Infant and Young Child Feeding in Emergencies (IFE)

1. Infant and Young Child Feeding in Emergencies (IFE)

2. Learning Objectives • Define optimal infant and young child feeding practices and relevance in emergencies • Identify key policy guidance relevant to IFE • Describe a minimum response on IFE • Appreciate importance of strong coordination, communication and orientation/training • Identify emergency preparedness activities 1

3. IFE concerns the protection and support of safe and appropriate (optimal)feeding for infants and young children in all types of emergencies, wherever they happen in the world. Protection of non-breastfed infants by minimising the risks of artificial feeding The well-being of mothers (nutritional, mental & physical health) is critical to the well-being of their children. What is IFE? 1

4. Pakistan, 2010 1

5. Optimal infant and young child feeding recommendations Early initiation of breastfeeding (within 1 hour of birth) Exclusive breastfeeding (0-<6m) Safe and appropriate infant and young child feeding in emergencies Continued breastfeeding (2 years or beyond) Complementary feeding (6-<24m) Complementary foods 1

6. Early initiation of breastfeeding Exclusive breastfeeding within one hour of birth saves infant and mothers’ lives 1

7. Steps to support early initiation Include early initiation of breastfeeding as a key intervention in reproductive health services and nutrition programmes Assess and support capacity of maternity services and traditional birth attendants to provide skilled breastfeeding support and encourage skin-to-skin contact Implement Baby-Friendly Hospital Initiative (BFHI) 10 steps to successful breastfeeding Promote early initiation of breastfeeding through antenatal services 1

8. Exclusive breastfeeding Only breastmilk, no other liquids or solids, not even water, with the exception of necessary vitamins, mineral supplements or medicines. 0-<6 months 1

9. Complement not substitute………… 1

10. 6-<24 month olds Support for continued breastfeeding for 2 years or beyond Introduce safe and appropriate complementary foods Frequentfeeding, adequatefood, appropriate texture and variety, active feeding, hygienically prepared (FATVAH) Complementary feeding 1

11. Complementary feeding is more than just food…… World Viision, Kenya 2009 1

12. Continuum of Infant and Young Child Feeding in South Sudan Source: Southern Sudan 2010 Household Survey abridged report, April 2011

13. Which do you think is the most effective intervention to prevent under five deaths? • Insecticide treated materials • Hib (meningitis) vaccine • Breastfeeding and complementary feeding • Vitamin A and Zinc 1

14. Answer:Breastfeeding and complementary feeding 1

15. Maternal and child undernutrition contributes to 35% U5 deaths Causes of death in children under 5, 2000-2003 UNDERNUTRITION underlies 53% of under five deaths Adapted from Bryce et al, Lancet 2005; Black et al, Lancet 2008 & Caulfield et al, Am J Clin Nutr 2002 1

16. The younger the infant, the more vulnerable The younger the infant, the more vulnerable if not breastfed Risk of death if breastfed is equivalent to one Age (months) 1 WHO Collaborative Study, Lancet, 2000

17. Protection and support of optimal infant and young child feeding is essential in both prevention and treatment of acute malnutrition Many emergencies characterised by increase in acute malnutrition prevalence Niger, 2005 95% of 43,529 malnourished children admitted for therapeutic care were U2 Defourny et al, Field Exchange, 2006. U2s contribute to global burden of acute malnutrition 1

18. Why is infant and young child feeding important in emergencies? Provides food security for the infant without dependence on supplies Reduces maternal bleeding after delivery by helping the uterus to contract Protects against pregnancy (birth spacing) Makes caring for baby easier Places less burden on the healthcare system Empowers mothers Reduces the risk of some cancers Gives long-term health benefits to the child Promotes bonding between mother and baby 1

19. Increases food insecurity and dependency Costly in time, resources and care Infant formula powder is not sterile Bottle and teats extra source of infection Bottle feeding increases risk No active protection Why artificial feeding is always risky Artificial feeding is always risky 1

20. A proportion of infants may not be breastfed when an emergency hits During an emergency, inappropriate aid may increase artificial feeding. Pre-emergencyfeeding practices may be sub-optimal Reasons for risky feeding practices Reasons for risky feeding practices 1

21. Risks of untargeted distribution fuelled by donations YogyakartaIndonesia post-2006 earthquake Relation between prevalence of diarrhoea and receipt of donated infant formula in children U2 Relation between prevalence of diarrhoea and receipt of donated infant formula, YogyakartaIndonesia post-2006 earthquake. Source: Hipgrave, et al: Accepted Public Health Nutrition Journal, 2010 1

22. Artificially fed infants are highly vulnerable in emergencies Mixed fed babies lose protection and invite infection 1

23. Managing artificial feeding in emergencies • Artificial feeding is where an infant or young child is fed with a breast milk substitute (BMS) • Infant formula is an appropriate BMS as it meets a specified formulation (Codex Alimentarius) • Infant formula is usually non-sterile powder, or a sterile liquid as a ready-to-use-infant-formula (RUIF) • If breastfeeding is not possible and breastmilk is unavailable, infants require a BMS: • until breastfeeding is re-established • or until at least 6 months of age • up to a maximum of 12 months • Cow’s milk is considered an appropriate BMS after 12 months 1

24. Indications for artificial feeding in emergencies • The mother has died or is absent for an unavoidable reason • The infant has been rejected by the mother due to having experienced rape or psychosocial trauma • Acceptable maternal or infant medical reasons for use of breastmilk substitutes • The infant was dependent on artificial feeding when emergency occurred • During relactation or whilst moving from mixed feeding to exclusive breastfeeding 1

25. Artificial feeding intervention Myanmar, 2008. A young infant and mother identified as in need of skilled support to establish breastfeeding and minimise the risks of artificial feeding. • Avoid, minimise and manage risks • Based on skilled assessment • Acceptable breastmilk substitute for as long as he or she needs it. • Expertise and capacity - breastfeeding counselling, logistics, supplies, medical and nutritional support and monitoring. • A last resort, when other safer options have been first eliminated. 1

26. Physical Immunological/Physiological Nutritional Psychological Practical Maternal Breastfeeding is a lifeline in emergencies 1

27. Ensure access to basic frontline feeding support Enabling access to age-appropriate, safe and appropriate complementary foods Frontline assistance to breastfeeding women and their children may involve: Enabling access to services Encouraging and supporting effective breastfeeding 1

28. Ensure access to basic frontline feeding support • Advise the family and mother how important the mother is to the nourishment and well being of her baby. • Encourage skin to skin contact between the mother and infant and frequent breastfeeding. • Refer the mother to any psychosocial services support available, and for medical assessment. • Register/ensure the family know how to access food, shelter • Refer for more specialised assistance for breastfeeding support, if/as available. • Be alert for donations of infant formula – a “good” media story. 1

29. Risk of HIV transmission from mother-to-child • Most HIV-positive mothers will not transmit HIV to their infants • Transmission of HIV virus from the HIV-positive mother may occur either during pregnancy, delivery or through breastfeeding • Transmission rate, without any antiretroviral drugs (ARV) intervention, is estimated at 5-10% during pregnancy • 10-20% during labour and delivery (the time of greatest risk) • The risk of transmission through breastfeeding is estimated at 5-20%, if a baby is breastfed for 2 years • Transmission through breastfeeding is more likely if a woman becomes infected with HIV during the breastfeeding period 1

30. What are infant feeding recommendations where HIV is prevalent? Consider HIV-free child survival (risk of HIV transmission and non-HIV causes of death) 1

31. Exclusive breastfeeding for the first six months, followed by continued breastfeeding for 2 years or beyond, with the introduction of safe and appropriate complementary feeding HIV status of motherunknown or HIV negative WHO recommendations on infant feeding and HIV (2010) If then 1

32. Mother is HIV-infected & on ARVs Exclusive breastfeeding for the first six months, followed by continued breastfeeding for at least 1 year, with the introduction of safe and appropriate complementary feeding WHO recommendations on infant feeding and HIV (2010) If then unless Replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) 1

33. Infant feeding and HIV Where HIV status of an individual mother is unknown or she is HIV negative, then recommended feeding practices are the same optimal feeding practices as for the general population, irrespective of the prevalence of HIV in the population. This offers the best chance of child survival. 1

34. True or false? If a mother’s HIV status is unknown, she should replacement feed until she knows it is safe to breastfeed An HIV-infected mother should breastfeed for 6 months only, then quickly switch to replacement feeding HIV-infected infants have a better chance of survival if breastfed HIV-infected mothers should be discouraged from breastfeeding if there are no ARVs available 1

35. True or false? If a mother’s HIV status is unknown, she should replacement feed until she knows it is safe to breastfeed A HIV infected mother should breastfeed for 6 months only, then quickly switch to relacement feeding HIV infected infants have a better chance of survival if breastfed HIV-infected mothers should be discouraged from breastfeeding if there are no ARVs available 1

36. Common misconceptions and myths with breastfeeding THESE ARE NOT TRUE: • Stress prevents mothers from producing milk or makes the milk dry up. • A malnourished mother cannot breastfeed. • When a woman has been raped, she cannot breastfeed. • The breastmilk has ‘gone bad’. • Breastmilk just goes away and that after a few weeks or months, all mothers lose their milk. • A mother should stop breastfeeding if the baby has diarrhoea. • Once stopped, breastfeeding cannot be started again. • A pregnant mother cannot breastfeed. • Women with breasts or nipples that are small, flat or soft cannot breastfeed. • Small babies need additional fluids such as water and tea. • HIV-positive mothers should never breastfeed. 1

37. Protection from commercial influences on infant feeding choices. • It does not ban the use of infant formula or bottles. • Controls how breastmilk substitutes, bottles and teats are produced, packaged, promoted and provided. • The Code prohibits free/low cost supplies in any part of the health care system. • Governments encouraged to take legislative measures. • Adoption and adherence to the Code is a minimum requirement worldwide. • Upholding the Code is even more critical in emergencies. The International Code of Marketing of Breastmilk Substitutes The International Code = World Health Assembly (WHA) Resolution (1981) + subsequent relevant WHA Resolutions 1

38. The companies who produce BMS Those involved in the humanitarian response Violations of the International Code in Emergencies International Code violations in emergencies Breastmilk substitute (BMS): “any food being marketed or otherwise represented as a partial or total replacement of breastmilk, whether or not suitable for that purpose” Emergencies may be seen as an opportunity to open or strengthen a market for infant formula & ‘baby foods’ or as a public relations exercise Often violations of the International Code in emergencies are unintentional but reflect poor awareness of the provisions of the Code 1

39. Infant and young child feeding is included in Sphere indicators to meet minimum standards on Food Assistance, Nutrition and Food Security • Infant and young child feeding is a key consideration for other sectors, e.g. WASH, Health, Security • Upholding the International Code and the Operational Guidance on IFE are central to meeting Sphere standards The Sphere Project 1

40. Minimum response in every emergency 1

41. Minimum response on IFE • Coordinated timely response informed by assessed need • Protective, well communicated policy & legislation • Simple measures across sectorsthat prioritise infants & young children and their carergivers • Basic interventions to protect and support optimal IYCF • Technical capacity • Strong communication • Capacity building (orientation & training) • Emergency preparedness • Accountable to actions and inaction 1

42. What must you do to protect and support safe and appropriate IFE? 1

43. Be ready with frontline assistance for mothers and children 1

44. A stressed mother can successfully breastfeed Acute stress can temporarily affect ‘let down’ or release of breastmilk. Reassuring support will help decrease a mother’s stress and increase her confidence. Protection, shelter, and a reassuring atmosphere will all help. Breastfeeding helps reduce stress in mothers. Breastmilk production is not affected by chronic stress. 1

45. A malnourished mother can successfully breastfeed Moderate malnutrition Does not affect breastmilk production but can affect micronutrient content. Micronutrient supplementation may be needed. Severe malnutrition Breastmilk production and quality may be reduced. Therapeutic care for mother and skilled breastfeeding support needed. Feed the mother and let her feed her baby 1

46. Skilled breastfeeding support Breastfeeding counselling is an emergency response 1

47. Prioritise pregnant and lactating women for shelter, food, water and security 1

48. Offer ‘safe places’ for breastfeeding and feeding support 1

49. Skilled support for challenging cases 1

50. Management of acute malnutrition in infants under 6 months • Currently management of infants <6 months is largely facility-based • Admission and discharge indicators should include breastfeeding status • Where appropriate infants <6 months should be included in nutrition surveys to determine programme coverage and burden of disease • For breastfed infants, case management should aim to restore exclusive breastfeeding • For non-breastfed infants, infant formula feeding should be supported for 12 months • Strategies with potential for effective community-based care include breastfeeding support, psychosocial support and women’s groups programmes 1