Adolescent Maternal Infant and Young

Child Nutrition Implementation Guideline

_______________

May 2022
Addis Ababa

September 2022
Addis Ababa
Adolescent Maternal Infant and Young
Child Nutrition Implementation Guideline

______________
September 2022
Addis Ababa

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 Recommended Citation
Government of Ethiopia, Federal Ministry of Health, 2022; National Guideline
for Adolescent, Maternal, Infant and Young child Nutrition, Addis Ababa:
FMOH.

Contact Information:

Ministry of Health, Nutrition Coordination Office,

Sudan Street, Post Office Box: 1234,
Telephone: +251 11 5517011
Fax: +251 11 551 9366
Email: [email protected];
Addis Ababa, Ethiopia

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Foreword
The Government of Ethiopia has demonstrated its policy commitment to nutrition
by developing the first ever food and nutrition policy, its implementation strategy
(2021-2030) and the Seqota Declaration to end under nutrition. Nutrition has been
incorporated into the nation’s development plan and mainstreamed in different
sectoral strategies and programs.

The national Food and Nutrition Strategy (FNS) has 13 strategic objectives with
different directions, initiatives, and actions. The strategic actions need guiding
documents for lower-level implementation, and for this, the Minister of Health
developed and endorsed the Adolescent, Maternal, Infant, and Young Child
Nutrition (AMIYCN) implementation guideline. This guideline is an updated version
of the 2016 AMIYCN guideline mainly revised based on the national FNS and also
aligned with other national and international recommendations.

The national guideline for AMIYCN aims to capacitate and guide nutrition
service providers into providing quality nutrition services. Intended users of the
guideline are food and nutrition service providers and program managers, food
and nutrition implementing sectors, partners, academia, and researchers at all
levels. This will help improve coordination and integration among actors, feeding
and caring practices, and ensure optimal nutritional status, productivity, longevity,
and quality of life across the life cycle. In this guideline, nutrition interventions
are standardized and packaged for quality service provision. The guideline mainly
focuses on the promotion of optimal nutrition in the first 1000 days plus nutrition
targeting adolescents, pregnant and lactating mothers, infants and young children.

To achieve the objectives of the guideline, commitment and accountability

of nutrition implementing sectors, coordination and linkage among different
stakeholders and actors as well as monitoring and evaluation exercises are critical.
If we all collaborate and coordinate our efforts, I assure you that we will achieve
our goal of ending all forms of malnutrition by 2030. We must prioritize and invest
our resources on nutrition for healthy and productive nation.

Lia Tadesse (MD, MHA),

Minister of Health
Federal Democratic Republic of Ethiopia

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 Acknowledgement
The Adolescent, Maternal, Infant, and Young Child Nutrition (AMIYCN)
implementation guideline was successfully completed with the efforts and
involvement of numerous organizations and individuals at different stages.

Ministry of Health would like to thank Alive & Thrive, Save the Children and
UNICEF for their financial support in the revision of the guideline. Special
acknowledgement goes to Alive and Thrive for hiring a consultant to support the
revision process.

The guideline was a product of a highly technical, intensive, and consultative

process led by the Nutrition Coordination Office of the Ministry of Health and
supported by members of the AMIYCN Technical Working Group. Finally, we
would like to acknowledge the various experts involved in the development of the
guideline.

S. No Name of participants Organization

Hiwot Darsene MOH
Yirgalem Mengistu MOH
Dr. Belaynesh Yifru MOH/UNICEF
Birara Melese MOH/Alive & Thrive /
Gelila Zewdu MOH/UNICEF
Kidist Woldesenbet MOH
Abera Dibabe MOH
Gobane Dea MOH
Firehiwot Girma MOH
Frezer Abebe MOH
Bezawit Tamiru MOH/SD
Fikru Sinishaw MOH/Alive & Thrive/
Dr. Abebe Negesso MOH/Child Health
Shiferaw Fisseha ABH
Mulat Tirfie Bahir Dar University
Zenebu Yimam SCI-GTN
Dr. Kedir Teji Haromya University
Dr. Kasahun Negash Amref-Health Africa
Wondwosen Retta Nutrition International
Tamirat Tafesse Alive & Thrive
Dr. Firehiwot Mesfine UNICEF
Meseret Assegid GAIN
Amare Demsie University of Gondar
Dr. Wossen Assefa Result for Development (R4D)
Aniley Kerie Care Ethiopia
Melkamu Birhane AAH

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S. No Name of participants Organization
Sablegenet Zewudie Concern Worldwide
Nardos Birru UNICEF
Sinksar Simeneh UNICEF
Dr. Bekele Nigussie ECSCU-SUN-SCI
Dr. Bilal Shikur Addis Ababa University
Dr. Abebe Negesso MOH Child health team
Gobene Dea MOH
Mulu G/Medihin WFP
Dereje Getahun Hawassa University
Girmay Ayana EPHI
Alemnesh petros EPHI
Alazar kirubel Hawassa University
Melese Linger Debrmarkos university

Meseret Zelalem (MD, Pediatrician),

Director, Maternal & Child Health, and
Nutrition Directorate of Federal Ministry of Health Ethiopia

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 Table of Contents
List of Tables........................................................................................................................................viii
List of Figures.......................................................................................................................................ix
Acronyms................................................................................................................................................x
Executive summary.............................................................................................................................xii
Definition of Terms..............................................................................................................................xiii
1. Introduction ..................................................................................................................................1
1.1. Background.............................................................................................................................1
1.2. Policy landscape.....................................................................................................................1
1.3. Rationale.................................................................................................................................2
1.4. Scope.......................................................................................................................................3
1.5. Objectives................................................................................................................................3
1.6. Users of the guideline............................................................................................................3
1.7. Expected outcomes of the guideline....................................................................................3
2. Nutritional Assessment ..............................................................................................................4
2.1. Anthropometric assessment...............................................................................................4
2.2. Biochemical assessment.....................................................................................................4
2.3. Clinical assessment..............................................................................................................5
2.4. Dietary Assessment..............................................................................................................6
3. Adolescent Nutrition.....................................................................................................................9
3.1. Introduction............................................................................................................................9
3.2. Objectives................................................................................................................................9
3.3. Nutritional requirements of adolescents............................................................................9
3.3.1. Macronutrient requirement........................................................................................9
3.3.2. Micronutrient Requirement......................................................................................11
3.4. Adolescent nutrition interventions....................................................................................11
3.4.1. Regular adolescent nutrition assessment ............................................................12
3.4.2. Improving diet diversity of adolescents .................................................................12
3.4.3. Meeting increased energy demand of adolescents .............................................13
3.4.4. Promoting healthy diet and eating behavior .........................................................13
3.4.5. Promoting physical activity and age-appropriate body weight and height........14
3.4.6. Preventing adolescent pregnancy and promoting school completion ...............15
3.4.7. Providing access to safe environment and hygiene for adolescents..................15
3.4.8. Addressing the dietary requirements of adolescents in special situations ......15
3.4.9. Adolescents with HIV/AIDS......................................................................................15
3.4.10. Adolescents with Acute malnutrition: ..................................................................16
3.4.11. Pregnant adolescents: . .........................................................................................16
3.4.12. Substance abuse: ...................................................................................................16
3.5. Implementation modality and integration of adolescent nutrition interventions.........17
3.5.1. Adolescents’ nutrition implementation modality..................................................17
3.5.2. Integration of adolescent nutrition interventions across different platforms....18

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4. Maternal Nutrition.......................................................................................................................19
4.1. Introduction..........................................................................................................................19
4.2. Objectives..............................................................................................................................19
4.3. Nutritional requirements during pre-conception, pregnancy & lactation.....................19
4.4. Nutritional interventions during preconception, pregnancy and lactation....................21
4.4.1. Nutritional interventions during preconception..............................................21
4.4.1.1. Implementation modality for preconception .....................................25
4.4.2. Nutritional Interventions during Pregnancy....................................................25
4.4.3. Implementation modality of nutrition services for pregnant mothers......30
4.4.4. Nutrition Interventions during lactation...........................................................31
4.4.4.1. Implementation modality for lactating women ................................33
4.4.5. Nutrition-sensitive interventions among women...........................................33
4.4.6. Maternal nutrition under special circumstances............................................34
5. Child Nutrition.............................................................................................................................37
5.1. Introduction..........................................................................................................................37
5.2. Objectives.............................................................................................................................37
5.3. Nutritional requirements of children................................................................................37
5.4. Child nutrition interventions and their implementation modalities..............................38
5.4.1. Recommended infant feeding practices among 0-6-month infants .................39
5.4.2. Key Interventions for children aged 6-24 months................................................44
5.4.3. Key interventions for children aged 24-59 months..............................................48
5.4.4. Key interventions for children aged 5-9 years.....................................................50
5.4.5. Infant and young child nutrition (IYCN) interventions in difficult
circumstances........................................................................................................52
5.4.6. IYCN integration with key sectors and programs.................................................56
6. Communication for Adolescent, Maternal, Infant and young child Nutrition.......................59
6.1. Introduction .........................................................................................................................59
6.2. Objectives.............................................................................................................................59
6.3. Implementation strategies ................................................................................................59
7. Monitoring, Evaluation, Accountability and Learning.............................................................66
7.1. Introduction .........................................................................................................................66
7.2. Objectives..............................................................................................................................66
7.3. Planning ...............................................................................................................................66
7.4. Monitoring.............................................................................................................................66
7.5. Documentation, reporting and feedback ..........................................................................66
7.6. Quality improvement ..........................................................................................................67
7.7. Data quality assurance and utilization..............................................................................67
7.8. Accountability.......................................................................................................................67
7.9. Learning................................................................................................................................67
7.10. Evaluation ..........................................................................................................................67
7.11. AMIYCN M&E Framework ................................................................................................68
References............................................................................................................................................83

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 List of Tables
Table 1: Biochemical Nutritional Assessments at different levels..............................................19
Table 2: Medical history for Nutritional Assessment....................................................................20
Table 3: Typical clinical signs for nutritional deficiencies.............................................................20
Table 4: Dietary assessment indicators.........................................................................................22
Table 5: Girls’ energy requirement in a population with three levels of habitual
physical activity...................................................................................................................25
Table 6: Boy’s energy requirement in a population with three levels of habitual
physical activity...................................................................................................................25
Table 7: Recommended dietary intake of minerals for adolescence..........................................26
Table 8: Recommended dietary intake of vitamins for adolescence...........................................26
Table 9: Nutritional status classification of adolescents 10-19 years of age (BMI/age)............27
Table 10: Food groups for minimum dietary diversity score.........................................................28
Table 11: Implementation modality and integration of adolescent nutrition interventions......34
Table 12: Recommended Dietary Intakes of minerals for pregnant and lactating
women.................................................................................................................................39
Table 13 Recommended Dietary Intakes of vitamins for pregnant and lactating women.........39
Table 14: Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and
Adequate Intakes, Total Water and Macronutrients........................................................40
Table 15: Nutritional status classification of WRA during preconception based on BMI............44
Table 16: Implementation modality of interventions among pre-conception..............................45
Table 17: Recommended micronutrient supplement.....................................................................46
Table 18: Recommended weight gain during pregnancy and dietary recommendation............49
Table 19: Implementation modality of interventions among lactating women............................54
Table 20: Nutrition sensitive interventions for women...................................................................55
Table 21: Common Diseases Affecting Pregnant Women and Pregnancy Outcome..................57
Table 22: Nutritional requirement of children..................................................................................61
Table 23: Recommended anthropometric assessments and nutritional status
classification of children 0-9 years...................................................................................61
Table 24: Nutritional status classification of children 5-9 years based on BMI/age...................62
Table 25: Summary of interventions and implementation modality among 0-6 month
Infants..................................................................................................................................68
Table 26: Interventions and implementation modality in children aged 6-24 months................44
Table 27: Interventions and implementation modality among 24-59 months children..............48
Table 28: Interventions and implementation modality among 5-9 years children......................51
Table 29: Interventions for Low-Birth-Weight infants....................................................................53
Table 30: Child nutrition Interventions in the context of HIV positive mothers............................54
Table 31: Interventions during emergency......................................................................................54
Table 32: Interventions for OVC.........................................................................................................55

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Table 33: Interventions during common childhood illnesses........................................................55
Table 34: SBCC Strategy, Problems, target audiences, expected outcomes and beneficiary
from SBCC interventions....................................................................................................62
Table 35: SBCC materials and channels...........................................................................................65
Table 36: AMIYCN Indicators for monitoring and evaluation..........................................................69

_________________________________
List of Figures
Figure 1: Food items among different food groups...........................................................................23
Figure 2: Types of breastfeeding position ..........................................................................................42
Figure 3: Communication approaches/implementation strategies................................................60
Figure 4: AMIYCN M&E Framework....................................................................................................68

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 Acronyms
AMIYCN Adolescent Maternal Infant and Young Child Nutrition
ANC Antenatal Care
BFHI Baby Friendly Hospital Initiative
CBHI Community Based Health Insurance
CF Complementary Feeding
DA Development agent
DRI Dietary Reference Index
ECD Early Childhood Development
EFDA Ethiopian Food and Drug Authority
EPI Expanded Program of Immunization
GMP Growth Monitoring and Promotion
HDA Health Development Army
HEW Health Extension Workers
HMIS Health Management Information System
HSTP Health Sector Transformation Plan
ITN Insecticide Treated Net
IDD Iodine Deficiency Disorder
IDP Internally Displaced People
IMAM Integrated Management Acute Malnutrition
IUGR Intrauterine Growth Retardation
IYCF Infant and Young Child Feeding
IYCN Infant and Young Child Nutrition
IYCN-E Infant and Young Child Nutrition in Emergency
LBW Low Birth Weight
LLITN Long Lasting Insecticide Treated Net
MOWE Ministry of Water and Energy
MAM Moderate Acute Malnutrition
MBFI Mother Baby Friendly Initiative
MCH Maternal and Child Health
MDD Minimum Diet diversity
MDD-W Minimum Diet Diversity for Women
MUAC Mid-Upper Arm Circumstance
NCD Non-Communicable Disease
OPD Out-patient Department
ORS Oral Rehydration Solution
OVC Orphan and Vulnerable Children
PLW Pregnant and Lactating Woman
PMTCT Prevention of Mother to Child Transmission
PNC Post Natal Care
PSNP Productive Safety Net Program
PTA Parent Teacher Association

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RDA Recommended Dietary Allowances
RMNCH Reproductive Maternal Newborn and Child Health
TSFP Targeted Supplementary Feedings Program
SBCC Social Behavioral Change Communication
SC Stabilization Center
SMEs Small- and Medium-sized Enterprises
UNICEF United Nations Children’s Fund
VAD Vitamin A Deficiency
VAS Vitamin A supplementation
WASH Water Sanitation and Hygiene
WHO World Health Organization
WIFAS Weekly Iron Folic Acid Supplementation
WRA Women of Reproductive Age

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 Executive summary
Background: Breaking the intergenerational cycle of malnutrition is vital as the
issues and concerns in one age group may spring from the nutritional issues and
concerns in the earlier age groups. Therefore, nutritional interventions focusing
only on one or few age groups may not be sufficient for sustainable improvements
in health and nutrition outcomes. Cognizant of these generational implications,
the National Food and Nutrition Policy and Strategy documents have incorporated
important initiatives to improve the nutritional status of adolescent, pregnant
and lactating women, infant and young children. For effective implementation
of the policy and strategy, it is critical to develop an implementation guideline
that provides direction for nutrition and health service providers to translate the
initiatives into actions. This guideline will provide the framework for standardization
of the prioritized nutrition interventions and address nutrition along the life cycle
using evidence-based, integrated, and multi-sectoral approaches.
Objective: This guideline aims to provide guidance to nutrition and health service
providers, program managers, food and nutrition implementing sectors, academia,
and researchers working on optimal adolescent, maternal, infant, and young child
nutrition services in Ethiopia.
Interventions and implementation strategies: The guideline includes both
nutrition-specific and sensitive interventions for women, adolescent, infant,
and young children comprising nutrition assessment, counseling and treatment,
promotion of optimal breastfeeding, complementary feeding, and growth
monitoring and promotion, supplementation, deworming, dietary diversification,
consumption of animal source foods and fruits and vegetables, food fortification,
WASH practices, physical activity, and healthy lifestyle. Furthermore, it provides
guidance for addressing nutrition issues during special situations.
Delivery modalities: Those interventions could be delivered through the existing
health system at different contact points in integrated ways and/or through
separate nutrition service delivery rooms/units at health facilities/outreach sites.
In addition, linkages with other nutrition sensitive intervention delivery points
such as schools, health and nutrition services centers/facilities, youth friendly
services/enters/, and existing structures for adolescent nutrition services could
be used as delivery platforms.

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Definition of Terms
Food: : any nutritious substance that people eat and drink to maintain life and
growth.

Nutrition: the science of ingestion, digestion, absorption, assimilation, biosynthesis,

transport, metabolism, excretion, and the actions of nutrients within the body
for physical and mental growth and development, prevention of diseases and
development of the immune system.

Nutrients: chemical substances obtained from food and used in the body to provide
energy, repair of body tissues, support growth and aid the normal functioning of
the body system.

Food security: food security exists when all people, at all times, have physical,
social and economic access to sufficient, safe and nutritious food to meet the
dietary needs and food preferences for active and healthy life.

Nutrition security: nutrition security is more than access to sufficient, safe and
nutritious foods. Individuals must also have safe water and adequate sanitation,
the ability to access health care services, and knowledge of proper household and
community practices in childcare, food storage and preparation and hygiene.

Food group: a collection of foods that share similar nutritional properties or

biological classifications.

Minimum meal frequency: examines the number of times children received

foods/meals other than breast milk for breast feeding child, and other milk for
non-breast-feeding child, and it is a proxy for a child’s energy requirements.

Minimum Diet Diversity (MDD): the consumption of five or more food groups out
of eight for children, and MDD-W is a dichotomous indicator of whether a woman
15–49 years of age has consumed at least five out of ten defined food groups the
previous day or night.

Minimum acceptable diet: a composite indicator of minimum dietary diversity

and minimum meal frequency.

Malnutrition: a state of deficiency, excess or, imbalance of energy and/or nutrient

intake or impaired nutrient utilization that causes measurable adverse effects on
health, body growth and function.

Under nutrition: lack of proper nutrition, caused by inadequate ingestion of

nutrients, mal-absorption, impaired metabolism, loss of nutrients due to diarrhea,
or increased nutritional requirements (as occurs in cancer or infection).

Stunting: a chronic or recurrent under nutrition from poor diet, repeated infection,
and inadequate psychosocial stimulation. Children are defined as stunted if their
height-for-age is less than negative two standard deviations (<-2 SD) according to
the WHO child growth standard.

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 Wasting: often indicates recent and severe weight loss. Children are defined as
wasted if their weight-for-height is less than negative two standard deviations (<-2
SD) according to the WHO child growth standard.

Underweight: low weight-for-age which reflects acute and/or chronic malnutrition.

Children are defined to be underweight if their weight-for-age is below negative
two standard deviations (<-2 SD) according to the WHO child growth standard.

Micronutrient deficiency: a deficiency of one or more vitamins or minerals required

for body function, optimal health, growth, and development.

Over nutrition a form of malnutrition arising from excessive intake of nutrients and
food, and imbalance between food intake and expenditure (physical exercises),
due to sedentary life leading to accumulation of body fat that may impair health
(i.e., overweight/obesity).

Anorexia nervosa: an eating disorder characterized by low weight, food

restriction, body image disturbance, fear of gaining weight, and an overpowering
desire to be thin.

Bulimia nervosa; eating large amounts of food with a loss of control over the
eating.

Food Intolerance: difficulty digesting certain foods and having unpleasant physical
reaction to them. It is important to note that food intolerance is different than a
food allergy.

Food allergy: an immune system reaction that occurs soon after eating a certain
food. Even a tiny amount of the allergy-causing food can trigger signs and
symptoms.

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1. Introduction
Malnutrition spans across generations, impacting populations through its vicious intergenerational
cycle of occurrence. Nutritional issues and concerns in one age group may derive from the nutritional
issues and concerns in the earlier age groups. Interventions focusing only on one or few age groups
may not be enough for sustainable improvements in health and nutrition outcomes. Hence, if
malnutrition is not addressed across all the different stages of the life cycle, the consequences
will lead to increased levels of maternal and neonatal mortality and morbidity, low birth weight
babies, impeded growth, impaired cognitive development of children, and poor socioeconomic
development. Optimal Adolescent, Maternal, Infant, and Young Child Nutrition (AMIYCN) service
delivery and utilization contribute to improved nutritional status, sustained growth & development,
child survival and optimal birth outcomes.

This guideline is updated to guide the implementation of AMIYCN interventions at facility and
community levels. It lays out the steps that service providers at different levels need to follow to
implement the interventions efficiently and effectively across regions. The guideline follows the
life cycle approach for easier use and delivering quality nutrition services. It includes introduction,
adolescent nutrition, maternal nutrition, infant and young child nutrition, social and behavioral
change communication (SBCC) and monitoring and evaluation (M & E) as its major topics. It also
guides the integration of nutrition-specific and nutrition-sensitive interventions. It will be regularly
reviewed and updated for addressing new nutrition interventions and changes on service delivery
platforms in the future.

1.1. Background
According to the Mini-Ethiopian Demographic and Health Survey (EDHS, 2019), 37%, 21%, and 7% of
under-five children were stunted, underweight and wasted, respectively. Even though breastfeeding
is universal (96%) in Ethiopia, only 59% of infants under 6 months are exclusively breastfed, 55%
of the children are fed a minimum number of times (minimum meal frequency), and 14% of the
children are fed a minimum number of food groups (minimum dietary diversity), resulting in only
11% of 6–23-month-old children receiving a minimum acceptable diet (EDHS, 2019).

In Ethiopia, 22%, 8%, and 24% of reproductive age women were thin, overweight or obese and
anemic respectively (EDHS 2016). In addition, 29%, 15% and 11.3% of adolescents (15-19 years)
were thin, stunted, obese or overweight respectively. More than 58% of adolescents are married
before their 18th birthday, which increases the risk of adverse pregnancy and birth outcomes and
exacerbates the vicious cycle of malnutrition in Ethiopia (EDHS, 2016). Regarding Iron Folic Acid (IFA)
supplements, only 11% of pregnant women took the recommended 90 plus days (EDHS, 2019).

1.2. Policy landscape

Good nutrition is fundamental to achieving the right to health. Moreover, as stated in the Convention
on the Rights of a Child, children have the right to adequate nutrition and access to safe and
nutritious food, and both are essential for fulfilling their right to the highest attainable standard of
health. No country can achieve universal health coverage without investing in essential nutrition
actions. The government of Ethiopia recognizes that food and nutrition security is a fundamental
human right. Thus, national policies integrate key aspects of ensuring safe and nutritious food that
meets the dietary needs of the population. Furthermore, Ethiopia, as a member, state commits to

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global policies and strategies that contribute to improving the nutrition and health of women of
reproductive age, children, adolescents and infants.

The AMIYCN guideline has been developed taking into consideration global and national policies and
guidelines including the following.

At global level:

a) Convention on the Rights of a Child

b) The 2030 Agenda for Sustainable Development
c) Global Strategy for Infant and Young Child Feeding
d) Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition
e) International Code of Marketing Breast Milk Substitutes
f) UN Decades of Action for Nutrition, 2030
g) World Health Assembly Target, 2025
Guideline; Implementing Effective Actions for Improving Adolescent Nutrition, WHO, 2018
h) Global Strategy for Women’s, Children’s, and Adolescents’ Health, 2016–2030
i) Africa Regional Nutrition Strategy, 2016-2025
j) SUN Movement Strategy, 2021-2025
At national level:
a) The Food and Nutrition policy Ethiopia, 2018
b) Food and nutrition implementation strategy, 2021-2030
c) Seqota Declaration Road Map, 2015-2030
d) Baby Food Directive, 2021
e) Infant Formula and Follow-up Formula Directive No.30/2016
f) The Ethiopia Health Sector Strategic Plan II 2020-2025,
g) Operational Guideline for Infant and Young Child Feeding during Emergencies, 2021
h) National Guideline on the Management of Acute Malnutrition

1.3. Rationale
Optimal nutrition through the life cycle is fundamental for survival, good health, growth, and
development. Implementation of optimum AMIYCN interventions is critical to break the inter-
generational cycle of malnutrition. Ethiopia is aiming to end malnutrition in all its forms through its
commitments to achieve the 2030 Sustainable Development Goal targets. The Ethiopian government
developed and endorsed a Food and Nutrition Policy and Strategy with detailed objectives, directions,
initiatives and actions. To implement the strategic actions, the revision of the AMIYCN implementation
guideline is found to be important. This AMIYCN guideline aims to improve the implementation of
recommended nutrition actions targeting adolescents, mothers, infants, and children in Ethiopia. It
provides guidance to health and nutrition service providers, program managers, food and nutrition
implementing sectors, academia, and researchers to deliver high quality and standardized nutrition
services to communities.

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1.4. Scope
This guideline covers recommended nutrition actions through the lifecycle approach targeting
adolescents, maternal, infants, and children and is aligned with the national food and nutrition
strategy.

1.5. Objectives
General Objective

To provide technical guidance to health and nutrition service providers, program managers, food
and nutrition implementing sectors, academia, and researchers in the design and implementation of
optimal adolescent, maternal, infant and young child nutrition services in Ethiopia.

Specific objectives
• To provide technical guidance on the implementation of AMIYCN interventions in Ethiopia at
facility and community levels
• To serve as a capacity building tool for quality AMIYCN service delivery by frontline workers and
program managers.

1.6. Users of the guideline

Primary users: Nutrition and health workers and program managers,
Secondary users: Food and nutrition strategy implementing sectors, academia, researchers, policy
makers, advocates, nutrition champions, development partners, media professionals and profes-
sional associations/societies.

1.7. Expected outcomes of the guideline

The AMIYCN guideline will contribute to the following.

Immediate outcomes:
• Guided and capacitated nutrition and health service providers and program managers;
• Used as reference for FNS implementing sectors, academia, researchers, instructors, policy
makers, advocates, nutrition champions, development partners, media professionals and pro-
fessional associations/societies.
Medium and long term outcomes:
• Improved food and nutrition leadership and management, and supplies, information system,
partnership and financing;
• Increased quality AMIYCN service coverage;
• Reduced under and over nutrition among AMIYC.

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2. Nutritional Assessment
Nutritional assessment is a detailed evaluation and interpretation of multiple parameters that
include Anthropometric, Biochemical, Clinical and Dietary assessments.

Nutritional screening is a brief evaluation to identify people at high risk which may include checking
for bilateral pitting edema, measuring weight and MUAC, and asking about recent illnesses and
appetite.

2.1. Anthropometric assessment

Anthropometry is the measurement of the human body. It is the most accessible, universally
applicable, cheap, simple, and noninvasive method. Common anthropometric measurements
include weight, height/length, MUAC, head circumference, waist circumference, waist to hip ratio,
and skinfold thickness.

The more frequently used anthropometric indexes are height for age (stunting), weight for age
(underweight), weight for height (wasting), BMI (underweight and overweight or obesity) and
BMI for age (thinness and obesity) expressed in percentiles or Z scores. The MUAC is also used as
a measurement for acute malnutrition, which is commonly applied for screening and admission
purposes. It is also used in nutritional screening of pregnant and lactating women. (Target group
specific anthropometric assessment methods and classifications are included in their respective
sections)

2.2. Biochemical assessment

Biochemical assessment involves measurement of either the total amount of the nutrient in the
body, or its concentration in a particular storage organ, blood, urine, saliva and stool. Biochemical
assessments can be done at various levels depending on the level of the nutritional status information
needed. However, as the laboratory assessment is expensive and may require sophisticated facilities;
only essential tests could be used. Biochemical assessments are summarized in the table below.

Table 1: Biochemical Nutritional Assessments at different levels

Levels of Approach Laboratory Evaluation

Minimal Level (HC and primary • Hemoglobin, urine analysis, and blood sugar
Hospitals)
Mid-level(General hospitals, and • Serum albumin, serum iron and TIBC, vitamin A and beta
regional research laboratories ) carotene
• RBC Indices, blood urea nitrogen (BUN), zinc and cholesterol
• Glucose, inflammatory markers, helminthes
In-depth (Specialized/referral • Blood tests: folate and vitamin C; alkaline phosphatase; RBC
hospitals and national research transketolase; RBC glutathione; lipids
laboratories )
• Urine: creatinine; nitrogen; zinc; thiamine; riboflavin; loading
tests (xanthurenic acid/FIGLU)
• Hair root: DNA; protein; zinc; other metals

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2.3. Clinical assessment
Clinical assessment of nutritional status involves a detailed history, a thorough physical examination,
and the interpretation of the signs and symptoms associated with malnutrition (Robert D Lee and
David C Neiman, Nutritional Assessment, 2013).

Medical history: It is required because nutritional problems may be caused by underlying medical
conditions. Additionally, specific medical conditions and their current status are important factors
altering nutrient requirements and dietary prescriptions.

Table 2: Medical history for nutritional assessment

Category Indicators of nutrition risk

History of body Presence of weight loss
weight Presence of weight gain
Weight before the nutritional problem started
Presence of recent change in appetite
Suspected reason of weight change
Past medical History of cardiovascular disease, hypertension, DM, hyperlipidemia, renal diseases,
history cancer, surgical history or medication use, substances abuse
Eating disorder Suffering from anorexia nervosa, bulimia nervosa, food allergies, food intolerance,
binge eating or emotional eating and difficulty chewing or swallowing

Physical examination: This examination focuses on signs of nutrient deficiency or excess. These signs
usually appear only when the deficiency is advanced and are not expected in marginal deficiencies.
The physical examination should start with a general visual assessment of the patient (wasting or
overweight or obese). Typical signs for selected nutritional deficiencies are presented in the table
below.

Table 3: Typical clinical signs for nutritional deficiencies

Deficiency Clinical signs

Wasting (acute malnutrition) • Emaciation (loss of muscle and fat tissue), bone and skin
• Dermatosis: abnormally light or dark in color, shedding of skin in
scales or sheets, and ulceration of the skin of the perineum, groin,
limbs, behind the ears, and in the armpits that could be seen in
children with acute malnutrition:
+ (mild): discoloration or a few rough patches of skin
+ + (moderate): multiple patches on arms and/or legs
+ + + (severe): flaking skin, raw skin, fissures (openings in the
skin)
• Bilateral pitting edema
Grade +: below the ankle
Grade ++: below the knee
• Grade +++: generalized edema
Protein deficiency • Dry and scaly skin, cellophane appearance

5
 • Interosseous muscle atrophy,
Protein, calories (protein
• Squaring off of shoulders,
energy deficiency)
• Poor hand grip and leg strength
Vitamin D deficiency bowlegged, musculoskeletal deformity, rachitic rosary (pigeon chest)
Zinc deficiency hair loss, changes in their nails
• Bitot’s spots (superficial foamy white spots on the conjunctiva (white
part of the eye)
• Night blindness
• Follicular hyperkeratosis
Vitamin A deficiency
• Corneal clouding: opaque appearance of the cornea (the transparent
layer that covers the pupil and iris
• Corneal ulceration: a break in the surface of the cornea (a sign of
severe vitamin A deficiency)
Niacin deficiency • Skin pigmentation changes
• Petechiae

Vitamin C deficiency • Lassitude, weakness, irritability, weight loss, and vague myalgias and
arthralgias may develop early. Symptoms of scurvy (related to defects
in connective tissues) develop after a few months of deficiency.
• Purpura -discoloration of skin or mucus due to hemorrhage in small
Vitamin C, vitamin K deficiency
vessels
Iron, vitamin B12, folate
• Palmar pallor
deficiency
Iron • Pale tongue
Iron, vitamin B12, folate • Conjunctiva pallor
Riboflavin, pyridoxine, niacin • Angular stomatitis/cheilosis (dry, cracking, ulcerated lips)
Riboflavin, niacin, B vitamins,
• Glossitis (inflammation and swelling of the tongue)
iron, folate
Vitamin C, riboflavin • Bleeding gums
riboflavin and niacin • Red tongue

2.4. Dietary Assessment

Dietary assessment is used to evaluate food and fluid intakes both qualitatively and quantitatively. It
provides information on dietary quantity, quality, frequency, eating patterns, identification of cultural
and religious patterns and reasons for inadequate and/or excessive food and nutrients intake. The
results are compared with recommended dietary practices and recommended dietary allowance
(RDA) on how to improve diets to prevent malnutrition or treat conditions affected by food intake and
nutritional status. Dietary assessment tools such as 24hr dietary recall, food records, diet histories,
and food frequency questionnaires can be used to collect data to estimate both inadequate and
excessive food and nutrient intakes.

6
Table 4: Dietary assessment indicators

Indicator Definition Remark

Introduction of Percentage of infants Amount
solid, semisolid 6–23 months of age who
Diversity
consumed
or soft foods
Consistency/Thickness
solid, semi-solid or soft foods
6–23 months
during the previous day Frequency
Responsive feeding
WASH practices
Minimum dietary Percentage of children Food groups are:
diversity 6–23 months of age who
1. Breast milk
consumed foods and
6–23 months
beverages from at least five 2. Grains, roots/tubers and plantains
out of eight defined food 3. Pulses (beans, peas, lentils, chickpeas, kidney bean
groups during the previous ), nuts and seeds
day
4. Dairy products (milk, yogurts, cheese)
5. Flesh foods (meat, fish, poultry, organ meats)
6. Eggs
7. Vitamin-A rich fruits and vegetables
8. Other fruits and vegetables.
Minimum meal Percentage of children Minimum number of feeds per day
frequency 6–23 months of age who
Breakfast, morning snack, lunch, afternoon snack and
consumed solid, semi-solid or
6–23 months dinner
soft foods for breastfeeding
children and milk feeds for Breast milk and other milk will not be counted for the
non-breastfed children t(he child feeding
minimum number of times NB: Encourage mothers on demand feeding.
or more during the previous
day)
Minimum Percentage of children Optimal meal frequency
acceptable diet 6–23 months of age who
Optimal dietary diversity
consumed a minimum
6–23 months
acceptable diet during the
previous day

7
 Minimum The proportion of WRA who The ten food groups
Dietary Diversity achieve the minimum of five
1. Grains, white roots and tubers & Plantains(varieties
for Women food groups out of ten in a
of banana and false banana)
(MDD_W) population
2. Pulses (beans, peas, chickpea, kidney beans and
WRA (15-49)
lentils)
3. Nuts and seeds
4. Milk and milk products
5. Meat, poultry and fish
6. Eggs
7. Dark green leafy vegetables
8. Other vitamin A-rich fruits & vegetables
9. Other vegetables
10. Other fruits
NB: Please see annex I for list of food items
Source: WHO, IYCF Indicators, 2021, and FAO, Minimum Dietary Diversity for Women Guide, 2021

Commonly used dietary assessment tools are:

24hr dietary recall: Gives information on the respondent’s exact food intake during the previous
24-h (preceding day). Information is used to characterize the mean intake of a group. Single 24-
hr recall indicates recent intakes while multiple replicates of 24-hr recalls are needed for habitual
intakes.

Weighed food record: Subjects are instructed to weigh all foods and beverages consumed over a
specified time.

Dietary history: estimates the usual food intake and meal pattern over relatively long time (often a
month).

Food Frequency Questionnaires (FFQ): asks respondents to report their usual frequency of
consumption of each food from a list of foods for a specific period of time. Unlike other methods,
the FFQ can be used to circumvent recent changes in diet (e.g., changes resulting from disease) by
obtaining information about individuals’ diets as recalled about a prior period.

8
3. Adolescent Nutrition
3.1. Introduction
Adolescence is defined as a person’s age between 10-19 years (WHO). It is the second-fastest growth
stage in life after infancy and creates an increased nutritional demand which makes them vulnerable
for malnutrition. Adolescents’ behavior and environmental factors are significant determinants to
improve their nutritional status. So far, initiatives to prevent malnutrition commonly target infants,
young children, pregnant and lactating women, but not adolescents which makes their need remain
unmet. Preventing malnutrition in adolescents has direct health and cognitive benefits to future
generations.

Why adolescent nutrition?

• Macro and micronutrient requirements increase during adolescence. The nutritional status of
adolescents has a profound impact on their immediate and future growth, development and
health.
• The period of adolescence offers a unique chance to address nutritional problems that
occur during the early age of life. It is a ‘second window of opportunity’ to break the
intergenerational cycle of malnutrition. Optimal adolescent nutrition impacts on their future
reproductive health/birth outcomes.
• Investing in adolescent health brings triple dividends: better health for adolescents now, for
their future adult life and for their children.
• Overweight and obesity in adolescence resulting from an unhealthy diet and inadequate
physical activity poses significant health problems including non -communicable diseases
(NCDs).
• It is a time of increased engagement with the environment and receptivity to new ideas. It is
also a time when identities, values, capacities and attitudes are formed, including those that
may shape an individual’s lifelong health, diet and eating practices.

3.2. Objectives
• To provide guidance for nutrition and health service providers and program managers on
recommended actions that promote and support adolescent nutrition at all levels
• To provide standardized guidance on the implementation modalities of adolescent friendly
nutrition services at health facilities, schools, and community levels
• To contribute to improve nutritional status of adolescents.

3.3. Nutritional requirements of adolescents

3.3.1. Macronutrient requirement

Adolescence is a critical period for gains in height as well as weight. Girls gain relatively more fat,
and boys gain relatively more muscle. Thus, the requirement of energy as well as protein increases
reaching the peak during this period. The protein requirement of adolescents aged 10-13 years is
34g/day for both sexes. For adolescents aged 14-18 years, it is 46 and 52 g/day for females and
males respectively (Dietary Reference Intakes Series, 2005). The energy requirement of adolescents
9
 depends on their physical activity level, age and sex. Carbohydrate and fat shall be the primary
energy sources. The table below shows energy requirement based on habitual physical activity
levels with age and sex.

Table 5: Girls’ energy requirement in a population with three levels of habitual physical activity

Daily energy requirement

Age *Light physical activity **Moderate physical activity ***Heavy physical activity
kcal/d/kg kcal/d/kg kcal/d/kg
9 -10 56 67 76
10 -11 55 65 74
11-12 53 62 72
12-13 51 60 69
13-14 49 58 66
14-15 48 56 65
15-16 45 53 62
16-17 44 52 59
17-18 43 50 57
Source: Energy requirement FAO 2001

Table 6: Boy’s energy requirement in a population with three levels of habitual physical activity

Daily energy requirement

Age *Light physical Activity **Moderate physical Activity ***Heavy physical activity
kcal/d/kg kcal/d/kg kcal/d/kg
9-10 52 61 70
10-11 49 58 66
11-12 47 55 63
12-13 44 52 60
13-14 42 49 57
14-15 40 47 54
15-16 39 45 52
16-17 38 44 51
17-18 37 44 51
Source: Energy requirement FAO 2001
*Light physical activities: Light activities that do not cause you to break a sweat or produce shortness
of breath. Some examples of light physical activities include walking slowly (i.e., shopping, walking
around the office), sitting at your computer, making the bed, eating, preparing food, and washing
dishes.
**Medium physical activities: Moderate-intensity activities are those that get you moving fast
enough or strenuously enough to burn off three to six times much energy per minute as you do when
you are sitting quietly or exercise that clock in at 3 to 6 METs. Some examples include sweeping the
floor, walking briskly, slow dancing, vacuuming, washing windows, and shooting a basketball.

10
***Heavy physical activities:- Jogging or running, race-walking, hiking uphill, cycling more than 10
miles per hour or steeply uphill, swimming fast or lap swimming, dancing, fast dancing, and step
aerobics, strength training and heavy gardening with digging, hoeing.

3.3.2. Micronutrient Requirement

Micronutrients play a crucial role in adolescent nutrition. Their requirement, such as those of iron
and folate increases during this period due to rapid growth with sharp increase in lean body mass
and blood volume. In addition, due to high burden of infectious diseases, parasitic infestations and
low bioavailability of iron from diets, iron requirement in adolescence is higher. In girls, some iron
is also lost during menstruation which further increases their iron requirement. Zinc is known to be
essential for growth and sexual maturation during puberty. It enhances bone formation and inhibits
bone loss. Iodine is also very important for high growth velocity of adolescents as well as for the
needs of the fetus in case of pregnancy. The requirements of other minerals and vitamins such as
calcium, vitamins A, C, and D also increase during adolescence and in case of pregnancy. The daily
requirement of these minerals and vitamins is summarized in the table below.

Table 7: Recommended dietary intake of minerals for adolescence

Adolescents Calcium(mg/ Selenium mg/ Magnesium mg/day) Zinc(mg/day)
day)
day) High Moderate Low
Females (10-18 years) 1300 26 220 4.3 7.2 14.4
Males (10-18 years) 1300 32 220 4.3 7.2 14.4

Report of a Joint FAO/WHO Expert Consultation: Food and Agriculture Organization, 2002

Table 8: Recommended dietary intake of vitamins for adolescence

Group Vitamin C Thiamine Riboflavin Niacin mg Vitamin B6 Pantothenate

(mg/day) (mg/day) (mg/day) (NE/day)
(mg/day) (mg/day)
Females (10–18 years) 40 1.1 1.0 16 1.2 5.0
Males (10–18 years) 40 1.2 1.3 16 1.3 5.0

Report of a Joint FAO/WHO Expert Consultation: Food and Agriculture Organization, 2002

3.4. Adolescent nutrition interventions

Adolescent nutrition interventions aim to enable optimal nutrition of adolescent boys and girls.
Nutritional interventions among adolescents should consider both undernutrition and overnutrition.
Providing regular nutritional assessment and screening is important to identify adolescents with
malnutrition.

To ensure optimal adolescent nutrition, it is recommended to promote consumption of adequate

macronutrient and micronutrient and discourage unhealthy food choices. Efforts should be made to
integrate nutrition services in adolescent-friendly platforms such as health facilities, community and
school platforms. The interventions also encourage completion of schooling, partly as a motivation to
delay the age of marriage until 21 years among adolescent girls. The following are the recommended
adolescent nutrition interventions.

11
 3.4.1. Regular adolescent nutrition assessment

Nutrition interventions need to be evidence based; thus, all interventions need to be tailored to the
identified gaps. Body Mass Index (BMI) for age is the recommended screening tool for overweight,
obesity, and thinness in adolescents. Implementing BMI measurement along with nutrition
counseling would support the adoption of optimal nutrition practices among adolescents. Table 9
summarizes the classification and cut off points for BMI. BMI in adolescents is calculated as adults
and then compared with Z-scores or percentiles.

Table 9: Nutritional status classification of adolescents 10-19 years of age (BMI/age)

Classification BMI-for-age Z-score Recommendation

Severe thinness <-3SD Counseling, treatment and/or referral to a health care
Thinness >or=-3SD &<-2 SD provider or dietician for evaluation of potential metabolic
disorders, chronic health conditions, or eating disorders
Normal >or = -2SD &+1SD Counsel to keep the normal weight
Overweight >+1SD &≤ +2SD Complete medical evaluation to determine potential
obesity related complications

Recommended actions
• Conduct quarterly school/facility or community-based adolescent weight and height
measurement, classification, and counseling services.
• Link adolescents with malnutrition to social protection services (PSNP/TSFP/other food support
programs).
• Promote lifestyle modification and physical exercise for adolescents with overweight/obesity.

3.4.2. Improving diet diversity of adolescents

Consuming a diverse diet from different food groups is necessary to meet the increased nutrient
demand. Consumption of a minimum of five food groups out of ten can be used as a proxy to describe
micronutrient adequacy at a population level (FAO, MDD-W Guide, 2021). The table below depicts
a summary of food groups.

Table 10: Food groups for minimum dietary diversity score

The ten food groups

1. Grains, white roots and tubers, 6. Eggs
and plantains 7. Dark green leafy vegetables
2. Pulses (beans, peas and lentils) 8. Other vitamin A-rich fruits and
3. Nuts and seeds vegetables
4. Milk and milk products 9. Other vegetables
5. Meat, poultry and fish 10. Other fruits

Recommended actions
• Provide nutrition counseling and support for adolescents and their guardians to enable them to
consume a diverse diet from different food groups including animal source foods and fruits and
vegetables.

12
• Ensure diversified and nutrient dense/rich meals are provided through school feeding
programs.
• Promote home and school gardening.
• Promote the consumption of bio fortified and fortified foods.
• Implement multi-sector nutrition coordination for year-round availability and access to a
diverse diet.
• Implement SBCC interventions targeting both in-school and out-of-school adolescents and their
influencers at multiple levels to improve diet diversity.
• Implement SBCC interventions to prevent girls’ cultural practices on food taboo.
• Enhance the skills of adolescents and their guardians on appropriate menu planning and
preparation for improved diversified food consumption.

3.4.3. Meeting increased energy demand of adolescents

To ensure energy adequacy, adolescents should consume adequate and diverse meals for breakfast,
lunch and dinner. In addition, at least one healthy snack should be consumed per day. In general, the
total energy pool is recommended to be 45-65% from carbohydrate, 20-35 % from fat, and 10-35 %
from protein.

Recommended actions
• Provide nutrition education/ counseling by engaging parents, focusing on adolescents’
consumption of adequate and diverse meals three times per day and at least one healthy
snack.
• Link food insecure households with livelihood interventions and social protection programs
such as PSNP.
• Ensure energy adequacy of meals provided through school feeding programs.
• Implement SBCC interventions to engage influencers at multiple levels for improved energy
adequacy.
• Counsel adolescents on the consumption of adequate energy based on their habitual physical
activity, age and sex.

3.4.4. Promoting healthy diet and eating behavior

Adolescents are encouraged to limit consumption of unhealthy diets such as high fat diet, junk foods,
processed and fried foods, free sugars/sweets and salt. It is recommended to increase consumption
of fruit, vegetables, and dietary fiber. Unhealthy behaviors such as skipping meals, unhealthy dieting,
repeated weight loss attempts, and sedentary behavior remain common among adolescents in the
urban and semi urban areas. Eating disorders such as anorexia nervosa and bulimia nervosa are also
emerging problems among urban adolescents.

Recommended actions
• Promote and counsel adolescents and guardians on limiting salty foods, sugary foods and
beverages consumption.

13
 • Promote and counsel adolescents and guardians on increased fruits, vegetables and dietary
fiber consumption.
• Counsel and educate adolescents on avoiding unhealthy eating behavior.
• Implement multi-sector nutrition coordination and linkage for accessibility of safe, affordable,
sustainable, and healthy foods.
• Engage the private sector in promoting healthy diet and discouraging unhealthy eating
behavior.
• Promote enforcement of policies/regulations that protect adolescents from the marketing of
unhealthy foods and beverages in schools and beyond.
• Promote the use of food and nutritional information labeling.
• Promote the establishment of a school health and nutrition clubs.

Micronutrient supplementation and fortification

Micronutrient deficiency among adolescents is associated with impaired growth, poor school
performance, reduced productivity and increased maternal and infant mortality.

Recommended actions
• Provide Iron and Folic Acid Supplements (WIFAS) once a week containing 60 mg of iron and 2.8
mg of folic acid for in-school and out-of-school adolescent girls. It should be given for 3 months
twice yearly. WHO recommends the intervention in areas where the prevalence of anemia in
adolescent girls and women of reproductive age is 20% or higher.
• Counsel and educate adolescents on the benefits and adherence to WIFAS.
• Counsel and educate on iron rich food consumption, iron absorption enhancers and inhibitors.
• Deworm annually or bi-annually with albendazole (400 mg) or mebendazole (500 mg),
to control and/or prevent anemia in adolescents. The annual and biannual deworming is
recommended if the prevalence of helminths infection is 20% - 50% and > 50% respectively.
• Promote proper hygiene and sanitation practices.
• Promote micronutrient fortification of staple foods, salt, and edible oil.

3.4.5. Promoting physical activity and age-appropriate body weight and height

Physical activity during adolescence is important to ensure energy balance, weight control and
prevention of overweight, obesity and related non-communicable diseases. It also contributes to
development of musculoskeletal tissues, bone health and reduces the risk of depression and anxiety
among adolescents.

Recommended actions
• Promote adequate regular physical activity of moderate to vigorous intensity for 30 minutes
daily. Most of the daily physical activity should be aerobic. Vigorous-intensity activities should
be incorporated, including those that strengthen muscle and bone, at least three times per
week.

14
• Create an enabling environment at schools for nutritional screening and physical activity.
• Provide regular nutritional assessment and counseling.
• Promote and provide public awareness programs on physical activity using adolescent friendly
media (social media, community radios, mini-media, and others).

3.4.6. Preventing adolescent pregnancy and promoting school completion

Preventing unintended pregnancies and reducing adolescent childbearing through universal access
to sexual and reproductive healthcare and girls’ education is crucial to the health and well-being of
the adolescent. Compared with women, adolescent girls are more likely to die during pregnancy and
childbirth. Delaying the age of childbearing until completion of growth and physiological maturation
is an important intervention for protecting and promoting adolescent nutrition.

Recommended actions
• Encourage and promote girls to remain longer in school through increasing educational
opportunities for them.
• Promote delaying the age of marriage until 21 and pregnancy until 24 through engaging
influencers.
• Provide life skills and reproductive health trainings to build adolescents’ negotiation, decision
making, leadership and bargaining skills
• Provide contraceptive counseling for those at risk of unintended pregnancy.

3.4.7. Providing access to safe environment and hygiene for adolescents

Inadequate access to safe water, hygiene and sanitation services are risk factors for malnutrition,
diarrheal diseases, soil transmitted helminths infections and other communicable diseases.

Recommended actions
• Promote personal hygiene and environmental sanitation.
• Engage in multi-sector advocacy to improve access to safe water, sanitation and hygiene
services for in-school and out-of-school adolescents.
• Advocate for improving access to nearby, safe, separate and private sanitation facilities
essential for menstrual hygiene management for in-school and out-of-school adolescents.
• Ensure safe working environment for adolescents.

3.4.8. Addressing the dietary requirements of adolescents in special situations

Addressing nutritional needs of adolescents in special situations such as refugees, internally

displaced, homeless, disabled, orphans and neglected adolescents requires a different strategy and
approach.

3.4.9. Adolescents with HIV/AIDS: Compared to other populations, adolescents face additional
barriers in accessing testing and treatment services. HIV positive adolescents also are less
likely than adults to adhere to their treatment regimens.

15
 Recommended actions
• Implement optimum nutritional screening, counseling, and support through improved
adolescent friendly HIV services.

3.4.10. Adolescents with Acute malnutrition: severe malnutrition is a common problem

among children. However, it may also occur in adolescents in special conditions such as
famine, refugee, and illness. Adolescents with malnutrition should be treated as per acute
malnutrition guidelines.

Recommended actions
• Counsel, treat and provide referral for adolescents with severe malnutrition (BMI for Age < -3
SD).
• Advocate for inclusion of treatment of severely malnourished adolescents in the national acute
malnutrition treatment guideline.
• Link malnourished and food insecure adolescents with household livelihood interventions and
social protection programs such as PSNP, Blanket Supplementary Feeding Program (BSFP).

3.4.11. Pregnant adolescents: Unintended and/or early pregnancy and unsafe abortion
have detrimental consequences on health and nutritional status of adolescents. Pregnant
adolescents are at higher risk of nutritional deficiencies with poor pregnancy and birth
outcomes.

Recommended actions
• Counsel on healthy eating behavior.
• Counsel on optimal weight gain patterns for optimal birth outcomes.
• Link pregnant adolescents in food insecure households with social protection programs.
• Promote regular ANC follow-up, skilled birth attendance and postnatal care among
adolescents.
• Avail reproductive health services for internally displaced adolescents.

3.4.12. Substance abuse: adolescents are vulnerable to the effects of substance abuse and are
at increased risk of developing long-term consequences including nutritional deficiencies.
The most common substance abuse includes alcohol consumption, chewing khat, shisha and
cigarette smoking.

Recommended actions
• Advocate for the enforcement of policies to reduce substance abuse.
• Implement SBC interventions to prevent substance abuse.
• Promote substance free school environment.
• Improve access to appropriate counseling and referral to rehabilitation centers for adolescents
affected by substance abuse.

16
3.5. Implementation modality and integration of adolescent nutrition
interventions
3.5.1. Adolescents’ nutrition implementation modality

Adolescent nutrition interventions are implemented using multi-sector engagement such as health,
agriculture, education, water, social protection and different platforms through various entry points.
Interventions should also target both in-school and out-of-school adolescents. The table below
shows a list of nutrition activities and delivery platforms.

Table 11: Implementation modality and integration of adolescent nutrition interventions

Platform Nutrition intervention Entry point
Health • Screening and assessment, treatment and • Youth friendly centers
System rehabilitation (micronutrient deficiency, SAM,
• OPD, ART and TB clinics,
substance abuse)
• ANC, PNC, FP, EPI
• Anemia prevention (WIFAS, Deworming, ITN
utilization) at Hospital, HC and HP levels
• Nutrition education and counseling (hygiene
and sanitation, dietary diversity, adequate meal
frequency, healthy eating behavior, physical
activity)
• Adolescent friendly reproductive health service
Education • Screening, assessment and referral • School clubs (nutrition, health,
(micronutrient deficiency, SAM) gender, mini media, flag
ceremony, etc.)
• Anemia prevention (WIFAS, Deworming)
• Mass media (traditional and social
• Nutrition education and counseling (hygiene
media, school radio and television)
and sanitation, dietary diversity, adequate meal
frequency, healthy eating behavior, physical • School clinics
activity, preventing adolescent pregnancy,
• Classrooms
substance abuse)
• School feeding programs
• Promoting child rights (girls’ education,
prevention of early marriage & child labor) • Parent Teacher Associations (PTAs)
• Promoting life skills training (assertiveness,
decision making, meal menu planning, school
gardening)
• Providing access to WASH services including
menstrual hygiene management (MHM).
• Promoting school feeding initiatives
Community • Screening, assessment and referral, • Traditional/community gatherings
(micronutrient deficiency, SAM) (festivals, events, etc.)
• Anemia prevention (WIFAS, deworming, ITN • Youth associations, youth centers
utilization)
• Farmer Training Centers (FTC)
• Nutrition education and counseling (hygiene
• Campaigns, health outreach visits
and sanitation, dietary diversity, adequate meal
frequency, healthy eating behavior, physical • Religious institutions
activity, preventing adolescent pregnancy & • Public libraries
substance abuse)
• Companies and factories
• Homestead gardening,
• Large scale farms (flower, coffee,
• Nutrition advocacy and social mobilization etc.
• Small scale businesses
17
 Household • Nutrition education and counseling (hygiene
and sanitation, dietary diversity, adequate meal
• House to house visits
frequency, healthy eating behavior, physical
activity, preventing adolescent pregnancy & • Religious and community leaders
substance abuse) • Media (community radio)
• Homestead gardening (seed and seedling
provision)
NB: For more information, please refer to the Adolescent Nutrition Implementation Guideline.

3.5.2. Integration of adolescent nutrition interventions across different platforms

Integration of adolescent nutrition interventions can be within sectors or across sectors. Intra-sector
integration and coordination is to harmonize adolescent nutrition programs that are implemented in
different departments or directorates within the same sector. Inter-sectorial integration is harmonizing
nutrition-specific and nutrition-sensitive adolescent nutrition interventions implemented by
different sectors so that they complement each other and have a cumulative impact on nutritionally
vulnerable adolescents. Each sector is required to ensure the following as a commitment to the
integration of adolescent nutrition services into the specific sector and across sectors.
• Review sector goals and objectives within an adolescent nutrition lens.
• Define the sector’s role and responsibility with respect to adolescent nutrition.
• Create common understanding within the sector and across sectors.
• Establish institutional structure and capacity for adolescent nutrition program implementation.
• Develop a sector-specific adolescent nutrition plan.

Potential integration within the health sector

• Integration with youth friendly services, family planning, EPI, ANC, OPD, IDP, Delivery, PNC
services and other support groups at community level.

Potential integration with other sectors

• Integration with education (e.g. school clubs, mini media, school feeding programs, school
gardening)
• Integration with agriculture (e.g. promoting NSA such as home gardening, poultry production
and consumption).
• Integration with culture and sports (such as promoting healthy lifestyle)
• Integration with the women and social affairs sector (such as empowering women, tackling
cultural taboos, promoting girls education, empowering adolescents economically through
access to micro credits and income generating activities (IGAs)).

18
4. Maternal Nutrition
4.1. Introduction
The time from conception to child’s second birthday is a time of rapid growth and nutritional
vulnerability. Nutrition during preconception, pregnancy and lactation has effect on pregnancy
outcomes and the health of the mother and the child. Furthermore, poor maternal dietary intake
and deficiencies of nutrients compromise the physical and mental potential of the child, increase
maternal complications and cause newborn and maternal death and birth defects. A woman’s
health and nutritional status during her reproductive years influences her overall wellbeing. One
who enters pregnancy with good nutritional status will have a lower risk of poor maternal-fetal
outcomes and reduce lifelong risk for chronic diseases for both the mother and child.

Women’s nutrition is influenced by access to and affordability of food , household dynamics, gender
inequality and socio-cultural norms. These factors one way or another affect their ability to make
decisions about their diets and nutritional care. Major strategies for promoting maternal nutrition
include creating a supportive environment that enables access to nutritious foods, adequate
nutrition services and positive nutrition practices which need to be an integral part of maternal
nutrition programs. Additionally, focus should be placed on enhancing the quality and coverage of
existing maternal nutrition services, bringing innovations, institutionalizing new service packages,
and working on a systems approach given the multidimensional determinants of maternal nutrition.
The platforms for the implementation of maternal nutrition services include ANC, delivery, PNC, FP, HH
visits, youth health service centers/rooms

4.2. Objectives
• To provide guidance to service providers and nutrition programmers on the implementation
of maternal nutrition services for prevention and treatment of all forms of malnutrition during
preconception, pregnancy, and lactation.
• To set implementation standards and improve the provision of quality maternal nutrition
services at health facilities and community platforms.

4.3. Nutritional requirements during pre-conception, pregnancy &

lactation
Women of reproductive age (WRA) do have more requirements for certain nutrients such as iron to
meet the body’s increased demand during menstruation. Therefore, ensuring dietary adequacy and
healthy weight is essential during a woman’s reproductive years and preconception period.

For positive pregnancy outcomes, all women who are planning to conceive are recommended to
receive folic acid supplements and attain optimal pre-pregnancy weight. Pregnant women need to
consume adequate quantities of nutritionally dense foods that not only balance maternal and fetal
energy expenditure but also provide additional energy for fetal growth, as well as the growth of
maternal tissues such as fat mass, breast tissue, uterus, and placenta. All women who are in their
first trimester of pregnancy are recommended to take an additional 100–200 kcal/day to support
proper fetal growth and the mother’s health. The energy requirement during the second and third
trimester is recommended to be 340kcal/day and 452kcal/day, respectively (Institute of Medicine
and National Research Council, 2009).

19
Deficiencies of micronutrients such as vitamin A, iron, iodine, and folate are particularly common
during pregnancy and lactation due to increased nutrient requirements of the mother and the
developing fetus. The daily requirement of nutrients during pregnancy and lactation are indicated in
the following table.

Table 12: Recommended Dietary Intakes of minerals for pregnant and lactating women

Zinc(mg/day)
Group Calcium Selenium Magnesium High Moderate Low
Pregnant women (mg/ (ug/day) (mg/day) Bioavailability Bioavailability Bioavailability
day)

First trimester 1000 26 220 3.4 5.5 11.0

Second trimester 1000 28 220 4.2 7.0 14.0
Third trimester 1200 30 220 6.0 10.0 20.0
Lactating women
0–3months 1000 35 270 5.8 9.5 19.0
3–6months 1000 35 270 5.3 8.8 17.5
7–12months 1000 42 270 4.3 7.2 14.4

Report of a Joint FAO/WHO Expert Consultation: Food and Agriculture Organization, 2002

Table 13: Recommended dietary intakes of vitamins for pregnant and lactating women

Group Vitamin C Vitamin Vitamin B2 Vitamin Vitamin B6 Vitamin B5

B1(Thia- (Riboflavin) B3 (Niacin) (Pyridoxine) (Pantothenate)
(Ascorbic Acid) mine(mg/day) (mg/day) (mg NE/ (mg/day)
(mg/day) day) (mg/day)
Pregnant 55 1.4 1.4 18 1.9 6.0
women
Lactating 70 1.5 1.6 17 2.0 7.0
women
Report of a Joint FAO/WHO Expert Consultation: Food and Agriculture Organization, 2002

Table 14: Dietary reference intakes (DRIs): Recommended dietary allowances and adequate
intakes, total water and macronutrients

Life Stage Group Total Water Carbohydrate Total Fiber Linoleic Acid α-Linolenic Acid Protein
(L/d) (g/d) (g/d) (g/d) (g/d) (g/d)
14–18 y 3.0* 175 28* 13* 1.4* 71
19–30 y 3.0* 175 28* 13* 1.4* 71
31–50 y 3.0* 175 28* 13* 1.4* 71
14–18 3.8* 210 29* 13* 1.3* 71
19–30 y 3.8* 210 29* 13* 1.3* 71
31–50 y 3.8* 210 29* 13* 1.3* 71
(Accessed form https://ods.od.nih.gov/HealthInformation/Dietary_Reference_Intakes.aspx# Accessed on 9
March 2022).

20
4.4. Nutritional interventions during preconception, pregnancy and
lactation
4.4.1. Nutritional interventions during preconception
Preconception nutrition involves a set of interventions that are to be provided before pregnancy
to ensure the health and well-being of women and their couples and ultimately facilitate positive
pregnancy and child-health outcomes. Preconception/pre-pregnancy nutrition service is the most
ignored, but critically important service for improving the outcome of pregnancy. A woman who
enters pregnancy maintaining a healthy weight and micronutrient status will have positive maternal-
fetal outcomes. The following interventions will be addressed during the pre-pregnancy period.

a) Micronutrients supplementation and counseling on adherence during preconception

Studies showed that taking folic acid before and during the first weeks of pregnancy helped to lower
the chance of neural tube defect (NTD). In Ethiopia, iron and folic combination or supplementation of
folic acid alone would be provided daily for the first three months of preconception period and that
continues throughout the first trimester. Women who have the risk of NTD would be supplemented
with a higher dose of folic acid.

Recommended actions
• Provide daily oral iron and folic acid tablet (elemental iron (30 - 60mg)) and folic acid
(400µg/0.4mg) which is equivalent to 1 tablet supplementation daily from 3 months before the
planned pregnancy or upon suspicion of pregnancy until 12 weeks of gestation. If not available,
it can be replaced by 300mg ferrous sulfate hepta-hydrate, 180mg ferrous fumarate or 500mg
of ferrous gluconate each of which is equivalent to 60mg of elemental iron.
• Provide folic acid (400g/0.4mg) daily to women in places where anemia is less than 20% from
3 months before the planned pregnancy or upon suspicion of pregnancy until 12 weeks of
gestation is an optional recommendation to the daily IFA provision.
• For women who have had a history of a fetus diagnosed with neural tube defect or given birth
to a baby with a neural tube defect should:

 Provide high-dose supplementation (5mg folic acid daily).

 Provide information on the risk of recurrence.

 Provide counseling on the protective effect of preconception folic acid supplementation and
adherence.

 Counsel to increase intake of foods rich in folate; dark green vegetables, beans, peanuts,
sunflower seeds, fresh fruits, whole grain, liver and sea foods( fish).

b) Improving dietary diversity during preconception

In resource limited countries like Ethiopia, women in the reproductive age (WRA) consume a
monotonous diet of predominantly starchy staples which often contain few or no animal source foods
with limited seasonal fruits and vegetables. Diversifying diet is essential to ensure micronutrient
adequacy among women.

21
Recommended Actions
• Provide nutrition counseling for women during preconception to engage their husbands/
partners to consume adequate and diversified foods (food from at least five food groups out of
ten) focusing on locally available ones and these include:

 Energy dense foods such as cereals (e.g. maize, rice, millet, sorghum), white roots and tubers
(e.g., potatoes, cassava) and plantains

 Protein and micronutrient rich foods including animal products such as meat, milk, eggs, and
fish

 Plant source, protein rich foods such as legumes including beans, peas, soybean, and
groundnuts

 Calcium rich foods such as dairy products (yoghurt, milk, and cheese), eggs, fish, beans,
soybeans, beef and cereals like whole millet and rice.

 Zinc rich foods such as meat, fish, legumes, seeds, nuts, dairy, eggs, whole grains, and some
vegetables.

 Counseling on intake of iodine through use of iodized salt for all WAR

The ten food groups “counted” in the minimum dietary diversity for women of reproductive age
indicator are:

 Grains, white roots and tubers, and plantains

 Pulses (beans, peas, and lentils)

 Nuts and seeds

 Dairy

 Meat, poultry, and fish

 Eggs

 Dark green leafy vegetables

 Other vitamin A-rich fruits and vegetables

 Other vegetables

 Other fruits

For ease of operationalizing and counseling on eating diversified diet, the above food groups are
clustered in to six category food groups of staples, legumes/nuts, vegetables, animal source foods,
fats and fruits as indicated below with examples of locally available food items under each food
group.

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Figure 1: Food items among different food groups

c) Promoting healthy eating behavior during preconception

Promoting healthy eating behavior during preconception is important for the current and future
wellbeing of the woman and enhances the health of the child and safety of her future pregnancy.
Healthy eating means eating a variety of foods that give you the nutrients you need to maintain
your health, feel good, and have energy. These nutrients include protein, carbohydrates, fat, water,
vitamins, and minerals. It is also important to avoiding consumption of unhealthy foods such as
consumption of saturated fats, sugary beverages, processed meats, and high sodium.

Recommended actions
• Promote regular consumption of fiber rich foods which are essential for bowel movement
(whole grains, fruits, vegetables).
• Promote consumption of adequate amounts of drinking water (at least 2 liters per day).
• Counsel on avoiding tea and coffee consumption (inhibitors of iron/zinc/calcium absorption)
within one hour before or after eating, and promote increased intake of absorption enhancers,
vitamin C-rich foods such as oranges, tangerines, mangoes etc.
• Counsel and educate on limiting consumption of processed and junk foods as well as soda and
other sweetened drinks to prevent overweight and chronic diseases.

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d) Promoting healthy weight during preconception

Pre-pregnancy BMI strongly influences gestational weight gain (GWG) and potentially fetal and
maternal outcomes. For women with a low pre-pregnancy BMI (<18.5kg/m2), inadequate weight
gain has been linked to low birth weight (LBW), preterm birth, and small for gestational age (SGA)
infants. Infants with low birth weight are known to have an increased risk of infant morbidity and
mortality (The Lancet. 2021). Non pregnant women’s nutritional status is classified based on their
BMI as presented in the table below.

Table 15: Nutritional status classification of WRA during preconception based on BMI

Nutritional status/Classification BMI (Kg/m2)

Underweight < 18.5
Normal weight 18.5-24.9
Overweight 25-29.9
Obese ≥30
Source: WHO; Recommendations on Antenatal Care for a positive pregnancy experience; 2020

Recommended actions
• Provide counseling and education on the importance of normal pre-pregnancy weight and
regular weight measurement and recording.
• Provide counseling and education on the consumption of safe, adequate, and diversified meals.
• Provide balanced energy and protein supplements for pre-pregnant women with low BMI
(supplement such as fortified blended foods, ready to use supplementary food).
• Provide counseling and education on healthy lifestyle for overweight and obese women.

e) Promoting lifestyle modification

The aim of pre-pregnancy lifestyle modification intervention is to optimize women to adapt to the
physiologic and anatomic changes and increased nutritional needs that will happen during pregnancy
and maximize fetal growth and development.

Recommended actions
• Provide counseling and education on avoiding alcohol consumption, smoking including
secondhand smoking, and substance abuse.
• Provide counseling and education on the importance of moderate regular physical activity 3-5
times per week for at least 30 minutes alongside with optimal nutrition
• Provide counseling and education for women on personal hygiene and environmental
sanitation.
• Promote and counsel on early initiation of antenatal care.
• Promote and counsel on healthy diet that includes fruits, vegetables, whole grains, proteins
and dairy in appropriate amounts and reducing processed high fat and sugar.
• Use different platforms such as reproductive clinics /workplace, youth clubs, schools and
universities to access young people and provide awareness on preconception care.

24
Preconception care should be integrated into existing family planning service contact points;
contraceptive discontinuation could be a good time to start.

4.4.1.1. Implementation modality for preconception

Table 16: Implementation modality of interventions among preconception

Interventions Implementation modalities Entry point

Micronutrient Counsel on the purpose of micronutrients School , FP and other
supplementation and supplementation during preconception health services, youth
counseling on adherence friendly services
Link the discontinuation of family planning
during preconception
services to folate supplementation

Provide micronutrient supplements

according to the guideline
Improving dietary diversity Promote consumption of micronutrient rich School , FP and other
during preconception foods health services, youth
friendly services
Promote consumption of fortified and
biofortified foods

Demonstrate gardening at school, YFS and

home
Promoting Healthy Counsel on consumption of unhealthy food School, FP and other
eating behavior during (pizza, fried food, burger, beverage etc) health services, youth
preconception friendly services
Promoting lifestyle Promote physical exercise School , FP and other
modification health services, youth
Counseling to avoid smoking, chewing khat,
friendly services
substance abuse, etc.

4.4.2. Nutritional Interventions during Pregnancy

Given the increased nutritional needs during pregnancy and the special care and support required
for pregnant women, there are a range of recommended nutritional interventions that need to be
provided at health facility and community levels.

a) Micronutrient supplementation and counseling on adherence during pregnancy

Deficiencies of micronutrients such as folate, iron, iodine and vitamin A, are particularly common
during pregnancy, due to increased nutrient requirements of the mother and developing fetus. These
deficiencies can negatively impact the health of the mother, her pregnancy, as well as the health of
the newborn baby. In response to this, in addition to dietary diversification pregnant women must
be provided with micronutrients supplements and counseling on adherence in every ANC contact.

25
Table 17: Recommended micronutrient supplement
Interventions Recommended Actions Delivery Modality
Daily oral iron • Provide daily oral IFA supplementation in composition ANC contacts,
and folic acid of 30 - 60mg elemental iron and 400µg/0.4mg folic acid) pregnant women
(IFA) which add up to 180 tablets for a total of 6 months. conferences,
home to home
• Counsel on the benefits of consuming 180 IFA tablets
visits, community
such as preventing maternal anemia, puerperal sepsis,
conversations,
low birth weight, and preterm birth.
Mother-to-mother
• Counsel on side effects and their management, when to support groups and
take tablets, drinks to be avoided while taking tablets. local media

• Counsel on IFA adherence that includes tracking of

number of tablets consumed

• Counsel to continue taking daily oral iron and folic

acid supplementation during lactation if a woman did
not finish the recommended 180 IFA tablets during
pregnancy.

• Counsel on the consumption of iron rich foods such as

animal source foods (liver, meat, etc), dark green leafy
vegetables.

Screening and • Treat a woman diagnosed with anemia during pregnancy • ANC contacts
treatment of with daily elemental iron of 120mg until her Hb
anemia during concentration rises to normal (Hb 110g/L or higher).
pregnancy Thereafter, she can resume the standard daily antenatal
iron dose (30 - 60mg) to prevent recurrence of anemia.

• Counsel on adherence of anemia treatment.

• Counsel on consumption of iron rich foods such as

animal source foods (liver, meat, dark green leafy
vegetables, etc.).

• Counsel on the utilization of bed net on malaria endemic

areas.

26
Calcium • In populations with low dietary calcium intake, daily • ANC contacts
supplements supplementation of 1.5–2.0gm oral elemental calcium is
recommended for 180 days.

• Promote consumption of locally available, calcium-rich

foods such as milk, other dairy products, and green leafy
vegetables.

• Counsel on the benefits of taking calcium in preventing

preeclampsia, blood clotting, building bones and teeth, ,
regulating nerve and muscle activity.
Preventive • Deworm all pregnant women with a single dose of • ANC contacts
deworming albendazole (400mg) or mebendazole (500mg) after the
• Household visits
first trimester.
• PW conferences,
• Albendazole and mebendazole are well tolerated, with
women
no adverse events when given after the first trimester.
conferences,
• Anthelmintic medicines (albendazole and mebendazole) community
must not be given during the first trimester of conversations
pregnancy.
Note: MMS would be used in place of IFA tablets once the ministry has issued guidelines based on
evidence gathered from the current implementation research undertakings.

b) Improving dietary diversity of pregnant women

Pregnancy imposes increased macro and micronutrient demands, deficiencies of micronutrients

such as vitamin A, iron, iodine, and folate are particularly common during pregnancy and lactation
falling short of increased nutrient requirements of the mother and the developing fetus. Pregnant
women need to consume a diverse diet in order to meet their increased energy and micronutrient
needs and ensure optimal pregnancy and positive birth outcomes.

Recommended actions

Provide nutrition counseling for pregnant women engaging their husbands/ partners and other
family members to consume adequate and diversified foods focusing on locally available foods and
these include:

 Roots and tubers: e.g., potatoes, cassava, and plantains

 Protein and micronutrient rich foods including animal products such as meat, milk, eggs, and
fish

 Plant based protein rich foods such as legumes like beans, peas, soybean, and groundnuts.

 Minerals and vitamin rich foods such as fruits and vegetables

• Provide counseling on the importance of iodine. Iodine is essential for healthy brain development

27
 of the fetus. A woman’s iodine requirements increase substantially during pregnancy to ensure
adequate supply to the fetus.
• Promote consumption of iodized salt and foods rich in iodine such as sea foods (e.g., fish).
Counsel and educate to add salt during serving or at the end of cooking during food preparation.
• Counsel on and encourage consuming foods that are rich in zinc such as meat, fish, legumes,
seeds, nuts, dairy, eggs, whole grains and some vegetables. Recognizing an adequate supply of
zinc is especially important for pregnant women due to the central role of zinc in cell division,
protein synthesis and growth.

c) Promote appropriate weight gain during pregnancy

Weight gain during pregnancy, referred to as gestational weight gain (GWG), is necessary for a
woman’s body to support adequate growth and development of the fetus and subsequent lactation
(breastfeeding upon birth). Inadequate GWG is associated with SGA, poor birth outcome, and child
growth and health.

Recommended weight gain during the first trimester is relatively low. Then the rate of weight gain
grows rapidly reaching its peak in the second trimester. During the third trimester, the rate of gain
slows down slightly, and then remains constant until the date of delivery. Steady increase of 1.5–2kgs
per month is expected from 4 months of pregnancy. On average, women are expected to gain 10-
12kgs average weight gain throughout pregnancy. The table below summarizes the recommended
weight gain based on pre-pregnancy BMI (weight gain during pregnancy, reexamining the guidelines.
2009).

Table 18: Recommended weight gain during pregnancy and dietary recommendation

Pre-pregnancy weight Recommended Rate of weight gain Recommended diet

total weight in the 2nd &3rd Tri-
Category (BMI in kg/m2)
gain in (kg) mester (kg/week)
Underweight (< 18.5) 12.5–18 0.51 (0.44-0.58) More calorie and protein diet, adequate
vegetables and fruits
Normal (18.5 to <24.9) 11.5–16 0.42 (0.35-0.50) Moderate carbohydrate and protein
diet and adequate vegetables and fruits
Overweight (25 to <29.9) 7–11.5 0.28 (0.23-0.33) Normal carbohydrate and protein diet,
very low fat, more vegetables and fruits
Obese (>= 30) 5–9 0.22 (0.17-0.27) Less carbohydrate and protein diet,
more vegetables and fruits, avoid fat
foods
Women are advised to increase their daily calorie intake during pregnancy according to their pre-
pregnancy body weight, physical activity, and gestational age. Counseling mothers to get at least
one additional nutrient-dense, safe, and diverse meals per day during pregnancy to fulfill the extra
energy and protein requirement is important.

Recommended actions
• Measure and monitor weight gain, and counsel on appropriate weight in every ANC contact.
• Provide counseling on the importance of appropriate weight gain for the mother as well as

28
 the baby, expected weight gain throughout pregnancy and expected increase in the upcoming
contact.
• Provide counseling and encouragement to take one additional diversified meal per day during
pregnancy to gain recommended weight.
• Provide counseling on addressing excessive weight gain.
• Promote the importance of adequate rest and care.
• Identify and link food insecure and malnourished pregnant women with PSNP, supplementary
feeding programs and other social support schemes.

d) Promoting healthy eating behavior and lifestyle during pregnancy

Promoting healthy eating behavior and lifestyle modification during pregnancy is important for the
mothers to stay healthy and prevent excessive weight gain during pregnancy.

Recommended actions
• Counsel and educate on avoidance of alcohol consumption, smoking, including secondhand
smoking, khat and other substance use to prevent congenital anomalies and spontaneous
abortion.
• Counsel and educate on the reduction of caffeine intake (Daily caffeine intake should not
exceed 300mg which is equivalent to 3 small cups of Ethiopian coffee.)
• Counsel on reduction of free sugar intake to less than 10% of the total energy intake.
• Counsel on reduction of salt intake to less than 5gm/day (2gm sodium per day) which is
equivalent to 1 teaspoon.
• Counsel on avoiding junk foods such as fast foods (e.g., burger, pizza, etc.).
• Counsel to engage in moderate regular physical activity 3-5 times per week for 30 minutes
alongside consuming nutritional diet to maintain healthy weight.
• Counsel on appropriate food preparation methods such as avoiding overcooking of vegetables
to prevent loss of nutrients.
• Promote consumption of adequate amounts of drinking water (at least 2 liters per day).

e) Promoting Food safety, safe drinking water, sanitation, and hygiene

Recommended actions
• Counsel on using clean and safe drinking water, and keeping personal hygiene
• Counsel on appropriate use of latrine and proper solid and liquid waste disposal and
management.
• Promote food safety such as keeping kitchen areas clean and free from insects and rodents,
separating raw and cooked foods, cooking thoroughly, keeping food at room temperature and
using safe ranges.

29
• Counsel on avoiding consumption of raw meat, raw /partially cooked eggs, mould-ripened soft
cheese, salad, unwashed raw vegetables, unpasteurized dairy products to prevent listeriosis,
toxoplasmosis, salmonella, miscarriage, still birth and premature delivery.
• Counsel on preventing excess weight gain by remaining physically active during pregnancy.

e) Promotion of early breastfeeding practice

Promotion of early breastfeeding practice is important to initiate and make the mother ready for
breastfeeding.

Recommended actions
• Establish and implement mother and baby friendly health facility initiatives.
• Inform all pregnant women about the benefits and management of breastfeeding.
• Help mothers initiate breastfeeding within the first one hour of birth.
• Give newborns no food or drink other than breast milk, unless medically indicated.
• Practice rooming-in - allow mothers and infants to remain together 24 hours a day.
• Encourage breastfeeding on demand.
• Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

4.4.3. Implementation modality of nutrition services for pregnant mothers

Interventions Implementation modalities Entry point
Micronutrient Counsel on the importance of micronutrient Health posts, health centers
supplementation supplementation to pregnant women. and hospitals (EPI, ANC,
and counseling on delivery, PNC units)
adherence during Provide IFA to pregnant women.
pregnancy Deworm after the first trimester
Improving dietary Promote consumption of safe, diversified and Health posts, health centers,
diversity of pregnant nutritious food. hospitals, villages, farmer
women training centers, women
Promote consumption of fortified and biofortified conferences, home to
food. home visits, community
Promote backyard gardening and small animal conversations,
raring. local media
Organize food cooking demonstration to mothers. Mother to mother support
group
Promoting Regularly monitor weight gain at ANC units. Outreach, health posts, health
appropriate centers, hospitals
weight gain during Interpret the result and proper counseling.
pregnancy (ANC)
Promoting healthy Counsel on consumption of health and nutritious Outreach, health posts, health
eating behavior food centers, hospitals
and lifestyle during
pregnancy Avoid consumption of alcohol, chewing khat, (ANC)
substance abuse, etc.

30
Promoting food Counsel mothers to clean raw food items Outreach, health posts, health
safety, safe drinking (vegetables, fruits and animal product) before centers, hospitals (ANC)
water, sanitation, consumption.
and hygiene
Counsel mothers to cook vegetables well and
animals source foods thoroughly.
Counsel mothers to drink safe and clean water
(piped water, boiled and treated water).
Counsel mothers to avoid consumption of raw
foods items or products.
Promotion of early Promote early initiation of breastfeeding within Outreach, health posts, health
breast-feeding one hour. centers, hospitals
practice.
Promote exclusive breastfeeding for the first six (ANC)
months of an infant’s life.

4.4.4. Nutrition Interventions during lactation

To support children’s optimal growth and development and women’s well-being during lactation,
women need to have access to adequate nutritious, safe, and affordable diets. This could be attained
through postnatal care services including nutrition counseling and support and a healthy environment
that enables access to healthy foods, adequate nutrition services and positive nutrition practices.

a) Promote adequate energy intake during lactation

Lactation places a high demand on maternal stores of energy, protein, and other nutrients. These
stores need to be established, conserved, and replenished. The energy, protein, and other nutrients
in breast milk come from a mother’s diet or her own body stores. Women who do not get enough
energy and nutrients in their diets are at risk of maternal depletion. As a result, lactating women
need an additional 640kcal/day (two additional diversified meals). Furthermore, lactating women
can be malnourished if they fail to take adequate energy. Lactating women up-to 6 months post-
partum with MUAC <23cm are classified to be underweight.

Recommended action
• Counsel on the consumption of two additional diversified and nutrient-dense meals, daily
during lactation.
• Prepare and disseminate context specific nutritious recipes for lactating women.
• Promote the importance of adequate rest and care for lactating mothers.
• Promote the engagement of husbands, grandparents, and other household members who play
key roles in providing continuous care for women.
• Counsel on family planning and birth spacing.
• Identify and link food insecure and malnourished LW with PSNP, supplementary feeding
programs and other social support schemes.

31
b) Improving dietary diversity of lactating women

Lactation imposes increased macro and micronutrient demands; lactating mothers need to consume
a diverse diet in order to meet their increased energy and micronutrient needs.

Recommended actions

Provide nutrition counseling for lactating women on engaging their husbands/ partners and other
family members to consume adequate and diversified foods (food from at least five food groups)
focusing on locally available foods including:

 Roots and tubers e.g., potatoes, cassava, and plantains

 Protein and micronutrient rich foods including animal products such as meat, milk, eggs, and
fish

 Plant based protein rich foods such as legumes like beans, peas, soybean, and groundnuts.

 Minerals and vitamin rich foods such as fruits and vegetables

• Provide counseling addressing the importance of iodine for the health of the mother and the
baby.
• Promote consumption of iodized salt and foods rich in iodine such as seafoods (e.g., fish).
• Counsel and educate to add iodized salt during serving or just at the end of cooking.
• Counsel and encourage consumption of foods that are rich in zinc such as meat, fish, legumes,
seeds, nuts, dairy, eggs, whole grains and some vegetables.

c) Promoting healthy eating behavior and lifestyle during lactation.

Promoting healthy eating behavior and lifestyle modification during lactation is important for the
mothers to stay healthy and prevent excessive weight gain during lactation.

Recommended actions
• Counsel and educate on avoidance of alcohol consumption, smoking including secondhand
smoking, khat chewing and other substance use to prevent congenital anomalies and
spontaneous abortion.
• Counsel on reduction of free sugar intake to less than 10% of the total energy intake.
• Counsel on reduction of salt intake to less than 5gm/day (2gm sodium per day) which is
equivalent to 1 teaspoon.
• Counsel on the consumption of junk foods such as fast foods.
• Counsel to engage in moderate regular physical activity 3-5 times per week for 30 minutes
alongside consuming nutritional diet to maintain healthy weight.
• Counsel on appropriate food preparation methods such as avoiding overcooking of vegetables
to prevent loss of nutrients.

32
4.4.4.1. Implementation modality for lactating women
Table 19: Implementation modality of interventions among lactating women

Interventions Implementation modalities Entry point

Promoting adequate Counsel lactating mothers to consume Health posts, health centers,
energy intake during food items that are energy rich ( hospitals (PNC, FP and EPI) and
carbohydrate and fat). PSNP
lactation
Promote utilization of labor and time
saving technologies.
Improving dietary diversity Promote consumption of safe, diversified Health posts, health centers,
of lactating women and nutritious diet. hospitals (PNC, FP and EPI) and
PSNP
Organize food cooking demonstration
sessions to lactating mothers
Promote backyard gardening and small
animal’s raring practices.
Promote consumption of fortified and
bio fortified foods.
Promoting healthy eating Avoid consumption of alcohol, chewing Health posts, health centers
behavior and lifestyle khat, substance abuse, etc. hospitals (PNC, FP and EPI) and
during lactation PSNP

4.4.5. Nutrition-sensitive interventions among women

Women’s diets are influenced by household food security, food affordability, women’s education
status, gender inequality and cultural norms affecting their ability to make decisions about their
nutrition and care. Barriers to nutritious diets during pregnancy and lactation include limited
knowledge about the quantity and quality of food to eat and the amount of weight to gain,
unavailability and unaffordability of nutritious foods, poor access to safe water supply and sanitation
facilities, cultural and social taboos that dictate what women can and cannot eat. The multifaceted
nature of barriers, therefore, needs multi sectorial collaborations.

Table 20: Nutrition sensitive interventions for women

Sectors Interventions
Agriculture • Establish communal fruit and vegetable gardens dedicated for PLW.
• Provide agriculture extension services to households with PLW for backyard gardening,
poultry production, small ruminant rearing.
• Introduce simple food processing and preserving techniques/technologies and train
PLW for year-round availability of fruits, vegetables, and animal source foods.
• Prioritize households with PLW for seed provision, livestock restocking, etc.
• Establish and strengthen cash transfer and conditional voucher programs that include
nutritious foods for PLW.
• Orient farmers/husbands on improved farming methods for increased production of
nutritious foods and on the benefits of dietary diversity for mothers in collaboration
with DAs/HEWs.
• Create market linkages with local tool makers to improve access to time and labor-
saving technologies for women
• Promote production and consumption of bio fortified crops (orange fleshed sweet
potato, high protein maize, etc.).
33
 WASH • Construct private/public latrines with handwashing facilities with special focus to PLW.
• Encourage small well/spring/surface water maintenance and treatment technologies.
• Regularly distribute and promote water treatment kits for PLW households.
• Mobilize community for rainwater collection, storage, and treatment with priority given
to PLW.
• Train and support community level WASH committee members to handle simple
maintenance problems for communal water points.
Social and • Promote water fetching services for PLW as one of the public work activities under
Women and PSNP.
Social Affairs • Early identify PLW and timely transition from public works to temporary direct support.
• Improve women empowerment and decision-making power.
• Promote maternal nutrition, care and support for PLW using public work and other
events under PSNP through availing counseling materials.
• Engage private sectors to provide baby-sitting services for lactating working mothers in
rural areas.
• Enforce compliance with maternity leave for pregnant and lactating women in both the
private and public sectors.
• Advocate for extension of maternity leave for up to six months.
• Promote engagement of men and boys in doing household chores.
• Advocate gender equity and equality for key influencers and religious leaders.

4.4.6. Maternal nutrition under special circumstances

a) Maternal nutrition in emergency situations

During emergencies, access for pregnant and non-pregnant women to essential routine services such
as antenatal care (ANC), routine obstetric care, reproductive health, and other disease prevention
and treatment services may be disrupted. The impact of emergencies such as limited mobility and
poor access to food can also exacerbate already existing vulnerabilities and risks for women and
their children. When food is in short supply, women and girls are more likely to reduce their intake
(either voluntarily or not) in favor of other household members.

Nutrient requirements may also increase due to malabsorption and nutrient losses caused by
diarrheal and infectious diseases. Hence, pregnant and lactating mothers are more vulnerable mainly
to wasting, deficiencies of iodine, vitamin A and iron in emergency situations. Increases in forced
early marriage may also lead to more adolescent pregnancies in protracted emergencies. There are
gaps in policy and guidance for addressing maternal nutrition in emergencies in the country.

Recommended actions
• Provide emergency food assistance, especially fortified food provision and link PLW with
livelihood programs such as cash incentive provisions.
• Prioritize PLW in humanitarian aid programs and support them to meet their energy and other
nutrient needs.
• Provide essential pregnancy related services during emergencies including micronutrient
supplementation and deworming.
• Provide safe childbirth and postpartum services during emergencies.

34
• Provide women’s education and nutritional counseling during emergencies
• Provide disease prevention and control services such as malaria, and HIV
• Develop water, sanitation and hygiene strategies.
• Provide family planning services for women during emergencies.
• Work towards prevention of gender-based violence during emergencies.
• Provide psychosocial support including ECD and mental health services for PLW.
• Ensure appropriate and workable policy and guidance to address maternal nutrition in
emergency situations.

b) Disease

The nutritional status of pregnant women is undermined by risks of communicable and non-
communicable diseases. The common diseases affecting pregnant women and pregnancy outcomes
are outlined in the table below.

Table 21: Common Diseases Affecting Pregnant Women and Pregnancy Outcome

Illness Risk Factors Recommended Actions

Hypertension • Family history (genetic • Provide clinical treatment and regular follow-up.
factors) • Encourage women to maintain a healthy diet
• Obesity during pregnancy.
• Lack of regular physical • Counsel on increasing exercise.
activity • Counsel on reducing intake of sodium/table salt
• Poor nutrition, • Counsel on increasing calcium intake.
especially low calcium
intake • Discourage the use of alcohol
• Stress • Provide psychosocial support to manage stress.
• Unhealthy food habits • Promote preconception services.
• Extreme ages
• Nulliparity
Diabetes • Family history • Counsel on eating small, regular meals to help
Mellitus (DM) • Obesity control weight and glucose levels.
or pregnancy • Counsel on eating a variety of foods to helps
induced DM • Sedentary lifestyle
maintain adequate nutrition.
• Environmental factors
and drug induced • Counsel on moderate exercise for 30 minutes or
more on most days of the week.
• Counsel on eating low fat foods.
• Encourage consumption of foods that contain
dietary fiber (e.g., fruits, vegetables, whole
wheat bread, cereals, brown rice, and legumes).
• Encourage PLW to avoid smoking and alcohol
intake.

35
 Malaria • Stagnant water • Encourage early diagnosis and treatment of
• Large mosquito pregnant mothers.
population living • Manage according to the current national
environment malaria protocols.
• Lack of long lasting • Provide free long-lasting ITNs in all malaria
insecticide treated net endemic areas and counsel to sleep under its
(LLITN) cover.
• Low health seeking • Counsel on increasing fluid intake including
behavior water.
• Small frequent meals of wide variety in case of
low appetite and vomiting.
• Promote continued intake of iron and folic acid
supplements.
HIV/AIDS: • Poor ANC attendance • Encourage pregnant women to attend ANC on
• Poor compliance with regular basis.
drugs • Ensure pregnant mothers know their HIV status.
• Poor diet intake • If possible, encourage them to take the ARV
drugs.
• Counsel on having adequate, safe, diversified and
nutritious diet.
COVID-19 • Failure to follow • Manage pregnant COVID patients based on the
appropriate COVID-19 national treatment protocol.
prevention actions • Counsel on appropriate COVID prevention
• Previous CVD actions.
• Previous lung disease • Counseling on Physical activity.
• Obesity • Counsel on eating fruit and vegetables.
• Counsel adequate fluid intake

36
5. Child Nutrition
5.1. Introduction
Access to adequate nutrition is a fundamental right of every child. Children who are fed with adequate,
diversified and age appropriate diet in the right way are more likely to be healthy, achieve physical
growth, cognitive and behavioral development. The first 1000 days of life is a “critical window’’ of
opportunity for implementing nutrition interventions to ensure optimal child nutrition.

Conditions like drought, flood, conflict, internal displacement, refuge, disease outbreaks and other
emergency situations are critical to prevent growth retardation, deterioration to severe malnutrition
and death. In addition, children with special needs such babies having HIV/ AIDS, those born preterm
and with low birth weight require special nutritional support.

Nutrition specific and sensitive interventions need to be aligned and integrated across all implementing
sectors. Therefore, it is crucial to bring synergy among food and nutrition implementing sectors,
development partners and all other relevant stakeholders.

5.2. Objectives
• To provide guidance on standard nutrition services for infants, young children and children
under 10
• To ensure optimal IYCF practices under normal and special circumstances
• To improve the nutritional status of under 10 children.

5.3. Nutritional requirements of children

The nutritional requirements of children depend on several factors including their age, sex, health
status, physical activity, and environmental conditions. The table below summarizes the standard
nutritional requirements of children.

Table 22: Nutritional requirement of children

Macro/micronutrients Age
0 - 6 months 6 - 12 months 1 - 3 years 4 to 8 years

Energy Kcal/day 615 686 900 1400 to 2000

Total water(L/d) * 0.7 0.8 1.3 1.7
Carbohydrate (g/d) 60 95 130 130
Total Fiber (g/d) ND ND 19 25
Fat (g/d) 31 30 ND ND
Protein (g/d) 9.1 11.0 13 19
Vitamin A (µg/d) 400 500 300 400
Vitamin C (mg/d) 40 50 15 25
Vitamin E (mg/d) 4 5 6 7

37
 Vitamin K (µg/d) 2.0 2.5 30 55
Vitamin B6 (mg/d) 0.1 0.3 0.5 0.6
Folate (µg/d) 65 80 150 200
Vitamin B12 (µg/d) 0.4 0.5 0.9 1.2
Calcium (mg/d) 200 600 700 1000
Iodine (µg/d) 110 130 90 90
Iron (mg/d) 0.27 11 7 10
Zinc (mg/d) 2 3 3 5
Potassium(g/d) 0.4 0.7 3.0 3.8
Sodium (g/d) 0.12 0.37 1.0 1.2
Chloride (g/d) 0.18 0.57 1.5 1.9
*
All water contained in food, beverages and drinking water
ND: Not Determinable due to lack of data of adverse effects
Source: Dietary Reference Intakes (DRIs): Estimated Average Requirements Food and Nutrition Board, Institute
of Medicine, National Academies.

5.4. Child nutrition interventions and their implementation modalities

Optimal breastfeeding, complementary feeding, GMP, micronutrient supplementation, dietary
diversification, nutritional assessment and counseling are among the key child nutrition interventions.
As a core component of nutritional intervention, nutritional assessment and screening are presented
in the table below.

Table 23: Recommended anthropometric assessments and nutritional status classification of

children 0-9 years

Measurement Age group Frequency Nutritional Status classification

Normal Moderate Severe
malnutrition malnutrition
WAZ • 0-59 Monthly ≥-2z-score • - 3 to <-2 <-3zs-score
months z scores (Severe
• 5-9 years (Moderate underweight)
underweight)
WHZ • 0-59 As required ≥-2z-score • - 3 to <-2 <-3zs-score
(Wasting/a months z scores (Severe wasting)
• 5-9 years (Moderate
wasting)
HAZ (Stunting) • 0-59 As ≥-2z-score • - 3 to <-2 <-3zs-score
months required* z scores (Severe stunting)
(Moderate
stunting)
MUAC • 6-24 As required ≥ 12.5 cm • 11.5 to <12.5 <11.5cm (Severe
(Acute months cm (Moderate wasting)
malnutrition) wasting)
• 24-59 As required ≥ 12.5 cm • 11.5 to < 12.5 <11.5cmb (Severe
months cm (Moderate wasting)
wasting)
• 5-9 years As required ≥ 14.5 cm • ≥ 13.5 to < 14.5 < 13.5 cm (Severe
cm (Moderate wasting)
wasting)
38
Based on the WHO growth standards, nutritional status of children 5-9 years can also be classified
using their BMI/age as presented in the table below.

Table 24: Nutritional status classification of children 5-9 years based on BMI/age

Classification BMI-for-age Z-score Recommendation

Sever thinness <-3SD Counsel, treat and/or refer for evaluation of potential met-
Thinness >or=-3SD &<-2 SD abolic disorders, chronic health conditions, or eating disor-
ders.
Normal >or = -2SD &+1SD Counsel to keep the normal weight.
Overweight >+1SD &≤ +2SD Complete medical evaluation to determine potential obesity
Obese >+2SD related complications.

5.4.1. Recommended infant feeding practices among 0-6-month infants

1. Delayed cord clamping

WHO recommends delayed cord clamping as part of the essential neonatal care services? Clamping
“not earlier than one minute” and delaying to 2-3 minutes or until cord pulsation ceases allow a
physiological transfer of placental blood to the infant, the majority of which occurs within 3 min.
Hence, this placental transfusion provides sufficient iron reserves and can improve the infant’s
iron status for up to 6 months. However, it should not be confused with milking of the cord (WHO.
Guideline: Delayed umbilical cord clamping for improved maternal and infant health and nutrition
outcomes. Geneva: World Health Organization; 2014)

Recommended action
• Delay clamping of the cord up to 1-3 minutes during the essential neonatal care.

2. Birth weight measurement

Birth weight should be measured immediately after delivery to assure that the neonate is in the
acceptable weight range. If a baby is diagnosed with low birth weight (LBW), it is mandatory to
provide or refer to appropriate care and feeding.

Recommended action
• Measure birth weight immediately after birth.
• Provide/refer LBW babies to appropriate care and feeding.

3. Skin-to-skin contact

Skin-to-skin contact refers to the practice where a baby is dried and laid directly on the mother’s
bare chest after birth. It is scientifically proven to be one of the best techniques for stimulating
the baby to move to the mother’s breast, attach and begin feeding. Evidence suggests that it
stimulates a specific part of the newborn’s brain. Additionally, it helps for better absorbance and
digestion of nutrients, effective thermoregulation, improved weight gain, more stable heartbeat
and breathing and higher blood oxygen levels. Long-term benefits also include improved brain
development and function, parental attachment, and stronger immune systems.

39
Recommended action
• Counsel on delaying bathing for a minimum of 24 hours or 1 day after birth.

4. Early initiation of breastfeeding

Early initiation of breastfeeding is understood as the optimal practice in which a newborn baby
is fed breast milk within the first hour of birth. It protects the newborn from acquiring infection,
reduces newborn mortality, facilitates emotional bonding of the mother and the baby, and has a
positive impact on duration of exclusive breastfeeding. It also prevents postpartum hemorrhage
and increases breast milk production. Rooming/bedding in of the mother and baby is important
for practicing early initiation of breastfeeding, breastfeeding on demand, and better-quality sleep.
The baby will develop a more regular sleep-wake cycle earlier, more stable body temperature and
be less crying.

Recommended action
• Counsel and support mothers to initiate breastfeeding within one hour of birth.

5. Feeding colostrum

Colostrum is the first milk babies get when they start breastfeeding during the first few days after
birth. It is a nutrient-dense substance which contains antibodies that protect the newborn against
disease. It has high protein, low fat and sugar, high level of secretory immunoglobulin A (SIgA) and
natural laxative.

Recommended action
• Counsel mothers on the benefits of colostrum.
• Support mothers to feed colostrum.

6. Avoiding pre-lacteal feeding

Pre-lacteal feeding is giving any solid or liquid foods other than breast milk during the first
three days after birth. It affects timely initiation of breastfeeding and exclusive breastfeeding
practices. Furthermore, pre-lacteal feeding is a source of infection and interfere with establishing
breastfeeding practices.

Recommended action
• Counsel mothers to practice no pre-lacteal feeding.

7. Exclusive breastfeeding

Breast milk contains all the necessary nutrients infants need in their first six months of life.
Infants should be exclusively breastfed for the first six months except for provision of prescribed
medications, vaccines, vitamins, and minerals. The use of bottles, teats or pacifiers should also be
avoided.

Breastfeeding reduces mortality from infections, decreases the risk of overweight/obesity

in childhood and adolescence, and increases intellectual abilities. It also prevents depression,
reduces the risk of breast cancer, ovarian cancer, and postmenopausal osteoporosis. It also helps
for birth spacing by delaying pregnancy.
40
Recommended actions
• Counsel mothers to exclusively breastfeed their infants for the first six months.
• Counsel and support expressed feeding of breast milk in situations where breastfeeding is not
feasible.
• Implement, monitor, and enforce the regulations on the marketing of breast milk substitutes
according to the national law.
• Advocate and ensure that employers protect and promote maternity rights and benefits.
• Ensure that all health facilities offering maternity services implement the Baby Friendly Health
Facility Initiative (BFHI) and become certified according to the BFHI requirements.

8. Breastfeeding on demand

Breastfeeding on demand means giving breast milk as often as the child wants; 8-12 times in 24
hours or more if needed. It ensures that infants get enough milk and is an ideal way to adjust the
mother’s milk production to the baby’s needs. The more the baby suckles, the more the breast
produces milk.

Recommended actions
• Advise and educate mothers to breastfeed their children day and night.
• Counsel and support mothers to breast feed frequently on demand, 8-12 times in 24 hours.
• Counsel and support mothers to continue and increase the frequency of breastfeeding when
the child is sick.
• Advise mothers to empty one breast before switching to the other.

9. Proper positioning and attachment

Successful breastfeeding depends on the proper positioning and attachment during breastfeeding.
It helps to ensure the baby feeds well and stimulate milk production. It is also important for the
mother to feel no pain during breastfeeding and prevent sore or cracked nipples.

Signs that an infant is properly positioned:

a. Infant’s whole body is in straight line and facing the mother (breast) and close to her.

b. Mother holds infant’s entire body, not just the neck and shoulders.

There are different ways to position babies that can be used in convenience for both the
baby and the mother as needed. The figure below illustrates the different breastfeeding
attachment positions.

41
 Correct infant latch-on Cradle hold

Cross-cradle hold Under arm

(rugby ball or clutch) Side lying (east and-sleep)

Figure 2: Types of breastfeeding position

Signs that an infant is properly attached:

a. Mother brings infant toward her breast, not the breast toward her infant.

b. Infant’s mouth is open wide.

c. Infant’s lips are curled outwards.

d. Infant’s chin touches mother’s breast.

e. Mother’s entire nipple and a good portion of the areola (dark skin around the nipple) are
in infant’s mouth. More areola is showing above rather than below the nipple.

Recommended actions
• Counsel, demonstrate, and support mothers on proper positioning and attachment during
breastfeeding.

10. Growth Monitoring and Promotion (GMP)

Growth Monitoring and Promotion (GMP) is an activity that tracks a child’s growth by consistently
measuring the child’s weight and age, comparing the child’s growth to a standard, identifying if the
growth is adequate, and providing the necessary follow-up actions through tailored counseling
and referral if needed. It is used for early detection of growth faltering to counsel parents so that
they can take actions to improve child growth.

Recommended actions
• Record age of the child.
• Measure weight of the child.
• Plot and interpret weight-for-age monthly.
• Discuss growth patterns with mother/involved parents/ caregivers.
• Identify problems & solutions involving mothers/caregivers.
42
• Provide age-appropriate nutrition counseling.
• Maintain a family folder/mother-&-child health card to monitor the growth and development
of the child.
• Follow-up/link children with growth faltering for further screening and management services.
• Link with social support programs (PSNP/TSFP and others/) when applicable.
• Demonstrate, counsel and support mothers to practice responsive caregiving, and age-
appropriate play and stimulation for the proper growth and development of the baby (ECD).

Table 25: Summary of interventions and implementation modality among 0-6 month infants

Interventions Implementation modality Place of delivery

• Delayed cord clamping • Provide essential newborn care and • Delivery room
nutrition services.
• Birth weight • PNC clinics
measurement
• Skin to skin contact
• Early initiation of
breastfeeding
• Giving colostrum • PNC clinics
• Avoiding pre-lacteal • Advice to avoid breast milk substitutes/ • ANC clinics
feeding artificial feedings and ensure the
implementation of Baby Friendly Health • Maternity room
• Exclusive breastfeeding Facility Initiative (BFHI) at hospitals and
health centers. • Breastfeeding
• Breastfeeding on demand corner
• Proper positioning and
attachment
• Growth Monitoring and • Ensure availability and utilization of
Promotion (GMP) field tested and contextualized job aids,
brochures, posters and documentation and • Nutrition/GMP
reporting tools to facilitate counseling with room
PLW and caregivers. • Under-five clinics/
• Ensure availability of anthropometric OPD
measurement equipment such as infant
weight scale.
• Integrate nutrition counseling and support
in ANC, delivery, PNC, well baby clinic and
immunization, GMP and sick baby clinic
service provisions.
• Advocate and ensure that employers
protect and promote maternity rights and
benefits.
• Promotion of key IYCF • Advocate and ensure that employers • Community;
practices at health facility protect and promote maternity rights and community
and community levels benefits. conversation (CC),
community care
• Implement, monitor, and enforce the association, women
regulations on the marketing of infant and development army
young child foods according to the national (WDA), agriculture
law. development army
(ADA)

43
5.4.2. Key Interventions for children aged 6-24 months
Optimal complementary feeding

Complementary feeding (CF): is giving infants and young children foods along with breast milk starting
from the age of 6 months. At the age of six months, children should be given age-appropriate
complementary food with adequate frequency, amount, thickness/consistency, safety, and diversity.
Active/responsive feeding and hygiene recommendations should also be followed while feeding
children. At one-year, young children should progress from eating soft to semi-solid foods to solid
and family foods.

Cooking demonstration: is a process of demonstrating how to prepare nutritious complementary

food to a target group through cooking and sharing nutritional messages. This includes discussing
different available foods and how they can be prepared at home, as well as cooking and tasting foods
prepared together.

Vitamin A supplementation: Oral vitamin A supplementation is a recommended practice to control

vitamin A deficiency (VAD) in most high-risk countries. It is recommended in populations where
the prevalence of night blindness is 1% or higher in children 24–59 months of age or where the
prevalence of VAD (serum retinol 0.70 µmol/l or lower) is 20% or higher in infants and children
6–59 months of age. In this section, we focus on a periodic prophylactic vitamin A supplementation
(VAS) to pre-school children 6-59 months of age who are at risk of VAD. Vitamin A supplementation
refers to the practices of providing all pre-school aged children with the WHO-recommended dose
of vitamin A every six months. Vitamin A supplementation is inexpensive; it costs about a dollar per
person per supplementation.

Multiple micronutrient powder: is a combination of iron, zinc, vitamin A and other micronutrients.
It is used to prevent anemia and other micronutrient deficiencies. The target age group is generally
those 6 months to 5 years of age. The MNP sachet should be mixed with solid or semi-solid food just
before serving. Children shall be given one sachet every day for a period of two months followed
by a period 3 to 4 months of supplementation. While no major side effects of MNP have been
documented, minimal abdominal discomfort may sometimes occur.

Table 26: Interventions and implementation modality in children aged 6-24 months

Interventions Implementation modality Place of delivery

Counseling • Register mothers with newborns and document for • MCH units during
mothers/care givers follow up. child vaccination
on timely initiation and PNC visits
of age-appropriate • Ensure availability of appropriate, culturally tailored
CF at 6 months BCC materials in the health centers, health posts and • Health posts
(start at the 181st for HDAs. during vaccination
day). • Create contact with pregnant mothers or mothers with • Household-HEWs
newborns at different points. This helps to counsel sessions during
mothers about initiation of CF at the age of 6 months. house-to-house
visits
• Pregnant
mothers’
conference in the
village

44
Counseling mothers • Counsel the mother on breast feeding up to 24 months. • Health centers
to continue
frequent and on • Set up user friendly breast-feeding corners equipped • Health posts
demand BF up to 24 with BCC materials.
• Hospitals
months and beyond
• Community
• Day care centers
Counseling • Understand the traditional way of food preparation, • Households
mothers/care givers and ensure diversity, density, and consistency.
on appropriate • Community
food preparation • Analyze the information and understand nutrition value
in terms of diversity, density, and consistency. • Health facilities
considering
diversity, density • Counsel mothers on the pros and cons of the traditional
and consistency way of food preparation and demonstrate the
acceptable recipe based on the local context.
Counseling mothers • Collect information on household measurement tools • Households
on the amount (cup, spoon, hand, etc.) and standardize them.
of food to be • Pregnant
provided using local • Counsel and educate mothers on how to measure with women’s
measurement local measurement tools. conference
Counseling on • Educate mothers to have responsive and on demand • Households
responsive feeding, feeding rather than feeding by force.
feeding frequency • Community
and use of locally • Ensure love, comfort and reassurance between baby platforms
available nutritious and mother. (women’s
food whenever conference,
Help mothers/caretakers understand they need to be mother-to-
possible patient until children adapt to the newly prepared food. mother support
groups, etc.)
• Health facilities
Counseling mothers • Educate mothers on the importance of animal source • Health facilities
to include animal foods for child health
source foods in • Community
children’s diets • Include animal products in a recipe and demonstrate platforms
how to prepare it. (women’s
conference,
• Allow all attendees to taste the food and get feedback pregnant
during cooking demonstrations. mothers’
conference)
Counseling on food • Educate mothers how to practice personal hygiene • Households
hygiene and safety while preparing food.
• Community
• Educate mothers how to clean utensils, and store food platforms
ingredients.
• Health facilities
Counseling mothers • Counsel mothers to continue breast feeding during and • Health facilities
on feeding during after a child’s illness.
and after illness.
• Counsel mothers that children after illness need to be
offered more food than usual to replenish the energy
and nourishment lost due to the illness.
Counseling mothers • Ensure availability of LLITN in households with children. • Households
on proper utilization
of ITN in malaria • Demonstrate how to make ITN over the bed. • Community
endemic areas platforms
• Educate mothers not to wash the ITNs. (Women’s
conference)

45
 Cooking • Identify major food products in the village and prepare • Selected sites
demonstration: appropriate recipe in line with the FMOH guideline. (schools, health
Organizing practical posts, FTC in the
cooking and feeding • Identify convenient sites for cooking demonstration. village)
demonstration • Educate mothers on the purpose of providing
sessions using diversified food for children before the demonstration.
locally available
food items • Clearly demonstrate how to cook food and engage
mothers in the cooking demonstration
• Give mothers and children the chance to taste the
food.
• Educate the community on how to exchange food items
that are not available in the house or market.

Promoting and • Collaborate with agriculture and water sectors. • FTCs

supporting backyard
gardening practices • Use culturally and locally tailored guideline. • HPs
• Educate mothers and family members on the possibility • Community
of practicing gardening in a small area around the
house.
• Organize demonstration sessions on how to prepare
backyard gardening.
• Randomly monitor the status of gardening.
• Provide refresher orientation after random assessment.
Growth monitoring • Ensure availability of measuring tools in facilities.
and promotion
(GMP) • Train nutrition service providers on how to conduct • GMP rooms
GMP.
• EPI rooms
• Record age of the child.
• Under five OPD
• Measure weight and height of the child.
• Health posts
• Plot and interpret weight-for-age monthly.
• Outreach sites
• Discuss growth patterns with mother/involved parents/
caregivers.
• Identify problems & solutions involving mothers/
caregivers.
• Provide age-appropriate nutrition counseling.
• Counsel mothers to maintain a family folder/mother-
&-child health card to monitor the growth and
development of the child.
• Follow-up/link children with growth faltering for further
screening and management services.
• Link with social support programs (PSNP/TSFP and
others/) when applicable.
• Demonstrate, counsel and support mothers to practice
responsive caregiving, and age-appropriate play and
stimulation for the proper growth and development of
the baby (ECD).
• Counsel on early childhood development.

46
Counseling mothers • Assess the traditional child play and stimulation Community
on age-appropriate practices.
play and stimulation HPs
for the proper • Identify barriers and facilitators.
HCs
growth and • Prepare/use messages for child play and stimulation.
development of the Hospitals
baby • Counsel and educate mothers/care givers on
appropriate play and stimulation practices. Media

• Monitor the changes in practice.

Biannual vitamin A • Ensure availability of vitamin A and deworming tablets. • Enhanced

supplementation outreach services,
for children 6-59 • Provide high dose vitamin A supplementation every community health
months and 6 months.; 100,000 IU (one capsule) for children 6-11 days
deworming for months, and 200,000 IU (2 capsules) for children 12-59
children 12 -24 months. • Routine HEP
months • Provide deworming tablets for children of age 1 – 2 • Outreach
years – give ½ tablet of albendazole (400 mg) or 1
tablet of mebendazole (500 mg). • Mobile health and
nutrition teams
• Place albendazole tablet inside a folded piece of paper,
then crush with a glass bottle and mix it with water in
a very small cup and slowly pour the stirred medicine
into the child’s mouth.
• Never force a child to take deworming, do not hold a
child’s nose to force them to swallow, and do not give it
to a child who is crying.
• Properly record and report vitamin A supplementation
and deworming activities.

Promoting use • Ensure the use of iodized salts using test kits • Households
of iodized salt
and fortified and • Discuss the result of the assessment with respective • Heath facilities
bio-fortified foods sector offices for action
complementary
foods
Providing multiple • Identify the target. • Community
micronutrient
powder • Ensure the availability of the multiple micronutrient • HPs
powder.
• HCs
• Estimate the amount needed.
• Hospitals
• Provide the supplement. • Schools
• Educate mothers about the benefits • Refugee center
• Monitor changes.

47
5.4.3. Key interventions for children aged 24-59 months
Nutrition interventions for the specified group range from ensuring dietary adequacy to, prevention
of micronutrient deficiencies, early detection, and management of acute malnutrition. The
interventions for this group extend to ensuring access and provision of integrated early childhood care
and development stimulation with existing community and facility-based child nutrition programs.

Table 27: Interventions and implementation modality among 24-59 months children

Place of
Interventions Implementation modality
delivery
Promote healthy, safe, diversified, adequate, balanced, and nutritious diet
Promoting • Identify target groups. Community,
consumption
of a safe, • Assess the locally available food items. HPs
diversified and • Prepare/utilize age and time appropriate messages for each food HCs
nutritious foods items.
and drinks with Hospitals
recommended • Deliver the messages to mothers/caregivers.
amount and Media
frequency. • Monitor the behavioral change.
Daycare centers
Kindergartens
(KG)
Promoting and • Assess and identify locally available animal source foods. Community
counseling
mothers on • prepare/use communication tools with appropriate messages. HPs
including animal • Educate mothers/caretakers about the benefits of animal source HCs
source foods in foods.
the child food Hospitals
items • Monitor the progress and behavioral changes among mothers.
Media
Counseling • Assess the cultural feeding and caring practices. Community,
and supporting
all mothers • Identify barriers and facilitators. HPs
to employ • Prepare/use messages of responsive feeding and caring HCs
responsive practices.
feeding and Hospitals
caring practices. • Counsel and educate mothers/caregivers on appropriate
responsive feeding and caring practices. Media

• Monitor the behavioral changes.

Counseling • Assess the traditional play and stimulation practices Community
mothers on age-
appropriate play • Identify barriers and facilitators. HPs
and stimulation • Prepare/use messages for play and stimulation practices. HCs
for the proper
growth and • Counsel and educate mothers/care givers on appropriate play Hospitals
development of and stimulation practices.
the baby Media
• Monitor the changes in practice.

48
Avoiding foods • Assess child feeding practices related to high sugar, salt, and fat Community
and drinks that consumption.
are high in sugar, HPs
salt and fat • Identify barriers and facilitators.
HCs
• Prepare/use communication materials.
Hospitals
• Educate mothers/care givers on consumption of sugar, salt and
fat in moderation. Media

• Monitor behavioral changes and impacts.

Growth • Ensure availability of measuring tools in facilities. Nutrition/GMP
monitoring rooms, under
and promotion • Train nutrition service providers on how to conduct GMP. five OPD, EPI
(GMP) • Record age of the child. rooms at /
Hospitals/ , HCs
• Measure the weight of child. /HPs
• Plot and interpret weight-for-age monthly. Community
outreach sites,
• Discuss growth patterns with mothers/involved parents/ mobile health
caregivers. and nutrition
• Identify problems & solutions involving mothers/caregivers. teams

• Provide age-appropriate nutrition counseling.

• Counsel mothers to maintain a family folder/mother-&-child
health card to monitor the growth and development of the child.
• Follow-up/link children with growth faltering for further
screening and management services.
• Link food insecure HHs.
Provision and • Identify stakeholders to collaborate for ITN provisions. Community
use of ITN in
malaria endemic • Ensure ITN distribution. HPs
areas • Support mothers with children to sleep under the net. HCs
• Monitor the implementation. Hospitals
Media
Providing • Provide 400 mg albendazole tabs or 500 mg of mebendazole Community,
deworming every six months for children 24-59 months.
services HPs,
• Counsel mothers/caregivers on the benefits of deworming.
HCs
• Record the data properly and report.
Hospitals
Media
EOS
CHD
Routine HEP

49
 Providing • Provide 200000 IU for children aged 24-59 months every six Community
vitamin A months.
supplementation HPs
• Counsel and educate mothers/caregivers on the benefits of VAS
HCs
• Record the data properly and report.
Hospitals
Media
EOS
CHD
Routine HEP
Promoting • Identify the major micronutrient deficiencies that are of public Community
the use and health importance.
consumption Health facility
of iodized salt, • Assess and identify fortified or bio fortified food items.
Media
fortified and bio • Prepare/Use promotional messages.
fortified foods
• Educate mothers/caregivers using the standardized messages on
consumption of fortified and bio fortified foods.
• Monitor the progress made.
Providing zinc • Identify children with diarrhea . Health facility
with ORS for
management • Ensure the availability of zinc with ORS.
of children with • Provide zinc with ORS for all children with diarrhea.
diarrhea.
• Counsel mothers on the benefits of zinc with ORS.
• Follow up and provide monitoring support.

5.4.4. Key interventions for children aged 5-9 years

Middle childhood, ages 5 to 9 years, is characterized by a slow, steady rate of physical growth.
However, cognitive, emotional, and social development occurs at a tremendous rate. The period
between 5 and 9 years of age is a time of continued growth and development. Physical, social, and
mental skills develop at a steady pace during middle childhood, and children become much more
capable of making decision maintaining sustained and following plans. To achieve optimal growth
and development during middle childhood, nutritious and safe diets, essential nutrition services
and positive nutrition practices are vital for children to grow, learn and stay active. In contrast, poor
nutrition can delay children’s physical growth and development throughout childhood.

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Table 28: Interventions and implementation modality among children 5-9 years

Key interventions Implementation modality Place of delivery

Promoting healthy • Coordinate between health and education Ministries of education
school and nutrition sectors to develop and implement school and health, regional
environment legislations on healthy environment. education and health
bureaus,
Organizing awareness • Develop and implement guidelines for enabling
raising sessions for healthy environments in and around schools on woreda health and
teachers, parents and nutrition, food, health, hygiene, and physical education offices,
formal and informal food activities.
vendors in and around health facilities.
the school • Promote enforcement of policies/regulations
that protect adolescents from the marketing of schools,
unhealthy foods and beverages in schools and PTAs
beyond.
• Strategically utilize school clubs, outdoor
environment, mini media, and parents’
gatherings to promote healthy diet and other
relevant information.
• Organize awareness raising sessions for
teachers, parents and formal and informal food
vendors in and around the school.
Providing annual / • Deworm annually or bi-annually with Primary schools,
biannual deworming albendazole (400 mg) or mebendazole (500
services mg), to control and/or prevent anemia health facilities (health
in adolescents. The annual and biannual posts, health centers
deworming is recommended if the prevalence and hospitals)
of helminths infection is 20% - 50% and > 50%
respectively.
• Ensure collaboration among education and
health sectors in planning and implementation
of supplementation and deworming programs
during targeting, supply procurement and
distribution, monitoring, and reporting
activities.
Promoting healthy diet • Advocate for regular physical exercise in the Primary schools ( mini
and lifestyle school media, clubs)
Ensuring availability • Use school formal structures such as mini health facilities (health
of safe drinking water media, clubs, and non-school platforms like posts, health Centers,
in schools Promoting youth clubs 30 minutes per day for promoting and hospitals)
school, health and healthy diet and lifestyle.
nutrition packages,
feeding programs, • Ensure coordination between water, education
gardening, and WASH. and health bureaus to increase access to safe
potable water at health centers, health posts,
schools, and outreach sites.
• Promote school health and nutrition packages,
feeding programs, gardening, and WASH.
• Promote provision of diversified and healthy
meal in school feeding programs.

51
 Conducting nutrition • Create coordination between schools and • Pediatric OPD
education/counseling health facilities in targeting, assessing, and
and assessments linking children for nutritional assessment and • Health posts
counseling. • School health and
• Provide periodic nutritional assessment and nutrition clubs
Identifying and counseling for children 5-9 years.
promoting the prevention • School feeding
of harmful traditional • Provide regular trainings for teachers and programs (school
practices (food taboos) health workers. meals)

• Identify and promote the prevention of harmful

traditional practices (food taboos).
Advocate for the use of • Ensure the support of health and agriculture Federal and regional
fortified staples in school sectors to develop and implement guidelines for bureaus of education,
feeding programs and food handlers and other actors to realize food agriculture, and health,
the fortification of school safety and hygiene standards in schools.
meals schools and woreda
• Support the Ministry of Education to conduct level health and
food audits to ensure adherence to nutrition education offices
guidelines and quality.
• Promote homegrown feeding programs in
schools.
• Advocate for the use of fortified staples in
school feeding programs and the fortification of
school meals.
Incorporating nutrition Promote the incorporation of nutrition education in Federal ministries of
education in formal the curriculum from pre-primary to higher grades. health and education
curriculum
Protecting and Strengthen establishment of Mobile Health and IDP and refugee camps
supporting children in Nutrition Teams (MHNT) and outreach services
special situations such where there is a need and it is applicable. Orphanage centers/
as refugees, internally foster care , centers for
displaced persons, kids with special needs
People living with HIV
& disabilities, orphans,
street children etc.)

5.4.5. Infant and young child nutrition (IYCN) interventions in difficult

circumstances
The Global Strategy for Infant and Young Child Feeding (WHO/UNICEF 2003) highlights the difficult
circumstances in which infants and young children and their families require special attention
regarding feeding. These include exposure to HIV, emergencies, severe malnutrition, low birth
weight, migration, and internal displacement. Other social circumstances also include orphans and
children in foster care, children born to adolescent mothers and mothers suffering from physical
or mental disabilities, or mothers who are imprisoned or part of disadvantaged or otherwise
marginalized populations. In the Ethiopian context, this guideline focuses on low birth weight, HIV/
AIDS, emergencies, orphanage and vulnerable children (OVC), disability and illness.

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Nutrition interventions for Low-Birth-Weight infants

Very low or low birth weight infants should be fed breast milk unless there is a medical contra-
indication. Very low or low birth weight infants who can be breastfeed should be put to the breast
after birth as soon as possible. They should also be exclusively breastfed until they turn 6 months. A
cup should be used for those who need to be fed by an alternative oral feeding method.

Table 29: Interventions for Low-Birth-Weight infants

Age group/category Intervention/Essential action Place of delivery

< 32 weeks gestational • Keep the child warm through incubator or KMC. • Newborn intensive
age or care units (NICU) /
• Refer to the nearby hospitals. Hospitals
Weight < 1500 g (Very
low birth weight). • Feed using naso-gastric tube for expressed breast
milk.
32-34 weeks • Exclusively breastfeed on demand for babies who • Health centers and
can suckle the breast. health posts
or
• Counsel mothers on how to express breast milk. • Home
weight between 1499
– 2500 g1 (Low birth • Feed expressed milk using a cup
weight)
• Counsel mothers to frequently breastfeed when
suckling is established.
• Give around 60 ml/kg/day tobabies who are
on cup feeding (that is 60 ml of breast milk for
every kilogram of the baby’s weight every day)
and increase this by 20 ml/kg/day as the baby
demands more feeding.
• Keep the child warm through KMC.
Supplementing iron for • Provide ¼ tablet of iron (50mg) daily. • Hospitals
LBW babies
• Use cups for those who can feed orally.
• Insert nasogastric (NG) tubes for those unable to
take orally.
• Begin giving iron supplements at 2 months and
continue until the infant is on complementary
feeding. This should be in conjunction with
measures to prevent and control malaria.
Source: https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=342&section=1.5

Child nutrition in the context of HIV

Nutritional assessment and support should be integrated into the routine care of HIV-infected
children. Dietary interventions should consider issues of food security, quantity, and quality, as well
as absorption and digestion of nutrients.

Current evidence indicates that exclusive breastfeeding and the use of antiretroviral drugs greatly
reduce mother-to-child transmission (MTCT). Counseling and support to the mothers based on the
infant feeding options for HIV positive according to the National PMTCT guidelines is necessary.

53
Table 30: Child nutrition Interventions in the context of HIV positive mothers

Target group Interventions Essential action Place of delivery

0-6 months Promote exclusive • Counsel mothers on exclusive MNCH units in
breastfeeding breastfeeding up to 6 months. health centers,
hospitals and
• Counsel mothers to take their ARV CBNC
drugs.
• Use SBCC materials.
Provide replacement feeding Counsel mothers on how to prepare
for women who cannot safe replacement feeding.
breastfeed and choose
replacement.
6-24 months Introduce complementary • Counsel mothers on age- RMNCH units in
feeding at 6 months and appropriate optimal CF. hospital, health
continue breastfeeding centers
until 24months. • Organize cooking demonstration
sessions. and health posts

Source: https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=342&section=1.5

Nutrition interventions in emergencies

During emergencies such as floods, drought, conflict, earthquakes, disease and deaths among
under-five children are generally higher than any other age group. Morbidity and mortality may
be particularly high due to the combined impact of rampant communicable diseases and soaring
rates of undernutrition. The best food for all infants in difficult circumstances is their own mothers’
milk unless medically contraindicated, given the multiple benefits of breastfeeding. The use of
replacement feeding is recommended only when the mother is absent and unable to breastfeed.
Complementary feeding for children 6-23 months of age and age specific nutrition interventions for
children 2-9 years of age is also recommended.

Table 31: Interventions during emergency

Interventions Essential action

Protect, promote, and support breastfeeding. Use IYCF-E- guideline
Facilitate and create conducive environment. Establish BF corners, facilitate a tent or any favorable
place for BF.
Avoid separating mothers and their infants to Provide special attention to BF women; give priority in
facilitate continued feeding and care. providing shelter, food etc.
Be aware of accurate and up-to-date information Introduce yourself with national and global guidelines
about infant feeding policies, guidelines, and such as like BMS code directive for emergency
practices. response.
Promote appropriate, timely and safe Use IYCF-E- guideline.
complementary feeding.
Screen and treat children with acute malnutrition Use national guideline for the treatment of acute
(0-59 months) malnutrition

Nutrition in orphanage and vulnerable children (OVC)

An OVC is a child who is at high risk of lacking adequate care and protection due to parental death,
disease, disaster, or acute poverty. There is evidence that showed the prevalence of stunting, wasting
and underweight among the OVC was higher than their counterparts.

54
Table 32: Interventions for OVC

Interventions Place of delivery

Identify orphan centers and volunteer community groups and train on Orphanagess, grassroot
how to provide nutritious food to the OVC group. platforms, women’s and social
affairs office.
Identify the vulnerable group through respective sectors and facilitate Orphan centers, grassroot
these group to get protection and service through PSNP or any other food platforms, women’s and social
support in the area. affairs office
Source: Adapted from “Nina Berr, Yemisrach Nigatu & Nebiyu Dereje. Nutritional status among orphans and
vulnerable children aged 6 to 59 months in Addis Ababa, Ethiopia: a community-based cross-sectional study:
BMC Nutrition volume 7, Article number: 24 (2021).”

Child nutrition during common illnesses

Proper understanding of the appropriate IYCF actions in the context of different infectious diseases
is necessary.

Table 33: Interventions during common childhood illnesses

Interventions Age Essential action Place of

group delivery
children • Counsel mothers on frequent breastfeeding, increase the Health
0-6 frequency of BF >12 times in 24 hrs. centers,
months health posts,
• If the child is too sick to suckle council mother on
expression of breast milk and cup feeding Community
• Council mother on the benefits of breast milk help to fight
the sickness and regain weight
• Counsel on use of ITN in malaria area
children • Counsel mothers to continue breastfeeding until 24 Health
Ensure 6-59 months. facilities
essential months
feeding • Counsel mothers to give diversified, age-appropriate Community
practices complementary foods.
during illness
• Encourage small frequent and responsive feeding.
• Counsel mothers to increase the frequency and amount of
food during recovery.
• Supplement with vitamin A every six months.
• Counsel mothers on the use of ITN in malaria prone areas.
• Counsel on hygiene and sanitation.
5-10 • Counsel mothers to give diversified and frequent diet.
years
• Counsel mothers to increase the frequency and
amount of food during recovery.
• Counsel mothers on the use of ITN in malaria prone
areas.
• Counsel on hygiene and sanitation.
Source: Adapted from Guideline for Infant and Young Child feeding in Emergency for Ethiopia, 2021

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5.4.6. IYCN integration with key sectors and programs
To facilitate and ensure proper integration of IYCN actions with food system, the following directions
should be considered at different levels.
• The Ministry of Trade would encourage, facilitate, and support SMEs to ensure the availability
of diversified, healthy processed and fortified complementary foods.
• Authorized government sectors [Ethiopian Standards Agency (ESA) and Ethiopian Food and
Drug Authority (EFDA)] ensure that market-available processed, and premix products are
produced as per the national standard.
• Strengthen the coordination, facilitation, and support of regular platforms for joint planning,
implementation, and monitoring of nutrition-sensitive actions between the health and
agriculture extension service providers [development agents (DA)].
• Use the Scaling up Nutrition (SUN) Business Network (SBN) as a platform to spread awareness,
encourage, and involve private sector engagement in IYCN action including healthy, safe, and
nutritionally sound production and marketing.
• Ensure that all local and international NGOs have one plan for food system intervention
through proper alignment and convergence.

Health sector: Integrating the IYCN service with under-5 OPD, ECD, EPI, ANC, delivery, PNC, and FP
services in the health program is an opportunity to promote and improve child nutrition.
• Build the capacity of health workers for IYCN integration.
• Integrate IYCN services with other RMNCAYH services.
• Record the nutrition services during integrated service delivery.
• Integrate IYCN indicators into other health services, ISS, performance review and monitoring
activities.
• Integrate IYCN promotion activities with other health service promotion activities.
• Integrate IYCN with ECD service delivery at community and health facility levels.

Women’s and social affairs sector: Social protection improves the effectiveness and efficiency of
investments in development activities including nutrition. Currently, the government is working
vigorously on Productive Safety Net Program (PSNP) to reduce extreme poverty, scaling up of
Community Based Health Insurance (CBHI) to increase health service uptake and child protection to
ensure children’s survival, health, and well-being.
• Social workers at kebele level should support the timely linkage of a mother having children
under two years with moderate or severe malnutrition.
• Health extension workers are expected to identify lactating mothers timely and provide health
and nutrition services as a co-responsibility for temporarily direct support clients.
• Ensure that optimal breastfeeding and complementary feeding are promoted for TDS and
public work participants through tailored behavioral change communication sessions on the
ground.

56
• Prioritize households who have children for cash transfer and other livelihood support
programs under PSNP implementations supported by government and partners.
• Ensure that CBHI scheme members can access health services free of charge.
• Support and promote membership to CBHI scheme at all levels to help facilitate informational
campaigns, registration of members, collection of contributions, and monitoring of health
service providers.
• Strengthen childbirth registration services as part of a civil registration and vital events system
to improve access and utilization of health and nutrition services.
• Strengthen collaborative efforts between the vital events registration sector and women’s,
children’s, and youth affairs office to ensure timely communication for different social
protection services.
• Ensure that engagement of community and local level government structures is in place to
coordinate and follow the functionality of child protection policies.

Water and energy sector: WASH and IYCF integration can be ensured through promoting personal
hygiene practices, environmental sanitation and access to safe water to reduce morbidity and
mortality among children.
• MoWE will need to ensure urban and rural communities’ access to safe and adequate water;
Proper handling and treatment of clean water during scarcity need to be considered.
• Coordinate water treatment intervention to reach all children.
• Health service providers need to ensure proper handling of waste and environmental hygiene
and sanitation practices through promotion of improved latrines.
• Health service providers need to promote baby wash friendly initiatives in the community to
minimize enteropathy and other diarrheal diseases.
• Extension workers should promote proper hand washing practices at critical times.
• Ensure workforces of existing and new healthcare systems are receiving capacitated with
hygiene promotion strategies and approaches.

Agriculture sector: The food system’s improvement is key to the availability of diverse, safe, and
quality food for all. The role of the agriculture sector in the food system is critical, and it includes the
production of food sources such as poultry, crops, animals, vegetables, and fruit. Moreover, small-
and-medium-sized enterprises (SMEs) are an important venture to make available new and value-
added complementary foods and other healthy child food processing and marketing. A recent study
confirmed that small-and-medium-sized enterprises (SMEs) in sub-Saharan Africa produce, process,
or market some 70% of the nutritious food, such as fresh fruits and vegetables and animal-sourced
proteins, sold in low-income markets.

Education sector: Poor health and malnutrition result in the loss of a considerable number of
school days annually. Children obtaining proper nutrition exhibit better IQ and school performance
compared to children who feed inappropriately and who develop different forms of malnutrition.
School feeding and nutrition education is an important strategy for a healthy food environment,
helping school children, adolescents, and their communities to improve their diets and food choices.
It further helps to build their capacity to act as agents of change.

57
According to the National School Health and Nutrition Strategy;
• Schools should have gardens for demonstration purposes, serving as resource centers for
learning more about nutrition.
• In hotspot woredas, school feeding programs shall be in place and home-grown feeding
promoted to minimize breakfast and lunch skipping.
• Standards and regulations shall be developed by the relevant ministries (MOH-FDA or ESA) for
controlling food handlers and school feeding programs that cover storage, preparation, and
quality of food served to students.
• Different health services including deworming to students in schools shall be strengthened by
healthcare providers and school communities.
• The water sector needs to ensure school communities’ sustained access to adequate and safe
water.
• Personal and environmental hygiene need to be promoted in schools through construction of
gender sensitive latrines with handwashing facilities.
• Guidelines and curriculums should consider regular physical exercise to all school communities.
• School teachers and supervisors should be equipped with appropriate nutrition information for
pre-school and school-age children.
• Linkages shall be created and promoted between regular health and nutrition services and
school activities, including regular monitoring of the nutritional status of children.

Note: The MOH should ensure that the coordination platforms work regularly and effectively as per
the indicators of IYCN related nutrition sensitive actions.

58
6. Communication for Adolescent, Maternal,
Infant and young child Nutrition
6.1. Introduction
Social and Behavioral Change Communication (SBCC) is a systematic application of interactive,
theory-based, and research-driven communication processes and strategies to address tipping points
for change at individual, community, and social levels. Communication in nutrition is the sharing,
receiving and understanding of instructions, concepts, opinions and information about nutrition
issues and reacting to those issues. By its very nature, nutrition requires the engagement of various
stakeholders having varying responsibilities and competing priorities. Therefore, communication is
crucial to coordinate activities through these stakeholders and ensure uptake of essential nutrition
messages with the targeted population.

6.2. Objectives
General Objective
• Improve AMIYCN services uptake through continued and quality advocacy, social mobilization,
and behavioral change communication at all levels.

Specific Objectives
• Advocate and lobby policy makers for their political attention and resource allocation for
AMIYCN activities at all levels.
• Conduct public awareness on AMIYCN issues through social mobilization.
• Improve knowledge, attitude, and practices of AMIYCN interventions at individual, community
and service delivery levels.

6.3. Implementation strategies

Improving feeding and caring practices along with the comprehensive food and nutrition service
delivery at all levels requires strong advocacy, lobbying, social mobilization, and behavior change
communication activities.

59
 ADVOCACY

O
C IAL M BILIZAT
SO IO
IOR CHAN

N
AV UNICAT G
M I

CO H

E N
M

B E

O
PLANNING CONTINUUM SERVICES & PRODUCTS
Individual & Community:
Multimedia, Participatory

ces
Nat

Approaches

n
lia
i on

Al
to d
al

c om an
ps
m unity: partnershi
Po
let t
i cal
t men
and So i
cial Comm

SOURCE: Adapted from McKee, N. Social Mobilization and Social Marketing in Developing Communities
(1992)

Figure 3: Communication approaches/implementation strategies

Advocacy: is a process to influence decisions within political, economic, social systems and
institutions. It includes activities to influence policy, laws and budget based on evidence. Advocacy
could be undertaken through activities such as media campaigns, public speaking, and publishing
research.

Lobbying: is a specialized form of advocacy. It is a strategic, planned, and informal way of influencing
decision-makers. Characteristics of lobbying are open (two-way) communication, influencing by
linking the interests of different stakeholders, creating win-win situations, and investing in long-term
relationships with decision-makers.

Social mobilization: is a process that raises awareness and motivates people to demand change
or a particular development. Social mobilization mostly used by the participation of institutions,
community networks, civic societies, and religious groups to raise demand for or sustain progress
toward a development objective. It usually is a broad-scale movement and engages a large number
of people in action. Social mobilization is most effective when composed of a mix of advocacy,
community participation, partnerships and capacity building activities for sustained action and
behavior change.

Behavioral change communication: refers to a stage of awareness/knowledge/practice of desired

behaviors to help position communication activities and messages according to the “Stages of
Behavior Change.’’ It involves face-to-face dialogue with individuals or groups to inform, motivate,
solve problems or plan with the objective to promote and sustain behavior change. Social mobilization
and behavior change communication will focus on igniting change at community, household, and
individual levels.

60
Counseling: is the use of an interactive helping process focusing on the needs, problems or feelings
of the client and significant others to enhance or support coping and problem solving.

For Effective counseling approaches;

The following 3-Steps will help to counsel mothers or caregivers about infant and young child feeding.
The 3-Steps are Assess, Analyze and Act (UNICEF, infant and young child feeding counseling guide
for community workers).

Step 1: Assess: ask, listen, and observe

• Greet the mother (or caregiver), using friendly language and gestures.
• Ask some initial questions that encourage her (or him) to talk.
• Listen to what is being said and observe what is going on using your listening, learning, building
confidence and giving support skills.
• Assess the age-appropriate feeding practice(s) and the condition or health of the child and
mother (or caregiver).

Step 2: Analyze: identify and prioritize difficulties

• Decide if the feeding you observe is age-appropriate and if the condition or health of the child
and mother (or caregiver) is good.
• If there are no apparent difficulties, praise the mother (or caregiver) and focus on providing
information needed for the next stage of the child’s development.
• If one or more feeding difficulties are present, or the condition or health of the child or mother
(or caregiver) is poor, prioritize the difficulties.
• Answer the mother’s (or caregiver’s) questions if any.

Step 3: Act: discuss, suggest a piece of relevant information, and agree on doable action
• Depending on the factors analyzed above, select a piece of information to share with the
mother or caregiver that is most relevant to her or his situation.
• Be sure to praise the mother or caregiver for what she or he is doing well.
• Present options for addressing the feeding difficulty or health condition of the child or
caregiver in terms of small do-able actions. These actions should be time-bound (within the
next few days or weeks).
• Share key information with the mother or caregiver, using the appropriate FHG, counseling
cards or take-home brochures and answering questions as needed.
• Help the mother or caregiver select one option that she or he agrees to try in order to address
or overcome the difficulty or condition that has been identified. This is called reaching-an-
agreement.
• Suggest where the mother or caregiver can find additional support. Refer them to the nearest
health facility if appropriate and/or encourage participation in WDA meetings and other
educational talks in the community.

61
• Confirm that the mother or caregiver knows where to find a community development army
and/or other health workers.
• Thank the mother or caregiver for her or his time.
• Agree on when you will meet again, if appropriate.

Table 34: SBCC Strategy, Problems, target audiences, expected outcomes and beneficiary from
SBCC interventions

Strategy Problem Target audience Expected Outcomes Beneficiaries

Advocacy / • Despite continued • Administrative • Nutrition owned • Children
lobbying efforts, malnutrition offices by decision makers under 10
rates in Ethiopia are at all levels years
unacceptably high. • Sectors offices
• Awareness on • Adolescents
• Nutrition lacks • Partners nutrition increased
priority and at all levels • PLW
• Private sectors
attention at all • AMIYC with
levels including • Community • Leadership,
commitment, special
media. leaders situations
coordination, and
• No nutrition • Media action increasedat
structure at facility all levels
and community • CSOs/CBOs
levels. • Nutrition structure
• Academia created
• The nutrition
workforce is • Adequate nutrition
inadequate. workforce
deployed
• Coordination in
nutrition among • Adequate budget
actors is sub- for nutrition
optimal. allocated

• Financial and • Private sector

organizational involvement
resources are strengthened
scarce.
• Private sector
involvement is
minimal.

62
Social • High prevalence of • Mothers/ • Prevalence of • Children
mobilization stunting, wasting Caregivers of stunting, wasting, under 10
and underweight children under 10 underweight, years
anemia and other
• High prevalence • Husbands/ micronutrient • Adolescents
of iron deficiency partners of PLW deficiencies
anemia, iodine • PLW
reduced
deficiency disorders • Relatives of PLW
• AMIYC with
(IDD), vitamin A • Neighbors and • Nutrition service special
deficiency, folate peers of caregivers coverage (GMP, situations
deficiency and and mothers of VAS, Deworming,
other micronutrient children under 10 Nutrition screening
deficiencies and counseling,
• Community media weight gain
• Poor health monitoring)
seeking behavior • Traditional healers improved
for nutritional
problems • Teachers, • dietary diversity
students, and and meal
• Low coverage of Parent-Teacher frequency
AMYCN services Associations improved
• Sub-optimal • Community, • Animal source
breastfeeding religious, clans, food consumption
practices kebele leaders and improved
elders
• Poor feeding and • Consumptions
caring practices • Social workers of fruits and
• Food taboos among • Women’s groups / vegetables
AMIYC structures improved

• Poor consumption • Traditional birth • Awareness

of fruit and attendants regarding of food
vegetables among taboos raised
AMIYC • Small shop owners
• Pre-lacteal feeding
• Poor consumption • Faith-based and bottle-
of animal source organizations feeding practices
foods such as meat, • abandoned
Youth structures
fish, milk, eggs • Optimal
among AMIYC • Higher education breastfeeding
institutions practices
• Grassroots • Complementary
community feeding practices
structures improved

63
 BCC • Inadequate • Mothers/fathers • Nutrition service • U10
knowledge on or care takers awareness among children
breastfeeding, mothers/fathers
complementary • Adolescents or care takers • Adolescents
feeding and GMP improved (10-19 yrs)
• Non-pregnant
• Poor nutritional women • Cooking • PLW
service utilization • PLW demonstration • Highly
skills improved vulnerable
• Sub-optimal • Displaced
cooking • Optimal feeding AMIYC
mothers/ care
demonstration skills takers and caring
practices
• Poor caring and • Adolescents with
feeding practices special needs (e.g., • Healthy eating
HIV/TB patients, behavior
• Unhealthy eating
behavior pregnant girls) • Service coverage
• PLW with special improved
• Low coverage
& quality of needs • Dietary diversity
adolescent and • Street children and minimum
youth health (AYH) meal frequency
services • Orphans improved
• Low awareness of • School community • Fruit, vegetable
early childhood care and animal source
& development / • Health care food consumption
ECCD/ providers improved
• Weak school health • WASH practices
and nutrition improved
programs
• Regular health
• Food taboos education
programs
• Pre-lacteal feeding increased
• Bottle feeding
• Formula feeding
• Poor dietary
diversity and meal
frequency
• Inadequate
consumption of
fruits, vegetables,
and animal source
foods
• Poor WASH
practices

64
Table 35: SBCC materials and channels

Strategy SBCC materials Dissemination channels

Advocacy and √√ Factsheets √√ Print media
lobbying
√√ Policy briefs √√ Electronic media
√√ Banners √√ Government structures (National to
kebele levels)
√√ Brochures
√√ CSO structures
√√ Presentations
√√ Business networks
√√ Advocacy videos
√√ Partner networks
√√ Learning visits
√√ Success stories
√√ Scientific conferences
Social mobilization √√ Banners √√ Print media
√√ Brochures √√ Electronic media
√√ Flyers √√ Local radios/Community radios
√√ Billboards √√ Educational radios
√√ Stickers √√ Social media
√√ TV/Radio spots √√ Community structures (Ekub, mahiber,
edir, religious networks, clan networks,
√√ TV/radio Messages woman machineries)
√√ Dramas √√ Government structures (National to
√√ Presentations kebele levels)
√√ Press release √√ CSO structures
√√ Roundtable discussions √√ Business networks
√√ Panel discussions √√ Partner networks
Behavioral change √√ Posters √√ Health facilities
communication
√√ Brochures √√ Households
√√ Stickers √√ Print media
√√ Pictures √√ Government structures (National to
kebele levels)
√√ Guidelines
√√ Community structures
√√ Job aids
√√ Youth centers
√√ Quick reference books
√√ School mini media
√√ Calendars
√√ School community
√√ Digital technologies
(mobile text messages, √√ CSO structures
mobile applications,
audio books, pico √√ Private sector
projectors) √√ Partner networks
√√ Innovators
65
7. Monitoring, Evaluation, Accountability and
Learning
7.1. Introduction
The monitoring and evaluation section of this guideline provides guidance on monitoring the
performance of the AMIYCN interventions across all levels. The aim of monitoring and evaluation is
to improve service provision by measuring the progress of output, outcome and impact indicators.
The indicators included in this guideline are affiliated with the national HSTP II targets and the
national food and nutrition strategic plan (2020-2030) which is aligned with the global sustainable
development goals (SDGs) set for 2030.

7.2. Objectives
1. Monitor implementation of AMIYCN interventions and measure progress (inputs, activities,
outputs, outcome and impact) against established indicators.

2. Summarize lessons learned, command of accountability and the decisions taken on the
AMIYCN activities and their effect on the progress.

7.3. Planning
Planning is the process of thinking regarding the activities required to achieve a desired goal. Before
initiating the implementation of AMIYCN at each level, appropriate monitoring and evaluation plan
should be developed. It is important to set measurable targets with clear objectives and activities in
line with this guideline.

7.4. Monitoring
Monitoring is a continuous process of collecting and analyzing program information, and comparing
actual performance against the planned activities in order to determine how well the intervention
are being implemented. It utilizes the data generated by the program itself and makes comparisons
across individuals and types of interventions so that actions can be taken. The existence of a reliable
monitoring system is essential for evaluation and correction of deficiencies as quickly as possible.

The Implementation of AMIYCN services can be monitored in addition to the routine health information
tracking system by forming a technical working group that would regularly and frequently follow the
progress, conduct strengthening performance reviews, integrated supportive supervisions, site visits
and apply timely feedback systems.

7.5. Documentation, reporting and feedback

A standard recording and reporting format with the selected AMIYCN indicators will be used for
capturing and reporting AMIYCN performance parameters. Recording and reporting formats include
nutrition cards, registers and tally sheets that are available at health posts, health centers and
hospitals according to the type of service delivery. These are the comprehensive integrated nutrition
service (CINS) register, adolescent nutrition registration, pregnant and lactating women (PLW)

66
nutrition screening register, therapeutic feeding program (TFP) register, MAM treatment for 6-59
months register and MAM treatment for PLW register and other nutrition service delivery related
registration templates. Other nutrition sensitive intervention indicators will be monitored using a
multi-sectoral scorecard. The selected indicators are expected to measure the service provision
with regard to the AMIYCN interventions. Following the reports, feedback mechanisms should be
put in place at all levels to improve the routine service delivery schemes from woreda to national
levels, ensure appropriate data handling, interpreting and use for decision making purposes. Ways
of providing feedback include supportive supervision and review meetings.

7.6. Quality improvement

Continuous quality assessment activities will be employed to achieve AMIYCN outcomes and generate
evidence based AMIYCN interventions. Hence, continuous monitoring and evaluation will take place
to improve AMIYCN services using standard national quality improvement methodologies.

7.7. Data quality assurance and utilization

To monitor data quality, a set of standard indicators in AMIYCN that will be employed at all levels
for routine reporting through facility information systems and quantifying problems around
data completeness, timeliness, consistency and accuracy. Local levels will apply simple analysis
mechanisms, which will help to improve the routine service provisions in AMIYCN, while regional
and federal levels will apply advanced data analytics to produce estimates, design and intervention
modalities, synthesize research findings and articulate insights for coordinated development and
revision of policies and strategies.

7.8. Accountability
Different accountability tools will be applied, including but not limited to community score cards,
community dialogues; joint monitoring, confidential complaints, and feedback mechanisms.
In addition, cultivating accountability mechanisms such as demonstration, reward, integrity,
responsiveness will be developed and employees shall be encouraged to share both successes
and challenges, measure results and explain to internal and external stakeholders, address non-
performance and recognize good performance and integrity.

7.9. Learning
Approaches to guide in learning include comparing results across time to determine which
interventions are used to achieve the set goals and expected results, facilitation of both formal and
informal learning will be facilitated for sharing experiences (positive and negative) with relevant
stakeholders using different platforms such as peer learning, performance review meetings,
experience sharing visits, workshops to reflect on lessons learned, and documentation of best
practices.

7.10. Evaluation
Systematic and objective evaluation will be conducted across the program from the design stage to,
implementation and results achieved to determine overall worth or significance of interventions.
This will help to generate data for decision-makers to identify ways to achieve more of the desired

67
results. The AMIYCN activities and interventions will be evaluated for their relevance, effectiveness,
efficiency, and impact in light of specified objectives. This evaluation will be conducted on quarterly,
biannually, and yearly bases. The detailed evaluations input, activity, output, outcome, and impact
indicators are listed on Table 36.

7.11. AMIYCN M&E Framework

MONITORING EVALUATION
( Weekly, Monthly, Quarterly, Annually) ( baseline, Widterm, end term)

Input Activities Outputs Outcomes Impacts

Available resourc Actions taken/ Feasible services Results likely to Final program
including financia works performed the program be achieved when goals, typically
l human, sui:Py to transform produces or beneficiaries achieved in the
and other inputs into delivers use outputs long-term
materials outputs

Implementation Result

LEARNING & ACCOUNTABILITY

Figure 4: AMIYCN M&E Framework

68
 Table 36: AMIYCN indicators for monitoring and evaluation

S.N Indicator Indicator Description Numerator Denominator Data source Frequency

of
Type reporting
Maternal Nutrition indicators
Outcome Proportion of No. of pregnant No. of pregnant Total No. of pregnant women who Survey Five years
pregnant women women who women who were included in the survey
who consumed at consumed one consumed one
least one additional additional meal additional meal
meal during pregnancy during pregnancy
Output Proportion of No. of pregnant No. of pregnant Total estimated No. of pregnant HMIS Monthly
pregnant women women who were women who were women
screened for acute screened for acute screened for acute
malnutrition malnutrition malnutrition
Outcome Prevalence of anemia No. of pregnant No. of pregnant Total No. of pregnant women who Survey Five Years
among pregnant women who were women who were were included in the survey
women anemic anemic
Output Proportion of No. of pregnant No. of pregnant Total estimated No. of pregnant HMIS/Survey Monthly/
pregnant women women who women who women Five years
who received at received at least received at least
least 90+ IFA tabs 90+ IFA tabs 90+ IFA tabs
supplementation supplementation supplementation
Output Proportion of No. of pregnant No. of pregnant Total estimated No. of pregnant HMIS/Survey Monthly/
pregnant women women who took women who took women Five years
who received deworming tablets deworming tablets
deworming tablets after first trimester
Output Proportion No. of pregnant No. of pregnant Total No. of pregnant women who Survey Five years
of pregnant women who got women who got were included in the survey
women who got preconception preconception
preconception nutrition counseling nutrition counseling
nutrition counseling services services
services

69
70
Output Proportion No. of pregnant No. of pregnant Total No. of pregnant women who Survey Five years
of pregnant women who got women who got were included in the survey
women who got preconception preconception Folate
preconception Folate Folate supplementation
supplementation supplementation
Output Proportion of No. of pregnant No. of pregnant Total estimated No. of pregnant Survey/HMIS Five years/
pregnant women women who were women who women monthly
counseled for counseled on received counseling
nutrition during ANC nutrition during service on nutrition
ANC during ANC
Output Proportion of No. of lactating No. of lactating Total estimated No. of lactating Survey/HMIS Five years/
lactating mothers mothers who were mothers who were mothers monthly
screened for acute screened for acute screened for acute
malnutrition malnutrition malnutrition
Outcome Proportion of No. of lactating No. of lactating Total No. of lactating mothers who Survey Five years
lactating mothers mothers who mothers who were included in the survey
who are underweight are underweight are underweight
(BMI<18.5) (BMI<18.5) (BMI<18.5)
Outcome Proportion of No. of lactating No. of lactating Total No. of lactating mothers who Survey Five years
lactating mothers mothers who mothers who were included in the survey
who consumed at consumed two consumed two
least two additional additional meals additional meals
meals during the first during lactation
6 months of
lactations
Output Proportion of PLWs No. of PLWs that No. of PLWs that Total estimated No. of PLWs who HMIS Monthly
that are linked to are linked to are linked to are targeted for PSNP
PSNP’s temporary PSNP’s temporary PSNP’s temporary
direct cash or food direct cash or food direct cash or food
support with soft support with soft support with soft
conditionality conditionality conditionality
Output Proportion of women No. of susceptible No. of women linked Total No. of susceptible women Survey Five Years
linked to an income women linked to to income generating who were included in the survey
generating activities income generating activities
activities
 Output Proportion of non- No. of non- No. of non-pregnant Total No. of non-pregnant and non- Survey Five
pregnant and non- pregnant and non- and non-lactating lactating women (-49 years of age)
lactating women lactating women women (15-49 who were included in the survey
(15-49 years of age) (15-49 years of age) years of age) who
who were screened who were screened were screened
and counseled on and counseled on and counseled on
nutrition nutrition nutrition
Output Proportion of No. of pregnant No. of pregnant Total No. of pregnant women in all HMIS Monthly
pregnant women in women in all women in all malaria malaria endemic areas
all malaria endemic malaria endemic endemic areas
areas who slept areas who slept who slept under
under insecticide- under insecticide- insecticide-treated
treated treated nets (ITNs)
nets (ITNs)
nets (ITNs)
Output Presence of Presence of No. of health Total No. of health facilities Admin report Annually
preconception health preconception facilities with
and nutrition service health and nutrition preconception
delivery platform in service delivery health and nutrition
health facilities platform service delivery
platform
Output Proportion of Every pregnant Number of Total No. of pregnant women HMIS Monthly
pregnant women woman who visited pregnant women
who weighed during the ANC should who measured her
pregnancy measured her pregnancy weight
weight to check her
weight gain
Outcome Proportion of No. of pregnant No. of pregnant Total No. of pregnant women HMIS Monthly
pregnant women women who gained women who gained
who gained at least at least 10-12kgs at least 10-12kgs
10-12kgs during during pregnancy during pregnancy
pregnancy (single (single preg. ) (single preg. )
preg. )
Output Proportion of PLW No. of PLW who No. of PLW uses Total No. of PLW who were included Administration Annually
who uses clean water uses clean water for clean water for in the survey report
for drinking drinking drinking

71
72
CHILD NUTRITION
Outcome Proportion of new-born No. of new-born babies to No. of new-born Total No. of new- Survey Five years
babies to whom breastfeeding whom breastfeeding was babies to whom born babies who
was initiated within one hour initiated within one hour of breastfeeding was were included in
of birth birth initiated within one the survey
hour of birth
Outcome Proportion of new-born babies No. of new-born babies who No. of new-born Total No. of new- Survey Five years
who were fed colostrum were fed colostrum babies who were born babies who
fed colostrum were included in
the survey
Outcome Proportion of infants No. of infants exclusively No. of infants Total No. of Survey Five years
exclusively breastfed for 6 breastfed for 6 months (180 exclusively breastfed infants under six
months (180 days) days) for 6 months (180 months who were
days) included in the
survey
Outcome Proportion of children 12–23 No. of children who No. of children Total No. of Survey Five years
months of age who were fed continued breastfeeding 12- 12–23 months of children 12 to 23
breast milk 24 months of age age who were fed months of age
breast milk during
during the previous day. the previous day.
Outcome Proportion of children who No. of children who received No. of children who Total No. of Survey Five years
received pre-lacteal feeding pre-lacteal feeding received pre-lacteal children aged less
feeding than six months in
the survey
Output Proportion of GMP No. of children under 2 years No. of GMP Total estimated HMIS Monthly
participation among children of age who participated GMP participation among No. of under 2
under 2 years of age services children under 2 children
years of age
Output Proportion of children with No. of children with growth No. of children with Total No. of HMIS Monthly
growth faltering linked to faltering linked to treatment growth faltering children who
treatment and care services and care services linked to treatment were monitored
and care services and have growth
faltering
 Output Proportion of infants of No. of infants of 0-6 months No. of infants of 0-6 Total estimated HMIS Monthly
0-6 months screened screened and identified for months screened No. of infants 0-6
and identified for acute acute malnutrition and identified for months
malnutrition acute malnutrition
Output Proportion of infants of No. of infants of 0-6 months No. of infants of 0-6 Total No. of HMIS Monthly
0-6 months with acute with acute malnutrition months treated for infants of 0-6
malnutrition treated treated acute malnutrition months identified
with acute
malnutrition
Outcome Proportion of children who No. of children who have No. of children who Total No. of Survey Five years
have 5 or more food groups consumed 5 or more food have consumed 5 or children who were
out of 8, where at least one groups out of 8, where at more food groups included in the
of the food groups is animal least one of the food groups out of 8, where survey
source food is animal source food at least one of
the food groups is
animal source food
Outcome Proportion of children with No. of children with No. of children Total No. of Survey Five years
minimum acceptable diet minimum acceptable diet with minimum children who were
that is with minimum meal acceptable diet included in the
frequency and minimum diet survey
diversity
Outcome Proportion of infants who No. of infants who start No. of infants Total No. of Survey Five years
start complementary feeding complementary feeding at 6 who start infants who were
at 6 months months complementary included in the
feeding at 6 months survey
Output Proportion of children with No. of children with special No. of children Total No. of Admin report Quarterly
special needs who have needs who have received with special needs children with
received treatment for acute treatment for acute who have received special needs
malnutrition malnutrition treatment for acute
malnutrition

73
74
Output Proportion of children 24- No. of children 24-59 months No. of children 24- Total No. of Survey Five years
59 months in PSNP areas in PSNP areas with access to 59 months in PSNP children 24-59
with access to nutrition and nutrition and health services areas with access to months in PSNP
health services (screening, (screening, counseling and nutrition and health areas that were
counseling and treatment) treatment) services (screening, included in the
counseling and survey
treatment)
Output Proportion of children 6-59 No. of children 6-59 months No. of children 6-59 Total No. of Survey Five years
months who received 2 doses who received 2 doses of months of age who children 6-59
of vitamin A in the last year vitamin A in the last year received 2 doses of months of
vitamin A in the last age who were
year included in the
survey
Output Proportion of children No. of children screened No. of children Total No. of Admin report Monthly
screened by Family MUAC in by Family MUAC in the screened by Family children screened
the community level for acute community level for acute MUAC at the by Family MUAC
malnutrition identification and malnutrition identification community level for at the community
linkage and linkage acute malnutrition level for acute
identified and linked malnutrition
Output Proportion of children under No. of children under the age No. of children Total estimated HMIS Monthly
the age of five screened for of five screened for acute under the age of No. of children
acute malnutrition malnutrition five screened for under the age of
acute malnutrition five
Output Treatment outcome for Treatment outcome for Treatment outcome Total No. of HMIS Monthly
management of severe acute management of SAM in for management children under
malnutrition in children under children under the age of 5 of severe acute the age of five
the age of five /disaggregated by recover, malnutrition in with severe acute
death, default, transfer/ children under malnutrition
the age of five / admitted for
disaggregated by treatment
recover, death,
default, transfer/
 Output Proportion of children aged No. of children aged 24-59 No. of children aged Total estimated HMIS Monthly
24-59 months that have months that have undergone 24-59 months that No. of children
undergone quarterly growth quarterly growth monitoring have undergone aged 24-59
monitoring (weight and height (weight and height quarterly growth months
measurement) measurement) monitoring
(weight and height
measurement)
Outcome Diet diversity score for No. of children who have No. of children who Total No. of Survey Five years
children of 24-59 months consumed 4 or more food have consumed 4 or children who were
groups out of 7, where at more food groups included in the
least one of the food groups out of 7, where survey
is animal source food at least one of
the food groups is
animal source food
Outcome Prevalence of anemia in No. of children 6-59 months No. of children 6-59 Total No. of Survey Five years
children of 6-59 months that are anemic months that are children 6-59
anemic months who were
included in the
survey
Output Proportion of children of No. of children of 24 No. of children Total No. of HMIS Monthly
24 -59 months dewormed -59 months dewormed of 24-59 months children 24 -59
biannually biannually dewormed months of age
biannually
Output Proportion of 6-10 years No. of 6-10 years old children No. of 6-10 years Total No. of Survey Five years
old children who were who were assessed and old children who children 6-10
assessed and counseled for counseled for malnutrition were assessed for years old that
malnutrition malnutrition were included in
the survey
Output Proportion of children 6-10 No. of children 6-10 years No. of children Total estimated HMIS Monthly
years old who accessed old who accessed nutritional 6-10 years old who No. of children
nutritional services services (treatment) accessed nutritional 6-10 years old
(treatment) services (treatment) (who visited)

75
76
Outcome Prevalence of vitamin A Vitamin A deficiency among No. of children Total No. of Survey Five years
deficiency among children children 6-10 years old 6-10 years old with children 6-10
6-10 years old vitamin A deficiency years old that
were included in
the survey
Outcome Prevalence of Iodine No. of children 6-10 years No. of children Total No. of Survey Five years
deficiency (urinary iodine) old with Iodine deficiency 6-10 years old with children 6-10
among children 6-10 years old (urinary iodine) Iodine deficiency years old that
(urinary iodine) were included in
the survey
Outcome Prevalence of zinc deficiency No. of children 6-10 years old No. of children 6-10 Total No. of Survey Five years
among children 6-10 years old with zinc deficiency years old with zinc children 6-10
deficiency years old that
were included in
the survey
Output Coverage of biannual No. of school and out-of- No. of school and Total No. of school Survey Five years
deworming for school children school children aged 6-10 out-of-school and out-of-school
and out-of-school children years old that dewormed children aged children aged 6-10
aged 6-10 years old biannually 6-10 years old years old that
that dewormed were included in
biannually the survey
Output Proportion of students No. of students benefiting No. of students Total No. of Admin report Annually
benefiting from school feeding from school feeding benefiting from students from
programs programs school feeding targeted schools
programs
outcome Proportion of children born No. of children born with No. of children born Total no. of
with LBW LBW with LBW children born
in the Health
facilities
 ADOLESCENT NUTRITION
Outcome Proportion of adolescents No. of adolescents with BMI No. of adolescents Total No. of Admin report Annually
with BMI for Age<-2SD for Age < -2SD with BMI for Age < adolescents who
-2SD were included in
the survey
Outcome Proportion of adolescents No. of adolescents with No. of adolescents Total No. of Admin report Annually
with HAZ <-2SD HAZ<-2SD with adolescents who
were included in
HAZ<-2SD the survey
Outcome Prevalence of adolescent girls No. of adolescent girls who No. of adolescent Total No. of Survey Five years
who became pregnant before became pregnant before girls who became adolescents who
turning 24 years turning 24 years pregnant before were included in
turning 24 years the survey
Outcome Proportion of married No. of married adolescent No. of married Total No. of Survey Five years
adolescent girls under 21 girls under 21 years of age adolescent girls adolescents who
years of age under 21 years of were included in
age the survey
Output Proportion of adolescents No. of adolescents linked to No. of adolescents Total No. of Survey Five years
linked to microfinance/IGA microfinance services linked to adolescents who
services microfinance were included in
services the survey
Outcome Proportion of adolescents No. of adolescents who No. of adolescents Total No. of Survey Five years
who consumed diversified consumed diversified (at who consumed adolescents who
food (at least 5 food groups least 5 food groups out of diversified (at least were included in
out of 10) 10) 5 food groups) the survey
Outcome Proportion of adolescents (10- No. of adolescents (10-19 No. of adolescents Total No. of Survey Five years
19 years old) with goiter years old) with goiter (10-19 years old) adolescents who
with goiter were included in
the survey
Outcome Prevalence of anemia among No. of adolescents aged 10- No. of adolescents Total No. of Survey Five years
adolescents aged 10-19 19 years that are anemic aged 10-19 years adolescents who
that are anemic were included in
the survey

77
78
Output Proportion of adolescents No. of adolescents aged No. of adolescents Total No. of Admin report Annually
aged 10-19 who received 10-19 years who received aged 10-19 years adolescents who
deworming tablets deworming tablets who received were included in
deworming tablets the survey
Output Proportion of adolescent girls No. of adolescent girls No. of adolescent Total No. of Admin report Annually
supplemented with weekly supplemented with weekly girls supplemented adolescents who
iron folic acid iron with folic acid with weekly iron were included in
with folic acid the survey
Output Proportion of adolescents No. of adolescents with No. of adolescents Total No. of Survey Five years
with special situations who special situations (HIV/AIDS, with special adolescents with
benefited from nutritional obesity, undernourishment, situations (HIV/ special situations
services substance abuse, mental AIDS, obesity, who were
health and eating undernourishment, included in the
disturbances) who benefited substance abuse, survey
from nutritional services mental health and
eating disturbances)
who benefited from
nutritional services
Output Proportions of adolescents No. of adolescents who No. of adolescents Total No. of HMIS Quarterly
who received routine received routine nutritional who received adolescents who
nutritional assessment and assessment and counseling routine nutritional were included in
counseling services at health services at health facilities assessment and the survey
facilities counseling services
at health facilities
NUTRITION FOR SPECIAL NEED
Output Proportion of PLWs in No. of PLWs in IDP camps No. of PLWs in Total no. of PLWs
IDP camps who received who received nutritional IDP camps who in IDP camps
nutritional counseling and counseling and support received nutritional
support counseling and
support
Outcome Proportion of PLWs with MDR No. of PLWs with MDR TB No. of PLWs with Total No. of PLWs Admin report Monthly
TB who were screened and who were screened and MDR TB who were with MDR TB
received therapeutic feeding received therapeutic feeding screened and
received therapeutic
feeding
 Outcome Proportion of clinically No. of clinically No. of clinically Total No. HMIS Monthly
undernourished WRA with undernourished people with undernourished of clinically
HIV on ART who received HIV on ART who received people with HIV on undernourished
therapeutic/supplementary therapeutic/supplementary ART who received people with HIV
foods foods therapeutic/ on ART
supplementary
foods
Output Proportion of WRA with HIV/ No. of WRA with HIV/ No. of WRA with Total No. of WRA Survey Five years
AIDS, TB or other infectious AIDS, TB or other infectious HIV/AIDS, TB or with HIV/AIDS, TB
diseases and malnutrition who diseases and malnutrition other infectious or other infectious
are linked to PSNP who are linked to PSNP diseases and diseases and
malnutrition who malnutrition who
are linked to PSNP were included in
the survey
Output Proportion of WRA with NCDs No. of WRA NCDs patients No. of WRA NCDs Total No. of WRA Survey Five years
screened and counseled on screened and counseled on patients screened screened in the
nutritional status nutritional status and counseled on survey
nutritional status
Outcome Proportion of WRA with No. of WRAs that were No. of WRA with Total No. of Survey Five years
obesity/overweight screened and have obesity/ obesity/overweight WRA that were
overweight included in the
survey
Output Proportion of WRA with No. of WRA with No. of WRA with Total No. of Survey Five years
hypertension hypertension hypertension WRA that were
included in the
survey
Output Proportion of WRA with No. of WRA with diabetes No. of WRA with Total No. of Survey Five years
diabetes mellitus mellitus diabetes mellitus WRA that were
included in the
survey
Output Proportion WRA with diet No. of WRA with diet related No. of WRA with Total No. of WRA Admin report Annually
related NCDs who received NCDs who received clinical diet related NCDs with diet related
clinical and dietary care and dietary care who received NCDs
clinical and dietary
care

79
80
Outcome Proportion of WRA who No. Of WRA who consume No. of WRA who Total WRA that Survey Five years
consume fruits at least five fruits at least 5 times a week consume fruits at were included in
times a week least five times a the survey
week
Outcome Proportion of WRA who No. of WRA who consume No. of WRA who Total No. of Survey Five years
consume vegetables at least vegetables at least five times consume vegetables WRA that were
five times a week a week at least five times a included in the
week survey
Outcome Proportion of PLW with No. of PLW with adequate No. of PLW Total No. of Survey 5 years
adequate knowledge about knowledge about safe food with adequate individuals that
safe food preparation preparation knowledge were included in
about safe food the survey
preparation
Output Percentage of households Percentage of households No. of households Total No. of Survey Every 5
using adequately iodized salt using adequately iodized salt using adequately households using years
(>15 PPM) iodized salt (>15 salt that are
PPM) included in the
survey

FACILITY
Output Proportion of health facilities No. of health No. of certified Total No. of Admin report Annually
implementing BFHI facilities health facilities health facilities
implementing implementing BFHI implementing
BFHI that are BFHI
certified
Outcome Presence of enforced regulations guidelines Presence No. of enforced Total available Admin report Annually
that discourage advertisements of of enforced regulations media outlets
unhealthy di­ets, beverages and behaviors regulations guidelines that
guidelines that discourage
discourage advertisements of
advertisements unhealthy di­ets,
of unhealthy beverages and
di­ets, beverages behaviors
and behaviors
 Outcome Proportion of private health institutions No. of private No. of private Total No. of Admin report Annually
providing nutrition services for their clients health health institutions private health
institutions providing nutrition institutions
providing services their clients providing services
nutrition for their clients
services ftheir
clients
Output Presence of well-equipped and functioning Presence of No. of well- Total No. of health Admin report Annually
growth monitoring and promotion room/ well-equipped equipped and facilities
site at all health facilities and community and functioning functioning growth
levels growth monitoring and
monitoring promotion room/
and promotion site at all health
room/site at all facilities and
health facilities community levels
and community
levels
Output Proportion of health facilities equipped The No. of Total No. of health Total No. of health Admin report Annually
with essential supplies, diagnostic health facilities facilities equipped facilities
equipment and other treatment inputs equipped with essential
with essential supplies, diagnostic
supplies, equipment and
diagnostic other treatment
equipment and inputs
other treatment
inputs
Outcome Proportion of health facilities providing No. of health No. of health Total No. of health Survey Every two
nutrition assessment and counseling facilities facilities providing facilities providing years
services for people with HIV/TB and other providing nutrition HIV/TB and
infectious diseases nutrition assessment and other infectious
assessment counseling services diseases that were
and counseling for people with included in the
services for HIV/TB and other survey
people with infectious diseases
HIV/TB and
other infectious
diseases

81
82
Output Proportion of health facilities providing No. of health No. of health Total No. of health Admin report Annually
food for mothers/caretakers at stabilization facilities facilities providing facilities that
centers (SC) providing food food for mothers/ have stabilization
for mothers/ caretakers at centers
caretakers at stabilization centers
stabilization (SC)
centers (SC)
Output Proportion of health facilities/community No. of health No. of health Total No. of Survey Five years
centers that perform food cooking facilities/ facilities/ health facilities/
demonstrations community community centers community
centers that that perform centers that were
perform food cooking included in the
food cooking demonstrations survey
demonstrations
Output Proportion of public institutions providing No. of public No. of public Total No. of public Admin report Annually
nutrition assessment and counseling institutions institutions institutions for
services for adolescents and youth providing providing nutrition adolescents and
nutrition assessment and youth
assessment counseling services
and counseling for adolescents and
services for youth
adolescents and
youth
Outcome Presence of surveillance on lifestyle-related Presence of No. of surveillance 1 Admin report Annually
NCDs surveillance on on lifestyle-related
lifestyle-related NCDs
NCDs
Outcome No. of surveys conducted on NCDs risk No. of surveys No. of surveys 1 Survey Five years
factors conducted conducted for NCDs
for NCDs risk risk factors
factors
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