Guidance Related to Nutrition Care Provision

Feeding counselling, nutrition assessment, and nutrition counselling and support

Mothers or caregivers of infants and children with cleft should have access to timely and appropriate feeding support and nutrition care that optimises nutrition, health, and survival and contributes to timely surgery. Older children, adolescents, and adults who have feeding difficulties and are malnourished should also be provided with appropriate feeding and nutrition services.

Smile Train’s partners are encouraged to provide feeding counselling, nutrition assessment, and nutrition support as a standard of care to all patients.

Smile Train works to assist its partners by:

providing financial support through this nutrition grant,
building capacity through nutrition training, and
creating awareness of relevant policies, guidelines, and materials to assist partners.

1) Guidance Related to Nutrition Care Provision

This document outlines key actions and professional competencies that are needed to ensure effective, appropriate, and safe feeding and nutrition care to all patients in need who are managed by Smile Train’s partners.

2) Definitions

Feeding counselling: This is the interactive process in which the health provider assesses the feeding situation and gaps in information and discusses with the mother/caregiver the strategies that can improve and maintain adequate feeding and care of the child. This is especially important for mothers/caregivers of infants aged 0-24 months who need support to overcome (breast)feeding difficulties as well as encouragement to adopt optimal infant and young child feeding practices.

Nutrition assessment: This step requires to evaluate and classify the nutritional status of children based on the accurate recording and interpretation of anthropometric indicators and clinical information. Clinical examination only is not sufficient to assess the nutritional status of a patient. Nutrition assessment is critical to identify problems and inform decisions to improve and maintain the nutritional status of patients.

Nutrition care: this includes (i) the counselling of caregivers on infant and young child feeding practices (IYCF) – to improve care and reduce the risk of malnutrition, morbidity, and mortality and (ii) the planning, implementation, monitoring, and evaluation of a nutrition care plan that may include the clinical management of malnutrition at facility level and follow-up services at community level.

3) Minimum Standards of Practice: Feeding Counselling, Nutrition Assessment, and Nutrition Support

3.1) Key Actions

General Support

Create an enabling environment to promote effective nutrition counselling and adequate care
Provide understanding and support to caregivers when children are ill, avoiding blame and assisting in care
Educate caregivers about the importance of good nutrition to support the growth and health of their children

Feeding Counselling

Target all mothers of newborns with early initiation of breastfeeding, exclusive breastfeeding for 6 months, and continued breastfeeding until 2 years and beyond together with appropriate complementary feeding from 6 months
Be especially concerned by low-birth weight infants, malnourished infants, and non-breastfed infants who require particular attention
Offer skilled breastfeeding counselling support to help all mothers who have difficulties breastfeeding
Enable access for mothers and caregivers whose infants require artificial feeding to an adequate amount of an appropriate breast milk substitute and offer support to handle it and the feeding method appropriately and safely. The supply of the milk substitute should be reliable and uninterrupted
Support timely, safe, adequate, and appropriate complementary feeding for children aged 6 months-2 years
Consider the nutritional, physical, and mental health of mothers that is central to the well-being of their children and support maternal nutrition if deemed necessary
Be aware of the International Code of Marketing of Breastmilk Substitutes that sets out the responsibilities of the infant food industry, governments, organisations, and health workers in relation to the marketing of breastmilk substitute

Nutrition Assessment

Conduct a physical evaluation to identify malnutrition or risk of malnutrition by recording with accuracy and interpreting anthropometric measures and indices and the presence/absence of bilateral oedema
Conduct a clinical evaluation to detect the presence of medical complications
Classify patients according to their nutritional status and the type and severity of malnutrition if identified
Document nutrition-related diagnoses that facilitate the determination of expected outcomes and care plan

Nutrition Care

Encourage mothers to adopt recommended infant and child feeding practices (IYCF) to prevent or reduce risks of morbidity, stunting, and mortality, and follow up to ensure commitment to change in practice, including exclusive breastfeeding for 6 months and continued breastfeeding from 6 months to 2 years and beyond together with timely, safe, adequate, and appropriate complementary feeding
Prevent illnesses and manage feeding and care of sick children: e.g., promoting IYCF, providing oral rehydration and zinc treatment for diarrhoea, antibiotics for pneumonia, chemotherapy for worm infection, antimalarials for malaria, vitamin A treatment for measles, iron supplementation for iron deficiency anaemia (…) according to national and international guidelines
Manage moderate and acute malnutrition according to national guidelines i.e. through therapeutic feeding and medical care for children with severe acute malnutrition and supplementary feeding and medical care for children with moderate acute malnutrition
Help mothers acquire nutrient dense and diverse foods (including animal source foods)
Support maternal nutrition, especially the nutrition of mothers of malnourished children

Additional Nutrition-Sensitive Activities

Train health providers at the facility and at community level such that feeding difficulties can be addressed and mother-child pairs receive appropriate care or referral in a timely manner
Strengthen community support e.g., through raising awareness of feeding difficulties of children with cleft and engaging key community influencers to change cultural norms and practices and better support mothers
Organize peer support groups where peers can learn from and support each other to overcome difficulties and practice optimal child care and feeding practices

3.2) Key Competencies

Feeding Counselling

Elicits the caregiver or the patient (if an adult)’s difficulties, needs, values, preferences, and knowledge in relation to feeding and nutrition
Assesses the patient’s ability to eat (considering structural, functional, and cognitive limitations)
Assesses the patient’s weight history (gain or loss)
Assesses the ability of the caregiver/patient to follow instructions and identifies barriers to improving/modifying practices or adopting new practices
Recognizes the impact of attitudes, values, and beliefs when designing a feeding plan
Provides nutrition education and information accommodating the level of education, the ability to understand, the communication style, and the culture/values of the mother/patient
Uses and/or develops educational material regarding infant and young child feeding practices and considering available community resources
Checks that the teaching of feeding nutrition information is effective and that changes in practice are understood and applied
Considers his/her responsibilities regarding the use of breastmilk substitutes (as defined by the International Code of Marketing of Breastmilk Substitutes) to support the feeding of infants who cannot be breastfed or who are fed an insufficient amount of breastmilk

Nutrition Assessment

Participates in assessment activities in relation to nutrition care
Uses appropriate assessment instruments and tools for nutrition assessment
Collects anthropometric measurements, i.e. at least weight and length/height
Uses standardized tools (i.e., WHO Standards Growth Charts, or WHO anthropometric z-score tables, or WHO anthropometric z-score calculator) to derive anthropometric indices expressed as z-scores (e.g., weight-for-height z score) from collected anthropometric measurements
Interprets growth trends and z-scores using standardized classification systems to determine the nutritional status and identify the diagnoses
Initiates and interprets diagnostic tests and procedures relevant to the patient’s nutritional assessment or collaborates with other healthcare professionals to collect additional information to determine the patient’s nutritional status
Interprets – independently or with other healthcare professionals – nutrition-related data and information obtained during the interview, nutrition examination, and physical examination to identify nutrition-related diagnoses
Identifies patients who are nutritionally at risk
Documents relevant anthropometric measurements, nutrition findings and nutrition-related diagnoses in the patient’s medical records
Reports all patients who are malnourished i.e. wasted and/or stunted and/or anaemic with/without nutritional oedema to STX nutrition data collection online. For infants (< 6 months), those who are underweight (for age) and those who are not classified as malnourished but who are not gaining weight (and thus at risk of malnutrition) can also be reported onto the collection system
Uses or develops operational mechanisms for the process by which patients who are malnourished or nutritionally at risk are referred to the next level of nutrition care

Nutrition Care

Has received formal training in nutrition and has the qualifications and credentials to manage patients who suffer from malnutrition (especially those with moderate/severe acute malnutrition who should be managed according to national recommended protocols)
Is well informed of the responsibilities of the health worker, as defined in the International Code of Marketing of Breastmilk Substitutes, regarding the use of breastmilk substitutes
Can counsel mothers on infant and young child feeding practices and assist them in procuring and preparing age-appropriate, diverse, and nutritionally dense meals
Elaborates and documents short-term and long-term goals of nutrition support that are achievable, realistic, measurable, and based on the nutrition-related diagnoses and modifies them according to changes in the nutrition status of the patient
Develops an appropriate nutrition support plan, specifying the strategies regarding care type (inpatient vs. outpatient), nutrition support type (maintenance, complementary, supplementary, therapeutic), route of delivery (and access device if needed) and administration rates, the parameters to monitor (weight, lab works, physical examination, formula tolerance), discharge plans (after initial inpatient care) with coordination for treatment continuation in the community and follow-up visits
Develops a plan with other healthcare professionals for appropriate nourishment, hydration, and management of medical issues
Provides consultation to other healthcare professionals for the review and interpretation of the patient’s clinical condition, physical assessment, laboratory values, procedures, and treatments to ensure the nutrition care plan is appropriate and safe
Organizes and manages the components of the nutrition support plan and documents the coordination of nutrition care
Recommends equipment and supplies based on the nutrition support plan
Provides leadership in the coordination of interprofessional nutrition care for integrated delivery of nutrition support patient care services
Assesses the caregiver (or patient if adult)’s understanding of the nutrition care plan and communicates
Assesses the caregiver (or patient if adult)’s willingness and ability to modify current feeding practice or adopt appropriate practice
Provides nutrition education and information accommodating the level of education, the ability to understand, the communication style, and the culture/values of the mother/patient
Uses and/or develops educational material referring to appropriate community resources
Checks that the teaching of nutrition information is effective and that changes in practice are understood and applied
Collaborates with the healthcare team to monitor and evaluate the patient and the nutrition care plan
Monitors clinical, physiological, and psychosocial data in order to appraise the adequacy and effectiveness of the nutrition care plan
Uses ongoing assessment data to revise the nutrition care plan if necessary
Documents the results of the nutrition-related monitoring and evaluation
Recommends transitions in care and recommends termination of nutrition support when it is no longer consistent with the patient’s needs