1. INFANT AND YOUNG CHILD FEEDING IN EMERGENCIES Acknowledgements: Harmonised Training Package v2, 2011. Ali Maclaine, Senior Humanitarian Nutrition Advisor, Save the Children

2. Learning Objectives • Define optimal infant and young child feeding practices • Discuss their relevance in emergencies • Identify key policy guidance relevant to IYCF-E • Identify emergency preparedness activities 1

3. What is IYCF-E? • IYCF-E 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. 1

4. Photo credit: by Heldur Netocny/Lineair Vietnam conflict, 1990

5. Mozambique floods Rositha - born in a tree

7. Angola

8. Zaire (DRC), 1994

9. Zaire (DRC), 1994

10. USA hurricane USA hurricane Associated Press

11. 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

13. Early initiation of breastfeeding Exclusive breastfeeding within one hour of birth saves infant and mothers’ lives 22% of neonatal deaths could be avoided by early initiation of breastfeeding 16% of neonatal deaths could be saved if all infants were breastfed from day 1. 1

14. 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

15. Effective Breastfeeding • Attachment • Positioning • Frequent Feeding • Confidence!

16. Evaluating attachment 2 1

17. Complementary feeding • 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

18. 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

19. Answer:Breastfeeding and complementary feeding 1

20. More breastfeeding gives more protection

21. Causes of death in children under 5, 2000-2003 UNDERNUTRITION underlies 53% of under five deaths Maternal and child undernutrition contributes to 45% U5 deaths Adapted from Bryce et al, Lancet 2005; Black et al, Lancet 2013 & Caulfield et al, Am J Clin Nutr 2002

22. 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

23. Artificial feeding is even riskier in emergencies Bacterial contamination Limited, insecure supplies and resources Contaminated water Daily survival takes time/energy Lack of knowledge

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

25. Donations to Lebanon Photo credit: Ali Maclaine, 2006

26. EQ Yogyakarta & C Java, Indonesia - 2006 • Statistical correlation between those who received donation and diarrhoea • Increase in consumption of formula if received a donation

27. Common misconceptions and myths with breastfeeding, especially in emergencies THESE ARE NOT TRUE: • Stress prevents mothers from producing milk or makes the milk dry up. • A malnourished mother cannot breastfeed. • The breastmilk has ‘gone bad’ • Breastfeeding passes on sadness / tension to baby • 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. • Babies in hot countries need additional fluids such as water and tea. • HIV-positive mothers should never breastfeed. 1

28. Lack of appropriate complementary foods

29. Key global legislation, frameworks, strategies & initiatives for IYCF-E The International Code of Marketing of Breastmilk Substitutes & relevant resolutions (International Code) The rights of women and children UNICEF conceptual framework Operational Guidance on IYCF-E International law and frameworks The Sphere Humanitarian Charter and Standards Millennium Development Goals Global strategy for Infant and Young Child Feeding Innocenti Declaration (2005) Agency Specific Policies Baby friendly initative

30. International Code of Marketing of Breastmilk Substitutes • The Code = 1981 + all subsequent relevant WHA Resolutions • Minimum requirement • Enact government legislation • Does not prohibit the use of artificial feeding • but the way in which they are procured, packaged and distributed

31. International Code in emergencies Emergency preparedness:Strong, enforced national legislation Protection:Uphold provisions of the International Code Accountability:Monitor and report on Code violations

32. Applies worldwide WHA Resolution 63.23, 2010

33. Latest guidance from WHA: Resolution 63.23 (May, 2010) Urges Member States: “to ensure that national and international preparedness plans and emergency responses follow the evidence-based Operational Guidance for Emergency Relief Staff and Programme Managers on infant and young child feeding in emergencies, which includes the protection,promotion and support for optimal breastfeeding, and the need to minimize the risks of artificial feeding, by ensuring that any required breast-milk substitutes are purchased, distributed and used according to strict criteria”

34. Current members and associate members: WHO WFP www.ennonline.net/ife

35. The Sphere Project • Two new IYCF standards in Sphere 2010. • Infant and young child feeding standard 1: Policy guidance and coordination • Infant and young child feeding standard 2: Basic and skilled support • Cross-cutting issue for other sectors, e.g. WASH, reproductive health, shelter • Upholds Operational Guidance on IYCF-E and the Code

36. Operational Guidance: 6 Practical Steps 1. Endorse or develop policies on infant feeding 2. Train staff (all sectors) 3. Coordinate operations 4. Assess and monitor 5. Protect, promote and support optimal IYCF 6. Minimise the risks of artificial feeding

37. A) Basic interventions to create an enabling environment to breastfeed • Prioritise mothers/caregivers for essential needs – household food, water, shelter, security • Register households with infants/young children • Establish secure and supportive places for breastfeeding • Provide for nutritional needs of PLW • Provide complementary foods 6m-2 years • Support for early initiation & exclusive breastfeeding for newborns • Consistent and appropriate communications • Prevent donations, inappropriate distribution and use of BMS, which undermine breastfeeding. Handle donations that do arrive. • Ensure appropriate frontline feeding support

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

39. Technical interventions to help specific breastfeeding problems in the form of skilled counselling by appropriately trained staff.

40. Non-breastfed infants in the population? Relactation, Wet nurses, Milk banks are preferred options as safer than infant formula Breastfeeding supplementer Photo credit: Yvonne Hughes, ACF, Afghanistan Relactation using supplemental-suckling by Grandmother in Afghanistan - ACF

41. Artificial feeding intervention Avoid, minimise and manage risks No donations or subsidised formula Based on skilled assessment Acceptablebreastmilk substitute (codex standard, Code compliant) 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 Myanmar, 2008. A young infant and mother identified as in need of skilled support to establish breastfeeding and minimise the risks of artificial feeding.

42. Haiti RUIF, 2010 Photos: A. Maclaine, 2010

43. RUIF SUPPLIES – HAITI Photo: V. Sibson. SC UK

44. Pictures from Myanmar, Cyclone Nargis, 2008 Photo credit: N. Berry Generic labelled PIF Guidelines on the preparation, use and storage of powdered infant formula in emergencies Powdered BMS ‘Kit’

45. Minimising risks of inappropriate milk products and artificial feeding • Replace bottles and teats with cups and spoons whenever possible.

46. 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

47. 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)

48. 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

49. 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

50. http://www.unicef.org/videoaudio/PDFs/IYCF_programming_guide_May_26_2011.pdfhttp://www.unicef.org/videoaudio/PDFs/IYCF_programming_guide_May_26_2011.pdf