 Hello everyone, today's third part of first session and we already discussed about NFHS4 and NFHS5 data on you know exclusive breastfeeding and also on complementary feeding and we also discussed about growth charts. So today I'm going to talk about framework that we had created at one of the NGO that you know I was working at and this was the framework for mental infant young child feeding practices you know we had to actually create a protocol and it took us almost I would say six to seven years to come up with this protocol from learning in the field. So this is what I'm going to discuss today to understand like you know what what we did and what helped actually and this is the same NGO which showed you know a good amount of reduction of not only wasting and underweight but also stunting. So you know before we again go deep into each factor just wanted to give you broad guideline you know that what we did. So first thing was basically we focused a lot on breastfeeding. It took us almost I would say long six seven years to understand what was missing in the breastfeeding aspect because initially in first four five years I was not getting results I mean our children were not gaining as good a weight as you know they were expected to and again you know experience from us as you know we were very strict on growth monitoring. So if children didn't grow well we had to immediately take an action you know and here I was I was trying to teach them you know breastfeeding holes and all which I had learnt by reading again you know not this training was not done in our medical curriculum not even an attendee level in US and pediatrics. So obviously looking at all these guidelines I was teaching them traditional holes you know cradle hold and I would say baspilado you know not focusing so much on intricacies of technicalities you know and when children were not gaining weight I was like thinking what to do I mean in US you know immediately mothers start formulas you know but here I was working in slums so I didn't want to think of even starting anything because that was out of question and for me giving exclusive breastfeeding was very very important and you know somehow we've kind of figured out when we continue seeing such cases you know most of the cases were not gaining weight actually and then you know one of the baby in fact kind of I would say it taught us and you know we came up with this 45 counseling points you know because of strict monitoring of our data you know and cross griddle actually worked really well so what we did is basically we taught mothers this cross griddle hold you know starting from I would say 2013 or so we started doing cross griddle hold and our goal was just to train this pregnant mothers who came in you know because when these mothers actually were not trained on proper breastfeeding technique you know when they would go for deliveries any outside a lot of those doctors would start formulas or you know they would say and they would start all this you know cow milk or formulas so we wanted to kind of empower our pregnant mothers you know and that's when we actually saw great results even when they delivered you know even if they were told not to give breast milk because babies were either born by cesarean or some of the other issue you know they did not listen to doctors they they give it so I think this is a very important point that I would like to discuss to you know teach your pregnant mothers this 45 points of counseling with cross griddle hold and you know you'll definitely see timely early initiation of breastfeeding you'll see amazing weight gain you know they don't lose so much weight this side that's what I saw that even in you as when I was using this whole every time I went you know in urgent care when mothers came we would teach them cross griddle hold you know at day two or day three post delivery and I was seeing just amazing results of like you know 50 60 grams a day and no wonder you know WHO table shows 200 gram weight gain in first week and that's what I saw actually you know which only we don't see it in India unfortunately you know maybe because of the mothers are not guided or probably I have I don't want to blame too many things but you know I saw similar results in India in our program when we started teaching cross griddle hold so that's why I was insisting on this kind of 45 points of counseling and what we did is basically here you know this is one of the project in Panaskata where all these pregnant mothers were brought in PhDs and they were taught you know using our health spoken tutorial which I'll speak in the next you know session and you know they were taught this whole when they were pregnant okay not only when they were pregnant they were asked to demonstrate okay with breast model and the doll and then immediately as as soon as they delivered you know PhD medical officers and A&M and Asha would train them on cross griddle hold and you know basically empower her right so that's what the important aspect and that's what we did in our program also we brought all these pregnant mothers in we not only of course talk about breastfeeding techniques but we also spoke about her nutrition because her nutrition was very important and we tried to kind of get all the mothers from first trimester onward you know because obviously what I noticed that there was a huge number of you know low birth weight babies being born in urban slums so I wanted to improve their birth weight so we kind of we brought them in early we would have you know one session per month or so even sometimes once every two weeks depending upon which trimester they were in and focused a lot on nutrition focused on red flags you know focused on understanding of you know minor aches and pains and pregnancy we did not do a lot of this you know obstetrician kind of care because we didn't have a gynecologist in our program so it was more of a kind of you know other things which were not done in the hospital that we kind of took care of so more of like a nutrition counselling breastfeeding counselling you know talking about issues just general issues teaching them some exercises and you know like a a paramedical stuff so that was important part of a program second part was basically teaching mothers giving them support on cross-cruel hold so again you can see this cross-cruel hold is completely opposite of what traditional hold is here baby's been held by opposite hand again I'll discuss more in detail later and here medical officer in panaskata district you know she's she's doing a home visit and she's teaching mother actually how to hold looking at the latch you know all those important points which she was taught you know in one of the training here this is another you know photograph of breastfeeding latching again you know what we noticed that in this hold baby could really open a big mouth had a very good extension of neck that extension of neck is really really important you know looking up a little bit like that it was difficult to get that in a traditional hold and you know the way mother was holding the breast was completely different it was U shape rather than a C shape which we already which we always see in the in the program you know and then after kind of you know trying this hold on I would say hundreds of babies we again and looking at the data that what helped what did not help our advice I'm talking about you know we eventually came up with 45 points okay now there's 45 points included everything starting from mother's preparation then the way she sits you know the way she holds the baby the way she brings the baby to the breast you know baby's position baby's latch you know mouth latch and other counseling points so it kind of encompasses the whole technicality of breastfeeding you know we've always told that breastfeeding is important breastfeeding is important but exactly what to do now if suppose for example if I have nobody to help me okay nobody nobody to teach me then how as a mother I would learn the skill on my own I would call it do it yourself and then basically practice you know breastfeeding on your baby you know so this so that's what that was a reason to come up with this kind of concise document you know of course this is really important for healthcare workers doctors and medical officers and nurses to to learn this but you know in case if mothers don't have any support physical support you know just by looking at it and understanding she can definitely try it and I have a lot of mothers who call us on a portion helpline and you know we just passed them this tutorial which we have created on 45 points and they do wonderful they do wonderful we have so many mothers telling us that oh you know just by looking at the skill videos you know I was I understood the problem and the problem is fixed within 20 40 40 hours so this is to just kind of standardize the process you know so that it becomes easy for capacity building you know so here we created this kind of brochures and the wall hangings in different languages basically all all different languages so if any you know NGOs working in different areas of India if they want if they would want to take it up you know we have it in all the different languages okay this is created sitara and spoken tutorial basically then what we did when mothers came to our program okay it was very important for for healthcare worker to assess breastfeeding now this is breastfeeding assessment tool that of course it it was created by WHO but we kind of modified it because you know our techniques were different you know we were promoting cross cradle whole so I wanted to add a lot of those points and also also wanted to in kind of add some of this counseling points which were not given in WHO assessment tool so we kind of modified that assessment tool and this is what basically we came up with you know just important points not too much which was not helping mothers to breastfeed or not helping babies to gain weight so we removed some of those points but put in kind of more about you know you know points which are very very relevant you know points which were relevant for example more on latching more on understanding if mother understood whether she you know she knew early hunger queues or she knew that baby need to be fed you know a few times at night all those points that you know we put it in there and what healthcare workers were supposed to do in my program is every time baby came with the mother I'm talking about first two to three weeks when mother is still learning breastfeeding they had to basically check okay so on left side you have all the favorable behaviors and on right side you have unfavorable behaviors or unfavorable sign symptoms or whatever you can say okay so if if suppose baby came with the mother you know we we would first weigh the baby I mean that was very important but then we would tell mother you breastfeed and I'm going to examine okay so healthcare healthcare workers would examine the mother and the baby and the way they breastfed by looking at it and by filling out these forms we could actually figure out the problem where the problem lied you know because then we immediately knew that okay this is a problem that mother don't know hunger queues then we would discuss more about that hunger queues or mother did not know how to bring the baby to the breast so we discussed that point but this assessment was very important you know when they came to our program so I definitely recommend to all the all my friends over here to kind of you know I will put a pdf for this form we have again you know recreated at its few more points from learning in past couple of years you know and then just kind of even if you if you're a mother and if you want to just assess your breastfeeding just fill this form form at home and then figure out where the issue is it's all basically like a in a problem oriented solutions you know that you need to know this then the breastfeeding will be very successful okay as I of course said well why this effective breastfeeding you know again I keep talking about not just timely early initiation or you know exclusive breastfeeding I keep talking about effective breastfeeding because you know I wanted to see that if you if mother knew breastfeeding then why would she start top feed or if if mother knew proper breastfeeding then why would she so much of sand so much of uh stunting under weight under under six months of age right because babies are only getting mother's milk so like obviously you know once we started learning this new techniques all these questions came to our mind that why every mother need to have every mother needs help you know whether it is a mother in tribal area slum area western world in fact western world mothers need much more help you know and we figured out there was a study which was done in UC Davis you know and what they found is basically 92% of the new mothers reported at least one breastfeeding concern okay and this is on day three now here are the institute where they have lactation consultant okay they have trained nurses they have lactation consultant they can go to in the hospital but still all these mothers had all these issues and you know by and large in US also they they tend to use traditional whole because you know that's that's been there for for probably generation you know so god knows how many generations but if mother had all these issues so on day three what issues were there 52% mothers they felt that they were not feeling well and the cohort was 532 first time mothers so that's a huge cohort okay 52% mothers they were not feeling well at breast 44% breastfeeding a person of mothers had breastfeeding pain and 40% mothers had perceived lack of sufficient milk so they felt that I was not getting milk okay now obviously when in a in a you know developed world when you have a big institute like UC Davis hospital who has trained lactation consultant if those mothers were showing all the symptoms and most of them left actually breastfeeding you know so then there has to be issue right and I did not figure out this issue for first five six years when I was working you know in this NGO but yes you know we did figure that it was the effectiveness of the breast breastfeeding which was the hindrance to mothers continuing breast milk or to improve you know wasting stunting and all those anthropometric measures okay so that was important now growth monitoring so growth monitoring was very important part of our program okay so here is the in this NGO what we did is basically we got all this you know small young babies to a program you know and then basically we worked a lot on you know monitoring on this babies you know growth monitoring and so here you know we had social workers who would basically take height and weight or length of this babies then we had and this all lactating mothers so we had a program for lactating mothers also where we would teach mothers her nutrition how to take care of herself and then talk about breastfeeding and complementary feeding and all that you know so it this clinic was not just for young children it was also for pregnant mothers and lactating mothers so all these lactating mothers were bringing the children you know depending upon the weight gain we would decide whether this baby would be seen in two days seven days two weeks one month you know but we had a set protocol you know so this this mother's when they would weigh their babies then they would come to you know like a doctor or nurse you know and they would be basically the data would be taken from them you know of course the history would be there we would do breastfeeding assessment imagine we were working in a very small room so we did not have any privacy you know again very contradictory to the place where I had come from you know where we had one huge room for one mother there was so much of privacy you know and unbelievable and here you know when I would tell mothers okay show me breastfeeding and so many times there were fathers there you know there were some other people there it was so difficult you know we had lack of space so this privacy is also kind of important you know in our setting that you know if anybody is coming to a clinic and if you want to assess breastfeeding it's important to have some space for mothers but we did not have it as you can see it from our if from our picture and then what would happen initially we did not have any software so we would do everything by hand we would plot all baby's growth chart you know we would do it teach mothers what food to eat for themselves and if babies were more than six months old we would tell them what to eat but this was our clinic of monitoring visits you know and our basically the follow-up of these babies I mean completely depend on the weight gain okay so babies are not gaining weight we were seeing them very frequently if babies were gaining weight we would see them once a month okay so that one-on-one counseling was very very important in our program okay now here this is in the same clinic you know once a mother brought that baby we would basically check the weight you know that weighing scale was also very important you know eventually we ended up buying a seca because seca was very very seca as a german product weighing scale very expensive so obviously initially when I came it was you know they had a salter weighing scale so on a salter you know that every time you put that baby in the salter weighing scale which I had not seen in the US at all you know and I said kept thinking that the baby was you know that weight was going here here here every time baby moved it would you know and I was used to seeing you know one gram incremental weight gain on sophisticated digital machines you know weighing scale and I said this would not work for me I mean I had to see even 15 gram weight gain and we could not make obviously figure out on a salter weighing scale whether 15 gram weight can occur in one day or two days or whatever you know so then eventually we moved to you know digital weighing scale but my goal was to get seca products so once we got some more funding we got some better weighing scales okay and this one was basically checking the length so length checking was very very important and what I see you know we are very strict on length how baby's length are checked in US okay because that's again our bread and butter but what I was seeing in in our program that all a lot of this healthcare workers you know it was very difficult to train them on length check because you know babies are very wiggly they cry you know they need lot of this holding of the head holding of the knee you know a lot of time babies would flex their knees you know they would bend their knees so it was it was important for us to do that you know so that's why like what I did and lot of time what was to happen there should be lot of kind of you know length would be wrong you know so when I would plot I said no no this can't be right length because last week it was this length and this time you cannot have increment of 3 centimeter in one week you know so then I would that we created a protocol that this length would be checked by two different individuals so then what we would do is basically you know we had two social workers so one person would basically check the length and then the other person would you know plot it and then we would have another person doing it you know again checking the length properly again second time you know whether there'll be a role reversal you know and we found that you know there was lot of discrepancies and then again we would have third person doing it so you know that I think finally they learned how to check length so it takes time you know so make sure in your program when you're when you're when you're doing maternal child health program this length checker is very very important you train your team train your staff how to check length okay because if your length is say change by two or three centimeter your child will go from normal to maybe ma'am or even Sam or even stunting you know so please that's really really important especially in first you know first few weeks of age you know another thing was basically so of course now I spoke about breastfeeding now obviously with that kind of level of training of breastfeeding counseling to mothers a lot of our babies were becoming very tall very big you know some of them were like as I showed you in the picture some of them were like becoming 10 cages by six months of age right but when those babies okay when they are big then they have good appetite okay when they have good appetite they will try everything whatever you give them they will try it okay but when you did not have a good growth in first six months of age those babies were thin those babies were cranky you know those babies are not happy cranky not eating well you know poor uptake of all different kind of foods so I strongly believe that if you want to have a good complementary feeding state you start your foundation strong okay what is your foundation some foundation strong means that you make sure that the babies breastfed well get that baby to good you know 9 10 cages 8 9 whatever 10 cages is good I mean I we have shown that results we don't so many babies we can target that because we want the children to be tall and there's a breastfed baby some not worried at all about the blood pressure or diabetes I'm not worried at all I don't know why people keep thinking whenever I put some healthy babies photographs who are excluded breastfed that oh this baby is overfed this baby is obese you guys are not worried when the babies are less than third percentile 33 36 percent children are less than third percentile in India but you are worried about children who are going more than 97 percentile on weight that to exclusively breastfed you know so I want to make sure that you know you guys understand that if babies breastfeeding beautifully and if they are gaining weight there are multiple papers out there that the BMI is much better you know this babies were growing faster on breast milk and the BMI is lower at one year of age compared to babies were formula fed okay so I don't want formula fed babies all those other babies you know cow cow milk babies to grow fast because those are the mother those are the babies who is going to develop diabetes and blood pressure but yes I want those breastfed babies to have amazing amount of milk transfer so they grow tall because I showed you and so so many I'll be showing more on when I talk about growth charge I'll show you many more you know examples of how this baby's grew leaps and bounds just on breast milk you know so it's important that you know just focus on your first six months a lot then your six months ke baat ka complementary feeding becomes much easier okay okay so here is your so this is you know Anna Prashan from one of the district Sabarkata district and you know we had done that project in 2000 late 2018 2019 and you can see this babies was just so big you know so it was a joy for you know government people to even feed them you know the complementary feeding because they would immediately take it you know and they were just so they would finish this the whole thing you know big appetite okay and even you know same in the same function basically you can see all these babies are just looking so especially the middle one you know so I think it's important it's important you know before we talk about complementary feeding it's important that our children grow well okay now this complementary feeding also we learned a lot okay believe me that many time many many actually most of the time I would say when the children were growing well on breastfeeding but at six months what would happen they growth would stagnant okay they would just not grow I mean I would keep telling asking my nutritionist I say why these children are not growing what's happening so we figured out the reason children were not growing because we were again just talking about chawal doh khichri doh usmissare sabji daalo ye karo wo karo it was everything the same thing that but what we were taught you know and it was not helping in our program children were not gaining weight and when the stagnation started in the weight the length also started stagnating so I was thinking my god we worked so hard on breastfeeding children are like at 97 percentile 85 percentile for length now children are not growing for weight obviously length is not going to grow right so we had to I mean we had to really come up with something solution for it you know and what I realized and I'm just fortunate is basically I got you know exposure or I would say training of Dr. Michael Golden okay so here in 2011 we had one concessor statement from in a kind of a pediatrics on management of SAM you know guide we were creating guidelines for pediatricians and we wanted to publish in Indian pediatrics and that's when we found that Lord this children were basically and he discussed about you know type 2 nutrients type 1 nutrients how the SAM children are lacking in type 2 nutrients and you know when so when I was attending those sessions I realized that okay so child had lack of this type 2 nutrients in and that's why they became SAM and then when you're giving those type 2 nutrients more in the form of special food which are given to which are recommended by WHO for SAM children it just kind of stuck to me that why not if we increase those type 2 nutrients in the diet of this six months old children and about in complementary foods then you would not have those children going into type type 2 nutrient deficiency right and again I will discuss about this type 1 type 2 nutrient in my other lecture but you know that's when like it just kind of you know it rung the bell or I would say you know it struck the light said maybe let's talk about this type 2 nutrient when we talk about foods you know and obviously he discussed Professor Michael Golden also discussed about 40 nutrients which are required in the diet you know and you know a lot of this programs they keep talking about iron calcium all that but none of the programs were discussing so much about the type 2 nutrient you know and that's when we came up with these recipes okay so these recipes are basically made from locally available beans and seeds and nuts and legumes and you know leaves you know like for example drumstick leaves or kari patta leaves or any of those leaves and obviously you know what happens is like when mother start food at six months they are so mono like the diet was so monotonous they would just give kichidi kichidi kichidi you know rice dal kichidi roti dipped in milk it's a little bit of vegetable here in there diet was absolutely monotonous no wonder our children were not gaining weight because we were recommending the same thing kichidi though which misare yeh sab vegetables daloh you know vitamin e rich food daloh malap malap nothing it was we were not focusing on protein as much you know and other type 2 nutrients like your magnesium your potassium you know your chloride so many other things we were not focusing at all your you know sulphur so zinc you know and because we had no knowledge we had no knowledge about what food to give which will give all this nutrition you know and the and the food that children were eating was so starch based it was very much starch based carbohydrate based you know and we realized and I really thank professor Michael Golden for giving me that opportunity to understand the importance type 2 nutrients okay so we told mothers and I will discuss about this type 2 nutrient dense food you know in my complement to feeding okay and then of course you know when we understood about this type 2 nutrients and of course important type 1 nutrients also we started creating cooking demos okay so what we would do we would ask all these mothers do and this is and this you know complementary feeding is not just about the dietary diversity but also about the amount how many times baby should be eating you know depending upon the age how to make those foods so everything was very very important you know so again you know it's one thing to tell mothers do this do that you know another thing and a lot of time we were telling that in the beginning but mothers you say you know we said okay let's start you know our cooking demos so we would bring all these mothers in the clinic okay this is a picture from our other NGO that I've been working since 2013 I've continued to work here and this is a rule-based NGO Srimati Malti Dhanukar Trust and here you know here is our team we have team of about 12 people so you know this here is a doctor there's a nutritionist you know she's a healthcare workers there's our social workers you know that we have three four nurses so here like you know we have a team of all these doctors nurses nutritionist social workers they all come come under one roof and help these children to improve their you know anthropometric measurements right that is that was my impact is to improve weight height and all that so here we would teach mothers exactly how to make you know from a locally available food which was not very expensive because you know we want to make sure these children mothers can afford the food that we are recommending we can't recommend something which is very expensive and expect them to buy those things you know we cannot say that okay buy walnut or buy almond or buy this exotic food you know we had to bring all this whatever is available locally so then what we would do is we should we would kind of show them all this ingredient and we would talk about you know nutrient content of each and every you know food and then we would feed the child right in front of the mother okay so that responsive feeding was very very important okay because lot of time you know mothers didn't know how to feed they would kind of make the child lie down and feed or you know they would force feed the child and all that was very very important part of training of this mothers okay so here we created you know from that from this ingredient you know we created this tiki you know which were which were giving to a little bit older child you know so this is about I think about eight to nine months old child and he's like enjoying that tiki which has egg which has you know so many different green leafy vegetables and you know ragi it has some ragi and then this is dal so we also wanted to show them that dal should be thick you know it should be nutrient dense over here I saw all these mothers were giving watery dal literally watery they will let me but you could choke or choke over so through cooking demo we would teach them how to make it and how to feed them okay junk food is the big problem all over the world okay and that's true even in urban slum rural areas tribal areas you go anywhere there's so much of junk food available and in our program what we found that lot of these babies were given you know biscuit by you know by four months of age marie biscuit and all these biscuits they were getting and I was very much against it so junk food awareness was very integral part of our program okay home visit was another integral part of our program where we would you know our social workers nurses nutritionists would go to mother's home and then basically see the environment around it because an environment was very important right we may tell them breastfeed karo complementary feeding karo but garpe if it's very very dirty if it's very if it's not you know clean then mother babies would definitely get diarrhea and all that right so those are those are very very important aspect of you know prevention of under nutrition so here you know there is a home visit going on and we are seeing how mother is burping the baby this is one point of a 45 points you're here you know she's making the baby sit on her lap okay but we wanted to see how she does it in the home environment and then another thing what we would see is with the and obviously whenever we would do home visit we would always have this breastfeeding doll and the baby doll breastfeeding more breast model and you know we would see whether she has prepared those powders or not whether she's kind of kept it in a clean container whether she has you know whether there is any other issues going on in the house how clean was the you know kitchen whether the how clean was it water where was she storing it so there were there was some you know 30 40 things that we were looking at and we were analyzing that how this mothers were doing at home so again that you know very rich data uh now last but not the least of course i wouldn't call it last one more point which is there i'll discuss which is very important but you know again coming from us i was used to electronic medical record okay we would using it for a long time and first four five years of course when i came to india i had to put everything on the paper you know documentation growth charts we had files which uh similarly how we would have it in us we would have a file for each child and we would not give that file to mother because i was afraid that if i would give that file to mother she would lose it so we would keep it in a clinic you know if every visitor we had some so many questions and we would fill out religiously and you know that's how we have learned growth monitoring that's how we have learned what worked what did not work but after four five years we decided that uh we need to get software okay because unless you have electronic uh data monitoring very very difficult to analyze to you know keep taking care of those files sometimes we would lose some of those files or know sometimes there would be uh the paper was drawn child was playing with that file so we had to basically switch to electronic data monitoring so we had this very sophisticated uh uh software uh amazing software you know uh and i'm so i'm so proud of uh that ngo fmch and i really appreciate uh you know dotty wagle who is the CEO of that uh fmch she's doing just wonderful work you know she got everything streamlined you know so uh not only the technical aspect of breastfeeding complementary feeding is important but streamlining the process is also very important you know putting protocols in place getting data collection data monitoring you know what works what doesn't work monitoring the program you know evaluation of overall program it's that's what she brought in that was her forte you know uh coming from us i mean that was completely her forte so she got everything streamlined and i really appreciate so we got this amazing software you know and that uh told us it would automatically kind of graph the children on wch growth chart so as soon as uh and it was all cloud-based so as soon as uh you know uh healthcare worker put in weight and height it would show up on uh our ipad or our tablet immediately to show up on my laptop and you know i could show mother look you know whatever we told you you did it and see look at the result she would be so happy to look at those growth charts so i if you want to really kind of do behavior change in mother plot your growth chart plot your growth chart because mother looks at a growth chart if she finds out that baby is not gained weight from that growth chart she will do anything whatever you tell her she will do it but mother needs to know how the child is growing okay so don't just go by saying that it na gram badna chai utna gram badna chai yeah of course you tell her that i'm expecting this much weight gain but then show her see if baby gained 40 grams this is where child is coming now okay so she understands because there's so much of myth in the uh in the practice out there not only in government sector but even in private pediatricians that you know they are saying a you know pansogram mainika badna chai that's completely wrong because if you plot that graph and show after one month the child has gained 500 gram mother will say you know so i recommend that please plot your graph you tell her what is expected weight gain and if it's not gaining weight after showing the proper technique then you figure out the problem there is an issue if if there's no if it's functional issue is taken care of then you figure out the organic cause you know but this is organic cause means we have to find out any medical condition why babies are not gaining weight okay but if we have very poor target weight then those babies are bound to get underweight in just two or three months matter of three months even babies born 3.3 kg 3 kg those people become underweight if you have target weight you know just 500 gram per month okay so again my experience from us that i brought to india uh was uh developmental classes because you know over there we have this mom and me class okay where not only kind of young children would go to mom and me class but even pregnant mothers would go to lama's class and so many other different class where you know she would stimulate that baby how we have gharpa sanskar right they also have their different ways of stimulating those babies you know in us and i feel that why we are not using that gharpa sanskar in our in our ngus and in our government setup so important you know meditation uh you know uh talk about uh you know good things read good books you know uh say some slogans if you're hindu say some prayers of any religion but you know i feel that it's important because it passes on those important you know sanskars and children and i do believe in uh you know kind of talking to babies when they are in the womb you know so here is one of our setup it's again the same program this was a temple actually you know we did not have such big place as you saw our clinic was so small so we did not have this setup so we asked one of the temple in our area if we could use that area to you know to show this developmental aspect of two mothers you know how to play with them how to massage them how to you know stimulate them how to talk to them just everything how to make some toys you know so this all and we would bring children of same age group okay so that you know for example this is uh mainly about say around three months or maybe four months old babies then from six months to nine months we would have a different you know program for developmental pediatrics we call it and then for older children we have a different program because each child is at different developmental stage so we would have different uh kind of you know praise or different uh advice for different age group so here you know we are this healthcare worker is teaching how to massage the babies okay so again you know uh again this are for people who are running different programs and also for government you know what are the point of contact for MIYC and counseling so there are so many times that especially and I have a lot of pediatricians attending this training so I want to show that you have ANC time you know you can talk about MIYC and ANC operas then you have you know during a prep room you know the early stage of labor you tell mothers that okay or even before she goes into labor during ANC time you talk about breast crawl talk about you know breast crawl or into skin during cesarean talk about labor room you know in labor room talk about that okay now baby is going to be born and you know we are going to put the baby on your tummy so that we can start early initiation so this all important contact point you know where uh not only pediatrician but ASHA ANM medical officers everybody can basically focus on those MIYC and contact point okay then you have PNC world absolutely important time period when mother is in the PNC you know post delivery she is in PHC or in hospital for two days some areas you have only for one day that's fine one day 24 hours is enough you know keep teaching them cross crawl hold in 45 points anytime mother comes for immunization you know either at PHC level or wherever look at breastfeeding do breastfeeding assessment find out if any there is an issue correct it okay unless you correct it mothers will continue doing wrong thing and you will not see good weight gain okay and then any pediatric opid if she if mother came to a pediatric opid to any opid you know for medical officers or any any opid if child came for a runny nose again ask about nutrition why do we only focus on runny nose and cough why are we only focusing on just pneumonia diarrhea ask about why did child get diarrhea why did pneumonia child get because there was a problem with breastfeeding so talk about breastfeeding talk about under the technicality skill not just breastfeeding okay that is just are you feeding baby are you eating or not I mean yes I would have eaten just one biscuit I say I am eating no the quality is important okay if you breastfeeding show me how you're doing breastfeeding show me because if you don't show her proper skill you may correct your pneumonia you may correct your diarrhea but she will go back in the community she will come back in two weeks with the same issue okay because you have not tackled the root cause the root cause is poor nutrition causing child to have pneumonia diarrhea any illnesses even runny nose and cough okay so while we are discussing about vaccines and all that please do not forget your basic fundamental of nutrition or that that's under six months is breastfeeding skills and six months onward is complementary feeding and continuation of breastfeeding okay so here I'm going to end my you know session I just talked about the framework that we worked under and if we can replicate this framework you know in our government system other NGOs other you know organizations you will definitely see results why not right because here we're really actually looking at the problem and solving the problem at the root cause so I hope you enjoyed the session and I'll see you again for the next session thank you