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

Exam Tips

• MLE questions often ask 'Who is the PRIMARY nutrition counselor at the BHS?' — the answer is the MIDWIFE.
• Remember the 1,000 days formula: 270 days pregnancy + 365 days year 1 + 365 days year 2 = 1,000 days.
• Any question about 'normal' nutrition care in the community context = midwife's scope; 'severe malnutrition management' = refer.

Key Points

• The FIRST 1,000 DAYS spans from CONCEPTION to the child's SECOND BIRTHDAY — this is when nutrition has the greatest lifelong impact on health, growth, and brain development.
• The midwife at the BHS/RHU is the PRIMARY nutrition counselor in the community, reaching mothers and children through prenatal visits, newborn care, and growth monitoring sessions.
• Nutrition counseling, micronutrient supplementation, breastfeeding support, complementary feeding guidance, and growth monitoring are ALL within the NORMAL scope of midwifery practice under RA 7392.
• The midwife uses simple, respectful, culturally appropriate language when counseling Filipino families, and always documents supplements given and growth data plotted.
• For severe malnutrition (severe wasting, edema/kwashiorkor, MUAC < 11.5 cm), the midwife's role is to DETECT and REFER — not independently manage.

Definitions

Section Title

The First 1,000 Days and the Midwife's Role

Common Mistakes

• Forgetting that nutrition counseling is a NORMAL midwifery function — it is NOT just a doctor's responsibility.
• Confusing the '1,000 days' endpoint — it ends at the SECOND birthday, not the first.
• Failing to remember that the midwife REFERS severely malnourished children rather than independently managing them.

Formulas

Exam Tips

• MEMORIZE the exact dose: 60 mg iron + 400 mcg folic acid = standard DOH pregnancy supplement.
• If asked when to start folic acid for NTD prevention = BEFORE CONCEPTION (periconceptional period).
• Vitamin A rule: NEVER in pregnancy (teratogenic); 200,000 IU ONCE postpartum (within 4 weeks).
• RA 8172 = ASIN Law = iodized salt — know the law number for MLE.
• Common MLE distractor: 'Give Vitamin A 200,000 IU to a pregnant woman at 28 weeks' — this is INCORRECT and must be refused.

Key Points

• The DOH standard pregnancy supplement is: 60 mg elemental iron + 400 mcg (0.4 mg) folic acid ONCE DAILY.
• Supplementation starts at the FIRST PRENATAL VISIT and continues throughout pregnancy AND for 3 MONTHS POSTPARTUM.
• Folic acid prevents NEURAL TUBE DEFECTS (spina bifida, anencephaly) — most protective when taken BEFORE CONCEPTION and during the FIRST TRIMESTER.
• Iron absorption is INCREASED by vitamin C-rich foods (calamansi, guava) and is DECREASED by tea, coffee, and calcium-rich foods taken at the same time.
• BLACK/DARK STOOLS after iron supplementation are NORMAL — counsel the mother so she is not alarmed.
• For DIAGNOSED IRON-DEFICIENCY ANEMIA, the dose may be increased to TWICE DAILY under protocol; REFER if severe anemia.
• HIGH-DOSE VITAMIN A IS CONTRAINDICATED IN PREGNANCY — it is teratogenic (causes birth defects).
• POSTPARTUM Vitamin A: 200,000 IU given ONCE within the first 4 weeks postpartum (while lactating and before menses return) to enrich breast milk and build maternal stores.
• Iodized salt is promoted under the ASIN LAW (RA 8172) to prevent iodine-deficiency disorders and goiter.
• Calcium supplementation may be used to reduce pre-eclampsia risk in populations with low dietary calcium intake.

Definitions

Section Title

Maternal Micronutrient Supplementation

Common Mistakes

• Giving the exact Vitamin A dose as '200,000 IU during pregnancy' — this is WRONG and dangerous; Vitamin A is given POSTPARTUM, not during pregnancy.
• Stating folic acid is only needed after pregnancy is confirmed — it should start BEFORE CONCEPTION for maximum NTD protection.
• Forgetting the POSTPARTUM extension — iron-folic acid continues for 3 months AFTER delivery, not just during pregnancy.
• Advising tea or coffee with iron supplements — these REDUCE iron absorption.
• Alarming the mother about dark stools — these are NORMAL and expected with iron supplementation.

Formulas

Exam Tips

• Easy memory trick: '6–11 months = 100,000 IU (single digit age in months starts with a 1, so 100,000); 12–59 months = 200,000 IU every 6 months.'
• Garantisadong Pambata = April and October = 2 times per year = every 6 months.
• If the question mentions Vitamin A + measles = it is given as ADJUNCT therapy in measles, NOT only in the GP rounds.
• Always link: Vitamin A is FAT-SOLUBLE → accumulates → must record dose → do NOT give below 6 months routinely.

Key Points

• Vitamin A deficiency causes NIGHT BLINDNESS, XEROPHTHALMIA (eye damage), and increased risk of severe infections and child mortality.
• Infants 6–11 months: 100,000 IU ONCE (single dose).
• Children 12–59 months (1–5 years): 200,000 IU EVERY 6 MONTHS.
• Vitamin A is NOT routinely given below 6 months to exclusively breastfed infants — they receive adequate Vitamin A through breast milk, especially if the mother received her postpartum dose.
• The twice-yearly distribution rounds are known as 'GARANTISADONG PAMBATA' (GP) — typically held every April and October.
• High-dose Vitamin A is also given as adjunct therapy in MEASLES and severe illness per DOH protocol.
• Vitamin A is FAT-SOLUBLE and accumulates in the body — the midwife must RECORD each dose to PREVENT OVERDOSE (Vitamin A toxicity/hypervitaminosis A).
• The midwife links each Vitamin A round with deworming and immunization status checks.

Definitions

Section Title

Infant and Child Vitamin A Supplementation

Common Mistakes

• Giving 200,000 IU to a 6-month-old — the correct dose for infants 6–11 months is 100,000 IU, NOT 200,000 IU.
• Giving Vitamin A routinely to infants under 6 months — this is NOT standard practice for exclusively breastfed infants.
• Forgetting to record the dose — recording is essential because Vitamin A is fat-soluble and overdose causes toxicity.
• Confusing the GP schedule — it is EVERY 6 MONTHS (twice a year), not monthly or quarterly.

Exam Tips

• Mnemonic for GOOD LATCH: 'MACE' — More areola above, Areola: mouth wide, Chin touching, Everted lower lip.
• Mnemonic for 4 positioning keys: 'SCAF' — Straight line, Close to mother, All body supported, Facing breast/nose to nipple.
• LAM mnemonic: 'SEA' — Six months (baby < 6 months), Exclusive breastfeeding, Amenorrhea (no period).
• Law cheat sheet: RA 10028 = 10 + 028 = 'Ten' = Promotion; RA 7600 = '7600 babies rooming in'; EO 51 = 'Milk ban'.
• If MLE asks about a working mother wanting to sustain EBF = cite RA 10028 (lactation breaks, lactation stations).
• Initiation within the first HOUR = EINC/Unang Yakap — connects breastfeeding to newborn care protocol.

Key Points

• EXCLUSIVE BREASTFEEDING means breast milk ONLY for the first 6 months — NO water, no juice, no other food or drinks, not even a little water in hot weather.
• The three key laws: RA 10028 (Expanded Breastfeeding Promotion Act of 2009), EO 51 (Milk Code), and RA 7600 (Rooming-In and Breastfeeding Act of 1992).
• INITIATE breastfeeding within the FIRST HOUR of life — this is EINC/Unang Yakap Step 3.
• COLOSTRUM (the first thick, yellowish milk) is packed with antibodies and immune factors — it must NEVER be discarded.
• Continue breastfeeding up to 2 YEARS AND BEYOND with appropriate complementary foods from 6 months.
• The Milk Code (EO 51) PROHIBITS advertising of breast-milk substitutes, feeding bottles, and teats, and forbids health workers from accepting or distributing formula samples.
• RA 10028 requires LACTATION STATIONS in workplaces and public places and mandates LACTATION BREAKS for working mothers.
• LAM (Lactational Amenorrhea Method): effective contraception only when ALL THREE conditions are met — baby < 6 months, EXCLUSIVELY breastfed, AND menses NOT yet returned.
• Breastfeeding benefits: ideal nutrition, immune protection, bonding, uterine involution, LAM contraception, reduced breast/ovarian cancer risk for mother.
• GOOD LATCH (attachment) signs: MORE AREOLA visible ABOVE the mouth than below; mouth WIDE OPEN; LOWER LIP turned OUTWARD (everted); CHIN touching the breast.
• GOOD POSITIONING keys (4): (1) baby's head and body in a STRAIGHT LINE, (2) baby held CLOSE to mother, (3) baby's WHOLE BODY SUPPORTED, (4) baby FACING the breast, NOSE TO NIPPLE.
• Signs of EFFECTIVE FEEDING: slow, deep sucks with pauses; audible/visible swallowing; baby releases breast when satisfied; 6 or more WET DIAPERS per day; adequate weight gain.
• Feed ON DEMAND, approximately 8–12 times per 24 hours.

Definitions

Section Title

Exclusive Breastfeeding — Laws, Benefits, and Technique

Common Mistakes

• Allowing WATER during 'exclusive' breastfeeding — exclusive means NO water at all, even in hot weather.
• Discarding colostrum — this is a dangerous cultural practice. Colostrum is the most valuable milk the baby receives.
• Confusing the three breastfeeding laws — RA 10028 (promotion + lactation stations), EO 51 (Milk Code/no advertising), RA 7600 (rooming-in).
• Stating LAM is effective without checking ALL THREE criteria — if only two conditions are met, LAM is NOT reliable.
• Describing good latch as 'equal areola above and below' — the CORRECT sign is MORE areola visible ABOVE than below.
• Advising the mother to alternate breasts every few minutes — baby should finish one side first to get the fat-rich hindmilk before switching.

Exam Tips

• Engorgement sequence: WARM before → FEED frequently → COLD after. (Hot then Cold = WFC)
• Sore nipples = poor latch = correct latch first; hindmilk soothes cracked nipples.
• Confirm 'enough milk' objectively: ≥6 wet diapers/day + appropriate weight gain = milk is sufficient.
• RA 10028 is the answer for 'what law protects working mothers who want to breastfeed?'

Key Points

• SORE/CRACKED NIPPLES: Almost ALWAYS caused by POOR ATTACHMENT (bad latch) — NOT by breastfeeding itself. Correct the latch; keep nipples dry; apply a few drops of HINDMILK to the nipple after feeding.
• 'NOT ENOUGH MILK' (perceived insufficient milk): This is the most COMMON reason mothers stop breastfeeding — and most of the time it is UNFOUNDED. Reassure: supply follows demand. Advise MORE FREQUENT feeding, both breasts, night feeds, ensure baby finishes one side before switching.
• TRUE insufficient milk is RARE — confirmed by POOR WEIGHT GAIN and fewer than 6 wet diapers per day.
• ENGORGEMENT: Feed FREQUENTLY (best treatment); express a little milk to soften the areola before latching; apply WARM compress before feeds and COLD compress after feeds.
• WORKING MOTHERS: Teach expression and safe storage of breast milk; cite RA 10028 rights — lactation breaks and lactation stations — so the mother can sustain EBF while at work.
• The LACTATING MOTHER needs approximately 500 kcal EXTRA per day and adequate fluid intake to support milk production.
• Even a modestly nourished mother can produce adequate breast milk — this is an important reassurance for food-insecure families.

Definitions

Section Title

Common Breastfeeding Problems and Midwife Solutions

Common Mistakes

• Immediately recommending formula when a mother says 'I don't have enough milk' — first check latch, feeding frequency, wet diapers, and weight gain.
• Advising cold compresses BEFORE feeding for engorgement — warm before, cold after.
• Forgetting to teach breast milk expression and storage for working mothers — this is a practical midwife intervention.
• Attributing sore nipples to breastfeeding itself rather than POOR LATCH — the root cause must be corrected.

Exam Tips

• Memory aid for meal frequency: '6–8 months = 2–3 meals' (single digit months = smaller number of meals); '9–23 months = 3–4 meals + snacks'.
• Always link complementary feeding to CONTINUED breastfeeding — they go together, not one replacing the other.
• If MLE asks about introducing foods: one food at a time, soft/mashed, iron-rich, at 6 months.
• The 4 Cs of complementary feeding: Correct time (6 months), Continues breastfeeding, Complete nutrients (iron-rich, varied), Clean/safe preparation.

Key Points

• COMPLEMENTARY FEEDING starts at EXACTLY 6 COMPLETED MONTHS — not 4 months, not 5 months, not 'when the baby shows interest.'
• At 6 months, breast milk ALONE no longer meets the baby's energy and nutrient needs — complementary foods are added WHILE BREASTFEEDING CONTINUES.
• The FOUR PRINCIPLES of complementary feeding: TIMELY (start at 6 months), ADEQUATE (enough energy, protein, nutrients), SAFE (hygienic preparation), PROPERLY FED (responsive feeding, appropriate texture/frequency).
• Introduce ONE NEW FOOD at a time to watch for allergies/intolerances.
• Start with SOFT, MASHED, ENERGY-DENSE foods (e.g., lugaw with egg, mashed camote, mashed banana).
• MEAL FREQUENCY by age: 6–8 months = 2–3 meals per day; 9–23 months = 3–4 meals per day PLUS 1–2 nutritious snacks from about 12 months.
• Include IRON-RICH and ANIMAL-SOURCE foods (egg, fish, chicken liver, meat, dilis) plus fruits/vegetables and a little added fat/oil for energy.
• Practice RESPONSIVE FEEDING — feed slowly, patiently, making eye contact; do not force-feed.
• Maintain strict FOOD HYGIENE — wash hands, use clean utensils — to prevent diarrhea.
• AVOID FEEDING BOTTLES (aligns with Milk Code/EO 51); avoid sugary drinks, tea, instant noodles, and low-nutrient 'junk' foods.
• Gradually increase THICKNESS and VARIETY with age — by 12 months, the child can eat most family foods.

Definitions

Section Title

Complementary Feeding from 6 Months

Common Mistakes

• Starting complementary foods before 6 months — this increases risk of infections, allergies, and displaces breast milk.
• Stopping breastfeeding at 6 months when complementary foods start — breastfeeding CONTINUES alongside complementary foods until 2 years and beyond.
• Giving complementary foods in a feeding bottle — this violates the Milk Code spirit and creates bottle dependency.
• Giving tea, juice, or sugary drinks as early foods — these are low-nutrient and may fill up the baby without providing needed nutrients.
• Forgetting to introduce iron-rich foods early — iron deficiency anemia peaks in the 6–24 month age group.

Formulas

Exam Tips

• Key rule: DIRECTION of the growth curve > single data point. Flat/falling = act; rising = praise.
• MUAC cut-offs: < 11.5 cm = SAM (RED = REFER); 11.5–12.5 cm = MAM (YELLOW = act); ≥ 12.5 cm = Normal (GREEN).
• Bilateral pedal edema in child = kwashiorkor = SAM = REFER. No exceptions.
• GMP is the MIDWIFE'S activity — she weighs, plots, counsels, and refers. This is high-yield because it defines her scope.
• Bundle services at GMP: Weight + Vitamin A + Deworming + Immunization check + Feeding advice.

Key Points

• GROWTH MONITORING AND PROMOTION (GMP) is a routine MIDWIFE-LED activity — typically MONTHLY for infants and at each child health visit.
• The midwife WEIGHS the child and PLOTS the weight on the GROWTH MONITORING CHART (Mother-Child Book / ECCD card / WHO Child Growth Standards).
• THE DIRECTION OF THE GROWTH CURVE IS MORE IMPORTANT THAN A SINGLE LOW WEIGHT — a FLAT or FALLING growth line is an early warning sign of nutritional problem.
• A child who is growing along a curve (even in a lower channel) is progressing; a child whose line flattens or drops is at risk.
• NUTRITIONAL STATUS classification from weight-for-age: Normal, Underweight, Severely Underweight.
• MUAC (Mid-Upper Arm Circumference) for children 6–59 months: MUAC < 11.5 cm = SEVERE ACUTE MALNUTRITION — REFER IMMEDIATELY.
• BILATERAL PEDAL EDEMA (pitting edema of both feet) = sign of KWASHIORKOR (protein malnutrition) = SEVERE ACUTE MALNUTRITION — REFER.
• At each GMP visit, the midwife also: gives FEEDING ADVICE, provides VITAMIN A and DEWORMING per schedule, checks IMMUNIZATION STATUS.
• The midwife uses EACH WEIGHING as a TEACHING MOMENT with the mother — explaining the growth chart, praising progress, and giving practical feeding guidance.
• REFER faltering or severely malnourished children to a physician or Therapeutic Feeding Program — the midwife detects and refers, does not independently treat SAM.

Definitions

Section Title

Growth Monitoring and Promotion at the BHS

Common Mistakes

• Focusing only on whether the current weight is 'low' rather than whether the CURVE is going up, flat, or down.
• Not measuring MUAC or checking for pedal edema during growth monitoring visits — these are key screening steps.
• Trying to 'manage' SAM at the BHS instead of referring — severe acute malnutrition requires physician care and therapeutic feeding programs.
• Doing growth monitoring once and not doing regular monthly follow-ups — the TREND requires serial measurements.

Formulas

Exam Tips

• Deworming dose memory: '12–23 months = 200 mg (half); ≥24 months = 400 mg (full)' — smaller child, smaller dose.
• Deworming timing: AFTER first trimester in pregnancy; NEVER below 12 months in children.
• GP rounds bundle: Vitamin A + Albendazole + Immunization check = TWICE YEARLY (April and October).
• RA 8976 = Food Fortification Law; RA 8172 = ASIN/Iodized Salt Law — know both for MLE.

Key Points

• Intestinal worm infection WORSENS anemia and undernutrition by stealing nutrients and causing intestinal blood loss.
• DOH policy: TWICE-YEARLY DEWORMING alongside Vitamin A rounds (Garantisadong Pambata).
• Drug: ALBENDAZOLE. Standard dose for children ≥24 months: 400 mg (single dose).
• Children 12–23 months: REDUCED DOSE of 200 mg albendazole (half dose) due to younger age.
• Deworming is NOT given below 12 months.
• PREGNANT WOMEN may be dewormed with albendazole AFTER THE FIRST TRIMESTER (from 2nd trimester onward) per DOH protocol.
• FOOD FORTIFICATION: The midwife promotes iron-fortified rice (Pilipinas Kitas), iodized salt (RA 8172/ASIN Law), and fortified cooking oil under the FOOD FORTIFICATION LAW (RA 8976).
• The midwife links families of malnourished children to SUPPLEMENTARY FEEDING PROGRAMS at the barangay or RHU level.

Definitions

Section Title

Deworming and Nutrition-Related Programs

Common Mistakes

• Giving albendazole 400 mg to a 15-month-old — the correct dose for 12–23 months is 200 mg.
• Deworming a child below 12 months — this is NOT done in standard protocol.
• Forgetting that pregnant women CAN be dewormed after the FIRST trimester — a common exam distractor that makes it sound like all pregnancy is off-limits.
• Giving deworming without checking age — always verify age to select the correct dose.