day on average

20. On the day after birth, a 1600-gram baby cannot breastfeed or cup

feed, and will be fed every three hours by a nasogastric tube. What

volume should be administered for the baby’s ﬁrst feeding?

1 mL

5 mL

12 mL

25 mL

21. A 1600-gram baby is fed by a nasogastric tube. After the initial day of

feedings, what is the daily increase in the volume of each feeding?

4 mL

5 mL

10 mL

15 mL

22. Which of the following indicates feeding intolerance and the need

for advanced care?

Spitting up small amounts

Tense abdominal distension

Stooling 6-8 times per day

Crying before each feeding

23. In a small baby being fed by an alternative method, how often should

breastfeeding readiness be assessed?

At least once per day

At least once per week

At least once every two weeks

At least once per month

24. A small baby is now 10 days old and has been fed by nasogastric tube

since birth. During the ﬁrst attempt to breast feed, he sucks actively,

and swallowing sounds are heard. What should be done next to

make the transition to breastfeeding?

Stop nasogastric feeding immediately, pull out the nasogastric tube,

and breastfeed only.

Continue with nasogastric feeding, while gradually increasing the number

of breastfeeding attempts per day.

Stop nasogastric feeding immediately and breastfeed only

throughout the daytime.

Continue with nasogastric feeding, wait two days, and try

breastfeeding again.

25. A 1600-gram baby has been receiving nasogastric feeding for 10 days

and now has started to feed at the breast. Which of the following is an

indication that the baby is ready to receive all the feedings by breast?

Waking and crying in between feedings.

Choking during occasional feedings

Sucking and swallowing audibly for 10 minutes during each feeding

Weight gain of 5 grams per day when no nasogastric feedings

are provided

26. Small babies should be regularly assessed for:

Frequency and success at feeding, temperature, presence of hiccups

Activity, breathing, color, temperature and weight gain

Breathing problems, temperature, and white blood cell count

Frequency and success at feeding, cough, presence of convulsions

27. A 2-day-old 1700-gram baby has a normal examination and breathing

rate. How often should the baby be assessed for temperature,

breathing and feeding tolerance?

Once per day

Every 2 to 3 hours

At least once per shift.

Only if the baby seems ill

28. When should the mother or other providers wash their hands in

order to protect a small baby?

Before touching the baby and before preparing a feeding

Before greeting the family

Before closing a window

Before leaving the hospital at the end of the day

29. A small baby needs to be referred for advanced care to a hospital

1 hour away. What should you do to prepare the baby for transport?

Place a nasogastric tube so that mother can feed through the tube during

transport.

Continuation of KMC in transit and communicate with health providers at

the receiving facility and the family, and prepare a referral note.

Bathe the baby to prevent infection.

Use a radiant warmer to warm the baby to 38˚C so that the baby will

maintain temperature during transport.

30. Which of the following statements below describes a small baby who

should be considered for discharge from the birth facility?

The mother has not demonstrated competence with infant feeding, the

baby has adequate weight gain documented over 3 consecutive days, and

breathes 40 breaths per minute.

The mother has demonstrated competence with infant feeding, the baby

has adequate weight gain documented over 3 consecutive days, and the

baby breathes 40 breaths per minute.

The mother has demonstrated competence with infant feeding, the baby

has adequate weight gain documented over 3 consecutive days, and the

baby is breathing 80 breaths per minute.

The mother has demonstrated competence with infant feeding, the baby

has adequate weight gain documented over 5 consecutive days, and the

baby is under a radiant warmer.

Answer to Knowledge Check (Pre and post-test)

1. B

2. C

3. A

4. C

5. C

6. D

7. C

8. B

9. C

10. D

11. A

12. C

13. A

14. A

15. D

16. A

17. B

18. B

19. B

20. C

21. A

22. B

23. A

24. B

25. C

26. B

27. C

28. A

29. B

30. B

ID:__________________________

OSCE A – Classify, Provide continuous skin-to-skin care and monitor

“I am going to read a role play case. Please show and tell me what you would do to take care of this small baby.

I will only give indication about the baby’s condition when you ask. No other feedback will be given until the end of the case.”

“A 28-year-old mother has given birth to a 1700 gram baby. You have provided essential care, including cord care, vitamin K,

and eye care. You perform your rst assessment. You nd that the baby is breathing well and the rest of the exam is normal;

the temperature is 36.3˚C. Tell me what information you will use, how you will classify the baby and what thermal care the

baby will need.”

Classify the small baby Done Not Done

Uses the weight, temperature and exam to classify the baby ................................................................................

Recognizes a well small baby ..........................................................................................................................................................

Plans to provide continuous skin-to-skin care ..............................................................................................................

Prompt: This is a well small baby who will need continuous skin-to- skin care.

Describe and show how you will help mother begin continuous skin-to-skin care.

Show the mother how to do skin-to-skin care

Explains to mother the steps and advantages of skin-to-skin care ......................................................................

Dresses baby with diaper, hat and socks (if available) ...............................................................................................

Places the baby upright on mother’s skin between breasts ....................................................................................

Positions baby with arms and legs exed, head turned............................................................................................

Secures snugly with a cloth pulled up to the ear .........................................................................................................

Covers with a garment or closes mother’s shirt ............................................................................................................

Prompt: The baby and mother are comfortable.

Please demonstrate how you will monitor the baby and show the mother about

how to monitor the baby while in skin-to-skin.

Monitors baby’s activity, breathing, color, temperature ...........................................................................................

Advises mother how to monitor activity, breathing, color, temperature ..........................................................

SCORING:

Successful completion requires a total score of 9 of 12. Incompletely done items should be marked as “Not Done.”

SCORE: ______________________________/ 12

ID:__________________________

OSCE B – Feeding with a nasogastric tube and daily assessment

“I am going to read a role play case. Please show and tell me what you would do to take care of this small baby.

I will only give indication about the baby’s condition when you ask. No other feedback will be given until the end of the case.”

“A 1700 gram baby is 8 hours old. The baby has a normal physical exam, and has been maintaining a temperature

of 36.7˚C with continuous skin-to-skin care. The baby did not latch well at the breast and did not tolerate cup feeding.

Mother has successfully expressed 15mL of milk. Describe and show what you will do next to feed this small baby.”

Done Not Done

Insert a nasogastric tube

Communicates with the mother about need for nasogastric feeding ...............................................................

Washes hands .............................................................................................................................................................................

Measures depth tube should be inserted and marks tube ......................................................................................

Lubricates tube with expressed breast milk ...................................................................................................................

Inserts tube ..................................................................................................................................................................................

Conrms proper placement ..................................................................................................................................................

Tapes tube on face ....................................................................................................................................................................

Prompt: Show how you will feed breast milk with the nasogastric tube.

Feed with a nasogastric tube

Determines amount of feeding baby requires (12 mL) .............................................................................................

Measures the amount to be fed ..........................................................................................................................................

Connects syringe and transfers milk with tube pinched ..........................................................................................

Allows milk to slowly enter stomach .................................................................................................................................

Removes syringe, recaps tube .............................................................................................................................................

Prompt: The baby is now ve days old and you are doing your daily assessment.

Tell me what you will assess and I will provide the ndings.

After completing your assessment please tell me your plan.

Describe a daily assessment

Maternal concerns (none) ......................................................................................................................................................

Physical assessment (active, breathing well, pink, warm) ........................................................................................

Temperature (36.7⁰C) ...........................................................................................................................................................................

Weight (1550 grams) ...............................................................................................................................................................

Intake (nasogastric feeds 24 mL every 3 hours, good tolerance) ...........................................................................

Output (7 wet diapers, 3 stools)...........................................................................................................................................

Recognizes that the baby remains well............................................................................................................................

Advance feedings to 28 mL every 3 hours ......................................................................................................................

SCORING:

Successful completion requires a total score of 16 of 20. Incompletely done items should be marked as “Not Done.”

SCORE: _____/20

26b

SKILL ASSESMENT TOOL