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Anganwadi Supervisor Paper-2: Child Development, Extension and Social Work · Chapter 2

Breastfeeding, Weaning and Immunization

What to remember

  • Breastfeed within one hour of birth, give only breast milk for the first six months, then add safe home foods and continue breastfeeding up to two years or more.
  • Weaning (complementary feeding) starts at six months, because breast milk alone can no longer meet the baby's needs for energy, iron and other nutrients.
  • Immunization protects a child by building immunity before the disease strikes; vaccines must be kept in the cold chain, and the Universal Immunization Programme gives them free.

Breastfeeding: why it is the best start

Breast milk is the natural and complete food for a baby. It is clean, always at the right temperature, free of cost and needs no preparation. Early and exclusive breastfeeding is the most effective low-cost step to reduce infant deaths.

Colostrum is the thick, yellowish first milk produced in the first few days after delivery. It is rich in protein, vitamin A and antibodies, especially secretory IgA. It acts like the baby's first vaccine and helps pass the first stool (meconium). It must never be thrown away.

Main benefits for the baby

  • Protects against diarrhoea, chest infections and ear infections.
  • Gives easily digested protein and fat suited to the baby's brain growth.
  • Supports bonding between mother and child.
  • Lowers the later risk of obesity and allergy.

Main benefits for the mother

  • Oxytocin helps the womb contract and reduces bleeding after delivery.
  • Gives natural, but temporary, protection against pregnancy (lactational amenorrhoea).
  • Lowers the risk of breast and ovarian cancer.
  • Saves money and time.

Composition of human milk

  • The sugar is lactose; it helps calcium absorption and brain growth.
  • The main whey protein is lactalbumin. Human milk is whey-dominant, and cow's milk is casein-dominant, so cow's milk curd is harder to digest.
  • Human milk contains lactoferrin, lysozyme and IgA, which fight germs.
  • It contains lipase, an enzyme that helps the baby digest fat.
  • Iron is small in amount but well absorbed.
  • The first part of a feed (foremilk) is watery and rich in lactose. The later part (hindmilk) is rich in fat and gives energy and a feeling of fullness. The baby should finish one breast before being moved to the other.

Hormones of lactation

  • Prolactin makes the breast produce milk. It rises when the baby suckles, so frequent feeding increases supply.
  • Oxytocin causes the "let-down" (milk ejection) reflex. Stress and pain can block it; calm and confidence help it.

Good positioning and attachment

  • The baby's body is turned towards the mother, close to her, with head and body in one line.
  • The mouth is wide open, the chin touches the breast, more of the dark area (areola) is seen above the mouth than below, and the lower lip turns outwards.
  • Slow, deep sucks with pauses show good attachment. Pain in the nipple usually means poor attachment.

Feeding practices

  • Feed on demand, day and night, including at least 8 to 12 feeds in 24 hours in the early weeks.
  • Give no water, honey, ghee, glucose or animal milk in the first six months. Such "pre-lacteal feeds" can carry infection.
  • A mother with mild illness can continue breastfeeding. Special advice is needed for a few conditions such as HIV; health workers must follow current national guidance.
  • Working mothers can express milk by hand, store it in a clean closed container for a short time and feed it with a cup and spoon. A bottle is avoided because it is hard to clean and may reduce suckling.

Promotion of breastfeeding: programmes and law

ItemKey point
Baby Friendly Hospital InitiativeLaunched by WHO and UNICEF in 1991; hospitals follow "Ten Steps to Successful Breastfeeding"
IMS ActInfant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1992, amended in 2003; bans advertising of infant milk substitutes and feeding bottles
World Breastfeeding Week1 to 7 August every year
MAA programme"Mothers' Absolute Affection", launched in 2016 to promote breastfeeding and counselling at health facilities
Maternity Benefit ActGives paid maternity leave and nursing breaks for working mothers

Weaning and complementary feeding

Weaning means the gradual change from only milk to the family diet. The new foods added to breast milk are called complementary foods. The aim is to add foods, not to stop breastfeeding suddenly.

Why start at six months

  • The baby's need for energy, iron, zinc and vitamin A grows beyond what breast milk gives.
  • The baby can now sit with support, shows interest in food and can move food in the mouth.
  • Starting too early raises infection risk and reduces suckling; starting too late causes growth failure and anaemia.

Rules for good complementary feeding

  • Begin with soft, semi-solid foods such as mashed rice with dal, ragi porridge, mashed banana or well-cooked mashed vegetables.
  • Start with small quantities (two to three spoons) and increase slowly.
  • Introduce one new food at a time and wait a few days to see whether the baby accepts it.
  • Thicken food; thin watery gruel gives too little energy.
  • Add a little oil or ghee to raise energy density.
  • Include foods rich in iron (green leafy vegetables, jaggery, pulses, egg, meat) and vitamin A (yellow fruits, leafy vegetables).
  • Feed with clean hands and clean utensils, and use a cup and spoon.
  • Keep breastfeeding on demand.
  • Feed actively and with patience; do not force the child.

Approximate pattern of feeding

AgeTextureNumber of food meals a day (besides breast milk)
6 to 8 monthsMashed, semi-solid2 to 3
9 to 11 monthsFinely chopped, mashed3 to 4 (plus a snack if hungry)
12 to 23 monthsFamily foods, chopped as needed3 to 4 meals plus 1 to 2 snacks

Common weaning problems

  • Diluted, low-energy gruels cause protein-energy malnutrition.
  • Unclean feeding causes repeated diarrhoea.
  • Feeding too late causes iron-deficiency anaemia.
  • Cow's or buffalo milk should not be the main drink before 12 months.
  • Low-cost homemade mixes of cereal, pulse and oil (for example, ragi with groundnut and jaggery) are better and cheaper than bought baby food.

Immunization

Immunity is the body's power to resist a disease. Active immunity is made by the body itself after infection or vaccination. Passive immunity comes ready-made, such as antibodies passed from mother to baby through the placenta and breast milk. A vaccine gives active, long-lasting protection; an immunoglobulin injection gives passive, short-term protection.

Universal Immunization Programme (UIP): India began the Expanded Programme of Immunization in 1978, and it became the Universal Immunization Programme in 1985. It targets diseases such as tuberculosis, diphtheria, whooping cough, tetanus, polio, hepatitis B, measles and rubella, with more vaccines added over time. Mission Indradhanush (2014) and its intensified versions aim to reach children and pregnant women who were missed. The digital platform U-WIN records vaccination.

National immunization schedule (outline; always check the latest official schedule)

AgeVaccines
BirthBCG, OPV-0 (zero dose), Hepatitis B birth dose
6, 10 and 14 weeksOPV, Pentavalent (DPT + Hepatitis B + Hib), Rotavirus; fractional IPV at 6 and 14 weeks; PCV as per schedule
9 to 12 monthsMeasles-Rubella first dose, JE where needed, vitamin A first dose
16 to 24 monthsMeasles-Rubella second dose, DPT booster, OPV booster, vitamin A further doses
5 to 6 yearsDPT booster (second)
10 and 16 yearsTd (tetanus and diphtheria)
Pregnant womanTd, two doses or a booster, as applicable

BCG is given by intradermal injection on the upper left arm; it protects mainly against severe forms of childhood tuberculosis. A small scar forms later. Pentavalent protects against five diseases: diphtheria, pertussis (whooping cough), tetanus, hepatitis B and Haemophilus influenzae type b. OPV is given as oral drops. Measles needs two doses because one dose may not protect all children.

Cold chain is the system that keeps vaccines at the right temperature from the maker to the child.

  • Cold chain equipment: walk-in coolers, deep freezers, ice-lined refrigerators (ILR), cold boxes, vaccine carriers and ice packs.
  • ILR temperature is 2 to 8 degrees Celsius. Deep freezer is about minus 15 to minus 25 degrees Celsius and is used for OPV and for making ice packs.
  • Heat-sensitive vaccines, destroyed by heat: OPV, measles, BCG after reconstitution.
  • Freeze-sensitive vaccines, destroyed by freezing: Hepatitis B, DPT, Pentavalent, Td, Hib. The "shake test" checks whether a freeze-sensitive vaccine has been frozen.
  • The Vaccine Vial Monitor (VVM) is a heat-sensitive label on the vial that changes colour when the vaccine has been exposed to too much heat.
  • Reconstituted BCG and measles vaccines must be used within a few hours.

After vaccination: mild fever, pain or swelling at the site is common. The Anganwadi worker should tell the mother about the next visit and about danger signs, and record the vaccination in the child's card. Village Health and Nutrition Day is the usual place where immunization and anganwadi services are given together.

Disease milestones: smallpox was eradicated from the world in 1980. India was certified polio-free in 2014. Pulse Polio began in India in 1995.

Exam traps

  • Colostrum is not harmful or "old" milk; it is the best first feed.
  • Exclusive breastfeeding means no water either; it is not "milk plus water".
  • Complementary foods begin at six months, not four.
  • Prolactin makes milk; oxytocin makes it flow.
  • Cow's milk is casein-dominant; human milk is whey-dominant.
  • BCG is intradermal; OPV is oral; DPT is intramuscular.
  • Heat-sensitive (OPV, measles) and freeze-sensitive (Hepatitis B, DPT, Td) vaccines are different groups.
  • IMS Act deals with marketing of infant milk substitutes; it does not ban the products themselves.
  • Passive immunity is short-lived; active immunity is long-lasting.
  • The deep freezer is for OPV and ice packs; the ILR is for most other vaccines.

One-liners

  • 1. Colostrum is rich in antibodies and vitamin A.
  • 2. Exclusive breastfeeding lasts six months.
  • 3. Prolactin is the milk-making hormone.
  • 4. Oxytocin causes the let-down reflex.
  • 5. World Breastfeeding Week is 1 to 7 August.
  • 6. The Baby Friendly Hospital Initiative began in 1991.
  • 7. IMS Act was passed in 1992 and amended in 2003.
  • 8. Weaning means adding complementary foods, not stopping breastfeeding.
  • 9. Lactose in breast milk helps calcium absorption.
  • 10. The ILR keeps vaccines at 2 to 8 degrees Celsius.
  • 11. VVM shows whether the vaccine has been damaged by heat.
  • 12. Pentavalent vaccine protects against five diseases.

Practice questions

  1. The thick, yellowish first milk produced in the first few days after delivery is called

    1. Mature milk
    2. Foremilk
    3. Hindmilk
    4. Colostrum
    Answer

    D. Colostrum

    Colostrum is rich in antibodies and vitamin A and acts as the baby's first vaccine.

  2. Exclusive breastfeeding is recommended for the first

    1. Six months
    2. Three months
    3. Nine months
    4. Four months
    Answer

    A. Six months

    Only breast milk, with no water or other food, is advised for the first six months.

  3. Which hormone stimulates the breast to produce milk?

    1. Insulin
    2. Adrenaline
    3. Thyroxine
    4. Prolactin
    Answer

    D. Prolactin

    Prolactin, released when the baby suckles, makes the breast produce milk.

  4. The let-down (milk ejection) reflex is caused by the hormone

    1. Prolactin
    2. Estrogen
    3. Oxytocin
    4. Progesterone
    Answer

    C. Oxytocin

    Oxytocin makes the milk-producing cells contract so that milk flows out.

  5. Complementary feeding should be started at about the age of

    1. Nine months
    2. Two months
    3. Twelve months
    4. Six months
    Answer

    D. Six months

    From six months breast milk alone cannot meet the needs for energy and iron.

  6. The main sugar in human milk is

    1. Maltose
    2. Sucrose
    3. Lactose
    4. Fructose
    Answer

    C. Lactose

    Lactose provides energy and helps calcium absorption and brain growth.

  7. The protein of human milk is mainly

    1. Whey protein (lactalbumin)
    2. Gluten
    3. Zein
    4. Casein
    Answer

    A. Whey protein (lactalbumin)

    Human milk is whey-dominant; cow's milk is casein-dominant and harder to digest.

  8. BCG vaccine is given by which route?

    1. Oral
    2. Intramuscular
    3. Intradermal
    4. Subcutaneous
    Answer

    C. Intradermal

    BCG is injected into the skin (intradermally), usually on the upper left arm.

  9. Oral Polio Vaccine (OPV) is given as

    1. Drops by mouth
    2. A nasal spray
    3. A skin patch
    4. A deep muscle injection
    Answer

    A. Drops by mouth

    OPV is given as oral drops.

  10. The recommended temperature range inside an ice-lined refrigerator for vaccines is

    1. 10 to 15 degrees Celsius
    2. 20 to 25 degrees Celsius
    3. Minus 15 to minus 25 degrees Celsius
    4. 2 to 8 degrees Celsius
    Answer

    D. 2 to 8 degrees Celsius

    An ILR keeps vaccines at 2 to 8 degrees Celsius.

  11. In the cold chain, the deep freezer is mainly used to store

    1. Tetanus-diphtheria vaccine
    2. OPV and to make ice packs
    3. DPT vaccine
    4. Hepatitis B vaccine
    Answer

    B. OPV and to make ice packs

    OPV can be frozen; the deep freezer also freezes ice packs for vaccine carriers.

  12. Pentavalent vaccine does NOT protect against

    1. Hepatitis B
    2. Polio
    3. Haemophilus influenzae type b
    4. Tetanus
    Answer

    B. Polio

    Pentavalent covers diphtheria, pertussis, tetanus, hepatitis B and Hib; polio is given separately.

  13. World Breastfeeding Week is observed every year during

    1. 14 to 20 November
    2. 1 to 7 March
    3. 1 to 7 August
    4. 1 to 7 December
    Answer

    C. 1 to 7 August

    World Breastfeeding Week is 1 to 7 August.

  14. The Baby Friendly Hospital Initiative was launched by WHO and UNICEF in

    1. 1975
    2. 2003
    3. 2016
    4. 1991
    Answer

    D. 1991

    BFHI began in 1991 with the Ten Steps to Successful Breastfeeding.

  15. India's MAA programme (Mothers' Absolute Affection) aims to promote

    1. Breastfeeding
    2. Polio eradication
    3. Family planning
    4. Pre-school education
    Answer

    A. Breastfeeding

    MAA promotes breastfeeding and counselling at health facilities.

  16. The IMS Act of 1992 mainly regulates

    1. Adoption of infants
    2. Hospital delivery charges
    3. Marketing of infant milk substitutes and feeding bottles
    4. Maternity leave of women
    Answer

    C. Marketing of infant milk substitutes and feeding bottles

    The Act controls production, supply, distribution and promotion of infant milk substitutes and feeding bottles.

  17. The Vaccine Vial Monitor (VVM) shows whether a vaccine has been

    1. Mixed with water
    2. Exposed to too much heat
    3. Stored for more than a year
    4. Used earlier
    Answer

    B. Exposed to too much heat

    VVM is a heat-sensitive label that changes colour with cumulative heat exposure.

  18. Which of the following vaccines is freeze-sensitive?

    1. Hepatitis B
    2. OPV
    3. BCG (dry powder)
    4. Measles (dry powder)
    Answer

    A. Hepatitis B

    Hepatitis B, DPT, Pentavalent and Td are damaged by freezing.

  19. Which vaccine is most sensitive to heat and may be kept frozen?

    1. DPT
    2. Hepatitis B
    3. Td
    4. OPV
    Answer

    D. OPV

    OPV is heat-sensitive but not harmed by freezing.

  20. The shake test is used to find out whether a vaccine such as DPT has been

    1. Damaged by freezing
    2. Diluted with water
    3. Overheated
    4. Contaminated with germs
    Answer

    A. Damaged by freezing

    A frozen and thawed vaccine settles faster than an unfrozen one in the shake test.

  21. A grandmother wants to give honey and water to a three-month-old baby. The best advice is that this is

    1. Needed to prevent jaundice
    2. Not advised, as it can carry infection and reduce suckling
    3. Needed to clean the mouth
    4. Good in summer
    Answer

    B. Not advised, as it can carry infection and reduce suckling

    No pre-lacteal or extra feeds are needed in the first six months; they can cause infection.

  22. A mother has painful nipples while feeding. The most likely cause is

    1. A baby who is too heavy
    2. Low prolactin
    3. Poor attachment of the baby to the breast
    4. Too much milk
    Answer

    C. Poor attachment of the baby to the breast

    Pain usually means the baby is not taking enough of the areola into the mouth.

  23. Which is the most suitable first complementary food for a six-month-old baby?

    1. Whole roasted groundnuts
    2. Plain tea with sugar
    3. Thin rice water
    4. Mashed rice with dal and a little oil
    Answer

    D. Mashed rice with dal and a little oil

    Soft, thick, energy-dense semi-solid food with some protein is suitable.

  24. A ten-month-old baby, besides breast milk, should get complementary foods about

    1. Once a day
    2. Only on festival days
    3. Twice a day
    4. Three to four times a day
    Answer

    D. Three to four times a day

    At 9 to 11 months three to four food meals a day are advised.

  25. Complementary foods are started at six months mainly because

    1. The mother must stop feeding
    2. Breast milk alone no longer meets the baby's energy and iron needs
    3. The baby cannot digest milk
    4. Breast milk becomes harmful
    Answer

    B. Breast milk alone no longer meets the baby's energy and iron needs

    Needs for energy, iron and zinc rise beyond what breast milk supplies.

  26. Antibodies passing from the mother to the baby through the placenta are an example of

    1. Active immunity
    2. Passive immunity
    3. Vaccine-induced immunity
    4. Herd immunity only
    Answer

    B. Passive immunity

    Ready-made antibodies give short-term passive immunity.

  27. Breastfeeding should be started after a normal delivery within

    1. Twenty-four hours
    2. Six hours
    3. One hour
    4. Twelve hours
    Answer

    C. One hour

    Early initiation within one hour gives the baby colostrum and helps the womb contract.

  28. The first dose of Measles-Rubella vaccine is given at

    1. 9 to 12 months
    2. 6 weeks
    3. Birth
    4. 14 weeks
    Answer

    A. 9 to 12 months

    The first dose is at 9 to 12 months and the second at 16 to 24 months.

  29. Mission Indradhanush was launched mainly to

    1. Reach children and pregnant women missed in routine immunization
    2. Ban infant formula
    3. Supply iron tablets to adolescents
    4. Build creches
    Answer

    A. Reach children and pregnant women missed in routine immunization

    It targeted partially or unvaccinated children and pregnant women.

  30. The Pulse Polio programme began in India in

    1. 2005
    2. 1985
    3. 2014
    4. 1995
    Answer

    D. 1995

    Pulse Polio immunization started in 1995; India was certified polio-free in 2014.

  31. The Universal Immunization Programme was started in India in

    1. 2005
    2. 1950
    3. 1985
    4. 1965
    Answer

    C. 1985

    The Expanded Programme of Immunization (1978) became the Universal Immunization Programme in 1985.

  32. On a Village Health and Nutrition Day the Anganwadi worker finds that the VVM of a vaccine vial has reached its discard point. She should

    1. Use it first
    2. Shake it and use it
    3. Use it only for adults
    4. Discard it
    Answer

    D. Discard it

    A vial whose VVM has reached the discard point has been damaged by heat and must not be used.

  33. Which pair is correctly matched?

    1. Prolactin - milk production
    2. Lipase - sugar digestion
    3. Oxytocin - milk production
    4. Lactose - protein of milk
    Answer

    A. Prolactin - milk production

    Prolactin makes milk; oxytocin ejects it; lactose is a sugar; lipase digests fat.

  34. Consider the statements. 1. Colostrum is rich in antibodies. 2. Water should be given to a breastfed baby after three months. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Colostrum has secretory IgA; exclusive breastfeeding means no water until six months.

  35. Consider the statements. 1. BCG is given orally. 2. OPV is given orally. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    BCG is intradermal; OPV is given as oral drops.

  36. Consider the statements. 1. Human milk contains lactoferrin. 2. Human milk is whey-dominant. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are true; lactoferrin fights germs and whey protein predominates in human milk.

  37. Consider the statements. 1. Weaning means stopping breastfeeding completely at six months. 2. OPV is destroyed by freezing. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    D. Neither 1 nor 2

    Breastfeeding continues during weaning; OPV is heat-sensitive but can be frozen.

  38. Consider the statements. 1. Oxytocin helps the womb contract after delivery. 2. Prolactin is secreted by the thyroid gland. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Prolactin comes from the pituitary gland, not the thyroid.

  39. Consider the statements. 1. An ice-lined refrigerator keeps vaccines at 2 to 8 degrees Celsius. 2. Reconstituted measles vaccine should be used within a few hours. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are correct cold chain rules.

  40. Consider the statements. 1. Td vaccine is given only to pregnant women. 2. Pentavalent vaccine contains Hib. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    B. 2 only

    Td is also given to children at 10 and 16 years; pentavalent includes the Hib component.

  41. Consider the statements. 1. Hindmilk is rich in fat. 2. Foremilk is richer in fat than hindmilk. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    A. 1 only

    Foremilk is watery; hindmilk, the later milk of a feed, has more fat.

  42. Consider the statements. 1. Lactational amenorrhoea gives temporary protection against pregnancy. 2. Breastfeeding lowers the mother's risk of breast cancer. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are recognised benefits of breastfeeding for the mother.

  43. Consider the statements. 1. A new complementary food should be introduced one at a time. 2. Thick foods give more energy than thin gruel. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    C. Both 1 and 2

    Both are good weaning practices.

  44. Consider the statements. 1. Passive immunity lasts for life. 2. A vaccine gives passive immunity. Which is/are correct?

    1. 1 only
    2. 2 only
    3. Both 1 and 2
    4. Neither 1 nor 2
    Answer

    D. Neither 1 nor 2

    Passive immunity is short-lived and vaccines give active immunity.

  45. Which is the better practice when feeding a baby at the breast?

    1. Limit feeds to four a day
    2. Let the baby finish one breast before offering the other
    3. Switch breasts every minute
    4. Give water after every feed
    Answer

    B. Let the baby finish one breast before offering the other

    Finishing one breast gives the fat-rich hindmilk that satisfies the baby.

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