Midwife Licensure Exam Midwifery Pharmacology & Newborn Procedures — Maternal & Child Nutrition Counseling (Midwife-led)Detailed Explanation

Maternal Micronutrient Supplementation in Pregnancy

Every pregnant woman in the Philippines receives iron and folic acid supplementation as a standard of prenatal care at the RHU or BHS. The standard DOH dose is 60 mg elemental iron + 400 micrograms (0.4 mg) folic acid, taken once daily, ideally starting at the first prenatal visit. This supplement is continued throughout the entire pregnancy and for 3 months postpartum to replenish iron stores depleted by blood loss during delivery. Why iron? Iron-deficiency anemia is one of the most common pregnancy complications among Filipino women. It increases the risk of preterm birth, low birth weight, and maternal death from postpartum hemorrhage (PPH) because a severely anemic mother cannot tolerate even small blood losses. The midwife monitors hemoglobin levels and refers women with severe anemia (Hgb < 7 g/dL) to a physician. Why folic acid? Folic acid (Vitamin B9) is essential for the formation of the neural tube — the structure that becomes the baby's brain and spinal cord. The neural tube closes in the first 28 days of life, often before the woman knows she is pregnant. This is why folic acid must be started BEFORE conception and continued through the first trimester for maximum protection against neural tube defects like spina bifida and anencephaly. The midwife actively counsels women of reproductive age planning a pregnancy to begin folic acid early. Counseling points for compliance: (1) Iron is best absorbed on an empty stomach or with vitamin-C-rich foods like calamansi juice or tomatoes. (2) Tea, coffee, and milk reduce iron absorption — avoid taking the supplement with these. (3) Black or dark stools are normal and expected — reassure the mother. (4) Constipation may occur; advise increased fluid and fiber intake. (5) If a woman has confirmed anemia, the dose may be doubled to twice daily per protocol, but severe cases are referred. Postpartum, Vitamin A supplementation may also be given. The DOH policy provides a postpartum dose of Vitamin A 200,000 IU within the early postpartum period (within the first 4 weeks while the mother is still breastfeeding and amenorrheic) to enrich breast milk and replenish maternal stores. CRITICAL: High-dose Vitamin A is TERATOGENIC and must NEVER be given during pregnancy. The midwife must always confirm the woman is postpartum and not pregnant again before giving this dose. For iodine, the midwife promotes iodized salt under RA 8172 (the ASIN Law) to prevent iodine-deficiency disorders, goiter, and cretinism in the newborn. Calcium supplementation is used in some protocols, particularly in women with low dietary calcium intake, as it helps reduce the risk of pre-eclampsia.

Infant and Child Vitamin A Supplementation

Vitamin A deficiency (VAD) in children causes serious consequences: night blindness (early sign), xerophthalmia (dry eye leading to blindness), and — most critically for child survival — increased susceptibility to severe infections like measles and diarrhea. It remains a public health problem in the Philippines, which is why the DOH has an aggressive supplementation program delivered through the 'Garantisadong Pambata' (GP) campaign held twice a year (typically February and August). The DOH age-based Vitamin A doses are exam essentials: - Children 6–11 months (infants): ONE dose of 100,000 IU - Children 12–59 months (1–5 years): ONE dose of 200,000 IU every 6 months - Vitamin A is NOT routinely given below 6 months to breastfed infants, because breast milk — especially if the mother received her postpartum dose — provides sufficient Vitamin A for this age group. Memory trick: Think of it as 'half the age, half the dose.' A 6-month-old gets 100,000 IU (half dose). A 1-year-old and up gets 200,000 IU (full dose). Vitamin A is fat-soluble, which means it is stored in the body (primarily in the liver) and can accumulate to toxic levels if over-dosed. The midwife ALWAYS records each dose on the child's health card/mother-child book to prevent accidental double-dosing during the same campaign. Signs of Vitamin A toxicity include bulging fontanelle in infants, nausea, headache, and skin peeling — these are reasons for referral. Additional indication: Vitamin A is given as an adjunct treatment in measles and severe illness per protocol, because measles rapidly depletes Vitamin A stores and worsening of infection increases mortality. This therapeutic use is above the routine schedule and follows specific protocol. The midwife links Vitamin A supplementation with the growth monitoring visit, deworming schedule, and immunization to maximize contact with children and families — this integrated approach is a hallmark of the DOH community health program.

Exclusive Breastfeeding — Laws, Policy, and Practice

Breastfeeding is both a public health priority and a legal mandate in the Philippines. The midwife is a key protector and promoter of exclusive breastfeeding (EBF) at the BHS, lying-in clinic, and during home visits. Understanding the laws, the WHO/DOH recommendations, and the practical technique is essential for the MLE. Legal Framework — Know These Laws: 1. RA 7600 — The Rooming-In and Breast-feeding Act of 1992: Requires rooming-in (keeping mother and baby together) and promotes breastfeeding in health facilities. 2. EO 51 — The Milk Code: Regulates the marketing of breast-milk substitutes. Prohibits advertising formula milk, feeding bottles, and teats to the public. Forbids health workers from accepting free formula samples or gifts from manufacturers. The midwife must NEVER promote, advertise, or distribute formula samples. 3. RA 10028 — The Expanded Breastfeeding Promotion Act of 2009: Mandates lactation stations in workplaces and public places; requires paid lactation breaks for working mothers; strengthens promotion of breastfeeding in all settings. WHO/DOH Breastfeeding Recommendations: - Initiate breastfeeding within the FIRST HOUR of life — this is the first step of EINC (Essential Intrapartum and Newborn Care / Unang Yakap) - Practice EXCLUSIVE breastfeeding for the first 6 MONTHS — breast milk ONLY; no water, no juice, no formula, no herbal teas, NO OTHER FOOD OR LIQUID - Continue breastfeeding UP TO 2 YEARS AND BEYOND with appropriate complementary foods introduced from 6 months Why exclusive breastfeeding — benefits to counsel: - Breast milk provides ideal, complete nutrition matched to the baby's developmental stage - Colostrum (the thick yellowish first milk) is packed with antibodies (immunoglobulins) and protective factors — it is the baby's FIRST IMMUNIZATION. It must NEVER be discarded ('binubuhos') - Reduces risk of diarrhea, respiratory infections, SIDS, and obesity in the child - Promotes mother-infant bonding - Supports uterine involution (oxytocin released during suckling causes uterine contractions) - Provides contraceptive benefit through LAM (Lactational Amenorrhea Method) - Cost-effective and always available LAM (Lactational Amenorrhea Method) as Family Planning: LAM is a natural family planning method. It is effective ONLY when ALL THREE conditions are met simultaneously: 1. Baby is UNDER 6 MONTHS of age 2. Mother is EXCLUSIVELY BREASTFEEDING (no supplements, no formula) 3. Mother's MENSTRUAL PERIOD HAS NOT RETURNED (amenorrheic) If any one condition is not met, LAM is no longer reliable and the mother needs another contraceptive method. Positioning and Latch — Four Keys to Good Positioning: 1. Baby's HEAD AND BODY in a STRAIGHT LINE (no twisting of the neck) 2. Baby held CLOSE to the mother's body (tummy to tummy) 3. Baby's WHOLE BODY SUPPORTED (not just the head) 4. Baby FACING THE BREAST — nose to nipple alignment so the baby tilts head back and opens wide Signs of GOOD LATCH (Correct Attachment): - MORE AREOLA IS VISIBLE ABOVE than below the baby's mouth - Mouth is WIDE OPEN (the baby takes a large mouthful of breast tissue, not just the nipple) - LOWER LIP IS TURNED OUTWARD (everted/flanged out) - CHIN TOUCHING THE BREAST Signs of EFFECTIVE FEEDING (Baby is getting milk): - Slow, deep sucks with visible swallowing pauses - Audible or visible swallowing - Baby releases the breast spontaneously when satisfied - 6 or more wet diapers per day (after day 4) - Steady weight gain (regains birth weight by day 10–14, then gains ~500 g/month) Feeding Frequency: On demand, approximately 8–12 times in 24 hours, including at night. Night feeds are important for maintaining milk supply. Common Breastfeeding Problems and Midwife Solutions: 1. Sore/cracked nipples — almost always from POOR LATCH/ATTACHMENT. Solution: Correct the latch. Apply a few drops of hindmilk to the nipple after feeding and let air dry. Do NOT use soap on nipples. 2. Perceived insufficient milk — The most common reason mothers stop breastfeeding. Almost always a misconception. Milk supply follows demand. Solution: Reassure the mother; advise more frequent feeds, feeding from both breasts, ensuring the baby empties one side before switching, and maintaining night feeds. Genuine insufficiency is rare and confirmed by poor weight gain and few wet diapers. 3. Engorgement — Breasts become swollen, hard, and painful, usually on days 3–5. Solution: Feed frequently; before each feed, express a little milk or apply warm compresses to soften the areola so the baby can latch; apply cold compresses after feeding for comfort. 4. Working mothers — Teach expression and safe storage of expressed breast milk. Cite the mother's rights under RA 10028 to lactation breaks and a clean lactation station at her workplace. This empowers her to continue exclusive breastfeeding even when returning to work.

Complementary Feeding from 6 Months

Complementary feeding means introducing other foods WHILE breastfeeding continues. It starts at 6 COMPLETED MONTHS of age — not before, not much later. Before 6 months, the baby's digestive system is not ready and breast milk is completely sufficient. After 6 months, breast milk alone can no longer meet the rapidly growing child's energy and nutrient needs — especially for iron, zinc, and energy — so complementary foods are needed. The Four Principles of Complementary Feeding (WHO/DOH): 1. TIMELY — Start at exactly 6 completed months 2. ADEQUATE — Meets the child's needs for energy, protein, and micronutrients 3. SAFE — Prepared and stored hygienically; no contamination; no feeding bottles 4. PROPERLY FED — Responsive feeding; the child is fed actively, not just left to feed themselves; appropriate consistency and frequency for age Feeding Frequency and Consistency by Age: - 6–8 months: 2–3 MEALS per day, start with thick purees and mashed food, gradually thicker; introduce one new food at a time (wait 3–5 days between new foods to check for reactions) - 9–11 months: 3–4 MEALS per day, finely chopped family foods, soft lumps; baby can start finger foods - 12–23 months: 3–4 MEALS per day + 1–2 NUTRITIOUS SNACKS (not junk food); family foods of normal consistency; continue breastfeeding Key Foods to Include: - Iron-rich and animal-source foods: egg, fish, meat, liver, chicken — these are particularly important because plant-source iron (non-heme) is less well absorbed - Fruits and vegetables (orange and dark-green colored varieties for beta-carotene/Vitamin A) - A small amount of added oil or fat for energy density (e.g., a few drops of cooking oil in the mash — babies need more fat per kilogram than adults) - Legumes (munggo, beans) for plant protein Foods to AVOID: - Anything given by FEEDING BOTTLE (aligns with the Milk Code / EO 51 — no bottles or teats) - Sugary drinks (juice drinks, cola, flavored milks) — replace nutrient-dense feeds with empty calories - Tea, coffee, herbal infusions — contain tannins that reduce iron absorption - Highly salted or processed foods — kidneys are immature - 'Junk food' and low-nutrient snacks (chips, candies) Responsive Feeding: The midwife counsels the mother to feed the child actively and with patience — look for hunger and satiety cues, offer food actively rather than forcing, and make feeding a positive, interactive experience. This is especially important for thin or sick children. Food Hygiene: Diarrhea is a major killer of young children and is often caused by contaminated food. Counsel on washing hands before food preparation and feeding, using clean utensils and covered containers, preparing fresh food for each meal (avoid storing cooked complementary food for long), and using safe water. For working mothers and caregivers, the midwife counsels on preparing and storing expressed breast milk safely and on home-based food preparation for the complementary feeding period. The midwife must always reinforce that BREASTFEEDING CONTINUES alongside complementary feeding. It is not a replacement — it is an addition. Breast milk continues to provide a significant portion of energy and nutrients and all the immune protection, especially for children 6–23 months.

Growth Monitoring and Promotion (GMP) at the BHS

Growth monitoring is the midwife's surveillance system for child nutrition in the community. By regularly weighing children and plotting their weight on a growth chart, the midwife can detect growth faltering early — before the child looks visibly malnourished — and act before the condition worsens. Key Principle: The DIRECTION of the growth curve is more important than a single weight measurement. A child whose weight curve is FLAT (not going up) or FALLING (going down) is in trouble, even if the child's weight today is in the normal range. A flat or falling curve signals growth faltering and must trigger feeding counseling — or referral if severe. The Growth Monitoring Visit: 1. WEIGH the child on a calibrated scale (infants in a sling scale; older children on a standing scale) 2. MEASURE length (lying down, under 2 years) or height (standing, 2 years and above) 3. PLOT on the growth chart in the Mother-Child Book (MCB) / ECCD card / WHO Child Growth Standards 4. INTERPRET: Is the weight-for-age appropriate? Is the curve going up, flat, or falling? 5. CLASSIFY nutritional status: Normal, Underweight, Severely Underweight; assess for acute malnutrition using MUAC and edema 6. ADVISE on feeding according to findings 7. PROVIDE Vitamin A and deworming per schedule 8. CHECK immunization status and give due vaccines 9. REFER if indicated MUAC (Mid-Upper Arm Circumference): A quick screening tool for acute malnutrition in children 6–59 months. Measure the circumference of the upper arm at the midpoint between the shoulder and elbow. - GREEN (≥ 12.5 cm): Normal/well-nourished - YELLOW (11.5–12.4 cm): Moderate acute malnutrition — increased monitoring and feeding support - RED (< 11.5 cm): SEVERE ACUTE MALNUTRITION (SAM) — REFER immediately Edema: Bilateral pitting edema of the feet/legs (kwashiorkor) is also a sign of severe acute malnutrition, regardless of the child's weight. Any child with bilateral pitting edema = refer. When to REFER: - MUAC < 11.5 cm (RED zone) - Bilateral pitting edema (kwashiorkor pattern) - Severe wasting (visibly very thin, ribs and bones prominent) - Child who is not gaining weight after two or three consecutive months of counseling - Signs of severe illness alongside malnutrition Integrated Actions at GMP Visit: Growth monitoring is not just weighing — the midwife uses it as an opportunity to deliver all child health interventions: feeding counseling, Vitamin A every 6 months, deworming twice a year, and immunization check. This integrated approach maximizes the impact of each BHS contact. Deworming Schedule: Intestinal parasites (roundworm, hookworm, whipworm) worsen anemia and malnutrition by competing for nutrients and causing intestinal blood loss. DOH protocol for deworming: - Children 12–23 months: Albendazole 200 mg, once - Children 24–59 months: Albendazole 400 mg, twice a year (integrated with GP rounds and Vitamin A) - Pregnant women: After the first trimester (2nd or 3rd trimester), Mebendazole 500 mg once or Albendazole 400 mg once per protocol Related Programs: - Food Fortification Law (RA 8976): Mandates fortification of staple foods — iron-fortified rice, iodized salt, Vitamin A-fortified cooking oil, iron-fortified flour — to reduce micronutrient deficiencies at the population level - Supplementary feeding programs at the BHS for malnourished children - Pantawid Pamilyang Pilipino Program (4Ps) — requires regular health/nutrition checkups as a condition for cash transfers

This is the standard DOH supplementation protocol. The two numbers most commonly tested are the iron dose (60 mg, not 30 mg or 120 mg) and the folic acid dose (400 mcg/0.4 mg, not 1 mg). The 3-month postpartum continuation is frequently omitted in wrong-answer options. Always complete the full course including the postpartum period.

Apply the two-tier DOH Vitamin A dosing schedule: 6–11 months = 100,000 IU; 12–59 months = 200,000 IU every 6 months. The 13-month-old and 3-year-old both fall in the 12–59-month bracket and receive the same 200,000 IU dose. The midwife documents each dose on the child health card to prevent double-dosing.

This tests all four signs of good latch simultaneously. The MLE may present a clinical scenario and ask whether the latch is correct. All four signs must be present for a good latch: more areola above than below; mouth wide open; lower lip turned OUT; chin touching the breast. Poor latch leads to sore nipples and insufficient milk transfer.

Either MUAC < 11.5 cm OR bilateral edema alone would warrant immediate referral. Having both is a clear, urgent SAM case. The midwife's role is DETECT AND REFER — not to independently treat SAM. This is a high-yield referral scenario on the MLE.

This integrates two important topics: complementary feeding initiation at 6 months and LAM effectiveness criteria. The midwife must proactively counsel mothers on family planning transition before it becomes a problem. Pre-planning the shift away from LAM before the 6-month mark is ideal counseling practice.

This tests practical application of complementary feeding principles. The MLE may present a mother's feeding story and ask the midwife to identify errors and give correct advice. The three key issues here are frequency/amount adequacy, food quality (iron-rich, energy-dense), and the feeding bottle prohibition under the Milk Code.