ENA.pptx

Essential Nutrition Action(ENA)

ENA
• ENA provides the WHO guidance on nutrition interventions
targeting the first 1000 days of life.
• ENA interventions are intended to be effective, feasible,
available and affordable. These interventions worked best when
combined with interventions to reduce infections, such as water,
sanitation and hygiene.

ENA
• Focusing on a package of essential nutrition actions (ENAs),
health programs could;
- Reduce infant and child mortality,
- Improve physical and mental growth and development, and
improve productivity.

Why ENA?
• For the past 30-40 years nutrition intervention programs were
often;
- Considered as vertical programs
- Not integrated
- Not action oriented
- Focused mainly on growth monitoring and promotion
activities.

Federal MOH based on the ENA approach:
The seven action areas of ENA
Control of Anemia
Optimal
Breastfeeding
Control of
Vitamin A deficiency
Control of Iodine
Deficiency Disorders
Women’s Nutrition
Complementary
Feeding to BF
Feeding
of the sick child
Estimated
decrease
of
child
mortality:
>23%

1. Promotion of Optimal Breast feeding
 Ealry Initiation of BF within 1 hour of birth
 Exclusive BF until 6 months
 BF day and night at least 10 times
 Correct positioning & attachment
 Empty one breast and switch to the other
Key Messages
National Strategy for IYCF, Fed MOH, April 2004

Promotion of Optimal Breast feeding
• Unequalled way of providing ideal food.
• Exclusive breastfeeding from birth is possible virtually for all
women and unrestricted exclusive breastfeeding results in
ample milk production.
• Also a learned behavior to build mothers’ confidence, improve
feeding technique, and prevent or resolve breastfeeding
problems.

• EBF for the first 6 months of life meets the energy and
nutrient needs of the vast majority of infants.
• Breast milk is 88% water, and is enough to satisfy a baby’s
thirst even in hot climates.
• Water and teas are commonly given to infants causing two-
fold increased risk of diarrhea.

• 6-10 times less likely to die.
• Less common among breast fed children;
- Infectious diseases
- Otitis media, UTI, meningitis, diaharrea, pneumonia
- Non-communicable diseases
- Leukemia, DM, HN, Obesity, atherosclerosis
- Allergies
- Asthma, atopic dermatitis
- Mental development IQ-3.2 pts higher.

For the mother EBF;
• Decreases risk of PPH.
• Decreases risk of breast and ovarian cancer.
• Accelerate recovery of pre-pregnancy weight.
• Family planning (LAM) only 2% risk of getting pregnant.

Promotion of Optimal Breastfeeding
• Women in paid employment can be helped to continue
breastfeeding by being provided with minimum enabling
conditions, for example:
- Paid maternity leave,
- Part-time work arrangements,
- On-site crèches,
- Breast feeding breaks

2. Complementary Feeding to BF
at
6 months
of age
National Strategy for IYCF, Fed MOH, April 2004

Guiding Principles for complementary feeding
• Guiding Principle 1: Practice exclusive breastfeeding from birth to
6 months of age and introduce complementary foods at 6 months
of age (180 days) while continuing to breastfeed.
- Exclusive breastfeeding is no longer sufficient to meet all energy
and nutrient needs by itself.
- At about 6 months of age, an infant is also developmentally ready
for other foods.
- Children between the age of 6 and 9 months can receive and hold
semi-solid foods in their mouth more easily.

• Guiding Principle 2: Continue frequent on-demand
breastfeeding until 2 years of age or beyond.
- It should be on demand, as often as the child wants.
- Sick children less often avoid breast milk.
- Decreases mortality secondary to malnutrition.
- Children tend to breastfeed less often when complementary
foods are introduced, so breastfeeding needs to be actively
encouraged to sustain breast-milk intake.

• Guiding Principle 3: Practice responsive feeding applying
the principles of psychosocial care
- Optimal complementary feeding depends not only on what
is fed but also on how, when, where and by whom a child is
fed.
- Young children are left to feed themselves, and
encouragement to eat is rarely observed.
- A more active style of feeding can improve dietary intake.

• Responsive feeding:
- Feed infants directly and assist older children when they feed themselves.
-Feed slowly and patiently, and encourage children to eat, but do not force
them.
- If children refuse many foods, experiment with different food combinations,
tastes, textures and methods of encouragement.
-Minimize distractions during meals if the child loses interest easily.
- Remember that feeding times are periods of learning and love – talk to
children during feeding, with eye-to-eye contact.

• Guiding Principle 4: Practice good hygiene and proper food
handling
- Microbial contamination of complementary foods is a major cause
of diarrheal disease, commonly 6 to12 months old.
- The use of bottles with teats to feed liquids is more likely to result
in transmission of infection than the use of cups.
- Food should be eaten right after preparation unless it is kept in a
refrigerator.

• Five keys to safer food
- Keep clean
- Separate raw and cooked food
- Cook thoroughly
- Keep food at safe temperatures
- Use safe water and raw materials

• Guiding Principle 5: Start at 6 months of age with small amounts
of food and increase the quantity as the child gets older, while
maintaining frequent breastfeeding
• The actual amount (weight or volume) of food required depends
on the energy density of the food offered.

Cont. . .
• If a complementary food is more energy dense, then a smaller
amount is needed to cover the energy gap.
• When complementary food is introduced, a child tends to
breastfeed less often, and his or her intake of breast milk
decreases, so the food effectively displaces breast milk.
• If the density is inadequate the complementary food
ineffectively displaces the breast milk leading to under
nutrition.

Practical guidance on the quality, frequency and amount of food to offer children 6–23 months of age
who are breastfed on demand
Age Energy needed per
day in addition to
breast milk
Texture Frequency Average amount food
per meal
6–8 months 200 kcal per day Start with thick
porridge, well
mashed foods
Continue with
mashed family foods
2–3 meals per day,
depending on the
child’s appetite, 1–2
snacks may be
offered
Start with 2–3 table
spoon full per feed,
increasing gradually
to ½ of a 250 ml cup
9–11 months 300 kcal per day Finely chopped or
mashed foods, and
foods that baby can
pick up
depending on the
child’s appetite,
1–2 snacks may be
offered
½ of a 250 ml
cup/bowl
12–23 months 550 kcal per day Family foods,
chopped or mashed
if necessary
depending on the
child’s appetite,
1–2 snacks may be
offered
¾ to full 250 ml
cup/bowl

• Guiding Principle 6: Gradually increase food consistency
and variety as the infant grows older, adapting to the
infant’s requirements and abilities.
• Beginning at 6 months, an infant can eat mashed or semi-
solid foods.
- By 8 months most infants can also eat finger foods.
- By 12 months, most children can eat the same types of
foods as consumed by the rest of the family.

• A complementary food should be thick enough so that it
stays on a spoon and does not drip off.
• Generally, foods that are thicker or more solid are more
energy- and nutrient-dense than thin, watery or soft foods.
• If the food is thick it is easier to give more kcal and to
include a variety of nutrient- rich ingredients including
animal-source foods.
• For optimal child development it is important to gradually
increase the solidity of food with age.

• Guiding Principle 7: Increase the number of times that the child
is fed complementary foods as the child gets older.
• Need for a larger total quantity of food each day, the food needs
to be divided into a larger number of meals.

• The number of meals that an infant or young child needs in
a day depends on:
How much energy the child needs to cover the energy gap.
- The more food a child needs each day, the more meals are
needed
 The amount that a child can eat at one meal.
- which is usually 30 ml per kg of the child’s body weight.
 The energy density of the food offered.
- Should be more than breast milk.

• Guiding Principle 8: Feed a variety of nutrient-rich foods to ensure
that all nutrient needs are met
- Should provide sufficient energy, protein and micronutrients to
cover a child’s energy and nutrient gaps, so that together with
breast milk, they meet all his or her needs.
- The basic ingredient of complementary foods is usually the local
staples; cereals, roots and starchy fruits that consist
mainly of carbohydrate and provide energy.

• Foods from animals or fish are good sources of protein, iron and
zinc.
• Liver also provides vitamin A and folate.
• Egg yolk is a good source of protein and vitamin A, but not of
iron. A child needs the solid part of these foods, not just the
watery sauce.
• Dairy products, such as milk, cheese and yoghurt, are useful
sources of calcium, protein, energy and B vitamins.

• Pulses – peas, beans, lentils, peanuts, and soybeans are
good sources of protein, and some iron. Eating sources of
vitamin C (for example, tomatoes, citrus and other fruits,
and green leafy vegetables) at the same time helps iron
absorption.
• Orange-coloured fruits and vegetables such as carrot,
pumpkin, mango and papaya, and dark-green leaves such as
spinach, are rich in carotene, from which vitamin A is made,
and also vitamin C.
• Fats and oils are concentrated sources of energy, and of
certain essential fats that children need to grow.

• Guiding Principle 9: Use fortified complementary foods or vitamin-
mineral supplements for the infant as needed
-Unfortified complementary foods generally provide insufficient
amounts of (particularly iron, zinc and vitamin B6) to meet
recommended nutrient intakes during complementary feeding.
-The amount of animal source food the child may consume may not
be enough apart from the limited accessibility of animal source
foods to children from low income countries.

• Therefore, in settings where little or no animal-source foods are
available, iron-fortified complementary foods are necessary.
• Caution; controlled iron supplementation in malaria endemic
areas.

• Guiding Principle 10. Increase fluid intake during illness,
including more frequent breastfeeding, and encourage the child
to eat soft, favorite foods. After illness, give food more often
than usual and encourage the child to eat more.
• The need for fluid often increases, so a child should be offered
and encouraged to take more, and breastfeeding on demand
should continue.
• A child’s appetite for food often decreases, while the desire to
breastfeed increases, and breast milk may become the main
source of both fluid and nutrients.

• Intake is usually better if the child is offered his or her favorite
foods, and if the foods are soft and appetizing.
• The amount eaten at any one time is likely to be less than usual,
so the caregiver may need to give more frequent, smaller meals.

3. Women’s Nutrition
 During pregnancy and lactation
-Iron/Folic Acid Supplementation
-Treatment & prevention of malaria
-Increase food intake
 Deworming during pregnancy
 Vitamin A Capsule within 45 days of delivery
Key Messages
National Strategy for MN, Fed MOH, April 2004

Cont. . .
• Nearly 41.8% of mothers are anemic.
• Commonest cause is iron deficiency.
• Administration;
- 1-tab daily
- For all pregnant women and adolescents.
- Starting early during pregnancy.
• Daily iron supplementation decreases maternal anemia at term by
70%.
• If diagnosed with anemia during pregnancy 120mg iron and 400 micg
Folic acid.

Cont. . .
• Additional interventions to consider:
- Fortification of staple foods with iron
- Health and nutrition education, increasing food intake.
- Control of parasitic infections and malaria
- Improvements in sanitation.

Cont. . .
For non-pregnant women and menstruating adolescents
• For non pregnant women and adolescents living in areas where
IDA>20%.
• Intermittent iron and folic acid supplementation is
recommended.
• 1-3 times per week for three months alternating with 3 months
break.

Vit-A supplementation during pregnancy
• Vit-A is important both for the mother and fetus.
- Organ development, skeletal growth, cell division, immunity,
development of vision in the fetus and maternal eye health and
vision.
• 19 million pregnant mothers are deficient.
• Supplementation is recommended if night blindness is > 5%

4. Nutritional care for the sick and
malnourished
Key messages
• Increase frequency of breastfeeding during and after illness
• Increase frequency of complementary feeding during and
after illness (6-24 months)
• Zinc supplementation for child with diarrhea
• Vitamin A supplementation as recommended
• Special care for malnourished child depending on severity
• Kangaroo care for low-birth weight newborns

Cont. . .
Zinc
• Protects cells from oxidative damage, cell growth, transport
of water and electrolytes in the intestine, immune system,
protein synthesis.
• ORS + Zinc reduces mortality by 23%.
• 14-15% reduction in pneumonia or diarrhea incidence.
• Poor people are prone for zinc deficiency.
- Inadequate access to animal source foods
- Effect of fibers and phytate on zinc absorption.

5. Control of Vitamin A Deficiency
 Breastfeeding: source of Vitamin A
 Vitamin A rich foods
 Maternal supplementation
 Child supplementation
 Food fortification
Key Messages

6. Control of Anemia
Supplementation for women and children (IMCI)
 Deworming for pregnant women and children
(twice/year)
 Malaria control
 Iron-rich foods
 Fortification
Key Messages

7. Control of Iodine Deficiency Disorders
 Access & consumption by all families of
iodized salt
Key Messages

Six critical contacts in the life cycle
12/13/2022 ENA by yalemwork G. 43
2. DELIVERY:
safe delivery,
EBF, Vitamin A
,Iron/folic acid,
diet, FP, STI
referral
1.PREGNANCY:TT,ANC
,Iron/folate, deworming,
antimalarial, diet,
EBF,risk signs,
FP,STI Prevention, safe
delivery, iodized salt
3.POSTNATAL AND
FAMILY
PLANNING:
EBF, Diet,
iron/folic ,diet, FP,
STI, Prevention,
child’s vaccination
4.IMMUNIZATION:
Vaccination, Vitamin A,
Deworming, assess and
treat infant’s anemia,
FP, and STI referal

Six critical contacts in the life cycle…
12/13/2022 ENA by yalemwork G. 44
5.WELL CHILD AND
GMP:
•Monitor growth
•assess and counsel on
feeding
• iodized salt
• check and complete
vaccination /Vitamin A
/Deworming
6. SICK CHILD :
•Monitor growth
•assess and treat per
IMCI counsel on
feeding
•assess and treat for
anemia
•check and complete
Vitamin A
/Immunization/dewo
rming

ENA.pptx

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