Infant and Young Child Feeding

Infant and Young Child Feeding
in Emergencies Orientation Some slides marked ‘bonus’ where, if time is limited, slide would be left out but the content still included. 1

What are optimal infant and young child feeding practices
Aims What are optimal infant and young child feeding practices The risks associated with sub-optimal feeding practices, especially in emergencies What does a minimum response on IFE involve Nature and source of key guidance and resources 2

The well-being of mothers is critical to the
What is IFE? 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. The well-being of mothers is critical to the well-being of their children. 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. The well-being of mothers is critical to the well-being of infants and young children. So the needs of mothers - or primary caregivers – is also a key consideration in IFE. 3

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) What are optimal IYCF recommendations? Safe and appropriate IYCF practices are optimal practices to minimise morbidity and mortality: Optimal IYCF recommendations are: Early initiation of exclusive breastfeeding (EBF) – this means breastfeeding within 1 hour of birth EBF for 6 months – exclusive breastfeeding means an infant receives only breastmilk, no other liquids or solids, not even water, with the exception of necessary vitamins, mineral supplements or medicines. Continued breastfeeding to 2 years or beyond. Complementary feeding encompasses continued breastfeeding, the introduction of complementary foods, and how that is done in the nutritional and developmental interests of the child. Complementary feeding (6-<24m) Complementary foods 4

Early initiation of breastfeeding
Supporting early initiation of exclusive and continued breastfeeding is the most effective intervention to reduce U5 deaths. Save one-fifth of neonatal deaths & reduce maternal post-partum haemorrhage One fifth of neonatal deaths (22%) could be avoided by breastfeeding within the recommended 1st hour after birth and 16% of neonatal deaths could be saved if all infants were breastfed from day 1. (Edmond, 2006) Early initiation of breastfeeding also reduces the risk of post-partum haemorrhage in the mother – a leading cause of maternal mortality worldwide. Edmond, K.M., et al. Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality. Pediatrics, (3): p. e BONUS SLIDE (information could be shared when describing summary slide on optimal IYCF recommendations) Exclusive breastfeeding within one hour of birth saves infant and mothers’ lives 5

Exclusive breastfeeding
Only breastmilk, no other liquids or solids, not even water, with the exception of necessary vitamins, mineral supplements or medicines. BONUS SLIDE (information could be shared when describing summary slide on optimal IYCF recommendations) 0-<6 months

Support for continued breastfeeding for 2 years or beyond
Complementary feeding 6-<24 month olds Support for continued breastfeeding for 2 years or beyond Introduce safe and appropriate complementary foods Frequent feeding, adequate food, appropriate texture and variety, active feeding, hygienically prepared (FATVAH) The complementary feeding is 6-<24 months. It concerns the introduction of safe, appropriate and nutritous foods to complement continued breastmilk. Sources of iron and zinc are especially important from complementary foods. Breastmilk continues to significantly contribute to energy and nutrient intake in children to 2 years of age or beyond. Complementary feeding involves not what is fed to the child but how it is fed – Frequent feeding, adequate food, appropriate texture and variety, active feeding, hygienically prepared (FATVAH) BONUS SLIDE (information could be shared when describing summary slide on optimal IYCF recommendations)

Insecticide treated materials Hib (meningitis) vaccine
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 Hib vaccine = Meningitis vaccination 8

Answer: Breastfeeding and complementary feeding
Preventative interventions Proportion of under 5 deaths prevented Exclusive and continued breastfeeding until 1 year of age 13% Insecticide treated materials 7% Appropriate complementary feeding 6% Zinc 5% Clean delivery 4% Hib vaccine Water, sanitation, hygiene 3% Antenatal steroids Newborn temperature management 2% Vitamin A Even in non-emergency situations, breastfeeding and complementary feeding interventions combined will prevent 19% (i.e. 1 in 5) of deaths in children under 5 years. Source: Jones et al. How many child deaths can we prevent this year? Lancet 2003; 362: 65–71 9

UNDERNUTRITION underlies 53% of under five deaths
Causes of death in children under 5, UNDERNUTRITION underlies 53% of under five deaths Maternal and child undernutrition contributes to 35% U5 deaths Why are optimal IYCF practices important? Maternal and child undernutrition is not an infectious disease, yet underlies 35% of U 5 deaths worldwide. Neonatal mortality is the biggest U5 killer. Outside the neontal period, the cause of death is often related to the disease pattern - diarrhoea & RTI, followed by malaria, measles, HIV Sub-optimal breastfeeding accounts for 1.4 million deaths and 10% disease burden in U5s. Black et al, 2008. REFERENCES ‘Fried egg’ modified from: WHO estimates of the causes of death in children Lancet 2005; 365: 1147–52 Jennifer Bryce, Cynthia Boschi-Pinto, Kenji Shibuya, Robert E Black, & WHO Child Health Epidemiology Reference Group* 35% from: Black et al, Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. Published Online January 17, DOI: /S0140 Reference for 1.5 million severe wasting: Caulfield LE, de Onis M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr 2002; 80: PubMed Adapted from Bryce et al, Lancet 2005; Black et al, Lancet 2008 & Caulfield et al, Am J Clin Nutr 2002 10

Risk of death if breastfed is equivalent to one
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 Infants who are not breastfed are at risk - the younger infants are, the more vulnerable they are, even in non-emergencies. This is reflected in these findings from a WHO collaborative study. Infants <2 months are nearly 6 times more likely to die if not breastfed. The risk falls but remains for older infants. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality, Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. The Lancet, (9202): p. 451–455. Age (months) WHO Collaborative Study, Lancet, 2000 11

Risks of not breastfeeding are even higher in emergencies
Conflict, Guinea-Bissau, 1998 Post-conflict, 9-20 month old children no longer breastfed were 6 times more likely to have died during the first three months of the war compared with children still breastfeeding. Before the conflict, there was no difference in mortality between breastfed and non-breastfed children before the conflict. Jacobsen, 2003. The risks of not breastfeeding are even higher in emergency contexts, and not just in infants. For example, in the months following conflict in Guinea-Bissau in 1998, there was a 6 fold difference in mortality between breastfed and non-breastfed children aged 9-20 months. Before the conflict, there was no difference in mortality between 9-20 month old children who were not breastfed before the conflict in Guinea-Bissau. Pre-conflict, these children may have been sicker and less healthy than their breastfeeding peers, but not to the degree as to impact on survival. This changed in the riskier enviornment of the emergency. So the same feeding pattern pre and post conflict carried a much higher risk in the emergency context. 12

Increased deaths (mortality)
Daily deaths per 10,000 people in selected refugee situations 1998 and 1999 Increased mortality in children U5 in emergencies people of all ages children under 5 years Deaths/10,000/Day The vulnerability of children U5 in emergencies is well recognised. This slide reflects mortality rates of children U5 compared to the total population in refugee camps. As you can see, the mortality is consistently higher in the children. Camp location Refugee Nutrition Information System, ACC/SCN at WHO, Geneva

U2s contribute to global burden of acute malnutrition
Many emergencies characterised by increase in acute malnutrition prevalence Niger, 2005 95% of 43,529 malnourished cases admitted for therapeutic care were U2 Defourny et al, Field Exchange, 2006. Children under 2 years are especially vulnerable in emergencies. The prevalence of acute malnutrition in children is often measured to indicate the nutritional state of the population. The problem of acute malnutrition in emergencies is reflected in admissions to selective feeding programmes that treat severe malnutrition. For example, in MSFs programme in Niger in 2005, 95% of 43,529 malnourished cases admitted for therapeutic care were under 2 years of age. Infant and young child feeding practices are a key consideration in U2s – both in how sub-optimal feeding practices contribute to malnutrition, and in terms of children who are malnourished need skilled feeding support as part of nutritional rehabilitation. Protection and support of optimal infant and young child feeding is essential in both prevention and treatment of acute malnutrition 14

Immunological/Physiological
Breastfeeding is a lifeline in emergencies Immunological/Physiological Nutritional Psychological Practical Breastfeeding is a lifeline for infants and young children in emergencies. Nutritional Immunlogical/Phsiological Practical Psychological Physical There are advantages for the mother: Maternal. Breastfeeding also benefits the family and wider community: See detailed notes on the different advantages by heading, that can be selected from to use in the presentation. You can ask the participants for suggestions for each category of ‘benefit’. (How much you expand on these will depend on the audience and time). Physical Maternal 15

Artificial feeding is always risky
Why artificial feeding is always risky No active protection Infant formula powder is not sterile Increases food insecurity and dependency Bottle and teats extra source of infection Bottle feeding increases risk Artificial feeding carries risk even in non-emergencies. It does not have the protection of breastmilk, it is not sterile, it increases food insecurity and dependency, it is costly in time, resources and care, and bottle feeding increases risk further due to difficulties in cleaning, adding a source of infection. Costly in time, resources and care 16

Artificial feeding is even riskier in emergencies
Bacterial contamination Limited supplies and poor resources Contaminated water The risks of artificial feeding are heightened in emergencies, with constraints on water and sanitation, fuel, preparation, storage and supplies. Emergencies are characterized by extremely infectious environments. Considerable skilled and well resourced support are needed to minimise the risks of artificial feeding in this environment. 17

Lessons from Botswana Many infants not breastfed (replacement feeding) Nov 2005 – Feb 2006: Unusually heavy rains, flooding, diarrhoea outbreak Year Time Period Cases U5 diarrhoea U5 Deaths 2004 Q1 8,478 24 2005 9,166 21 2006 35,046 532++ The vulnerability of infants who are artificially fed were reflected in Botswana in Here many infants were on replacement feeding as part of a national prevention of mother to child transmission (PMTCT) programme. Flooding led to contamination of water supplies and a largescale outbreak of diarrhoea that led to the death of many infants and young children. This table shows the escalation in cases of U5 diarrhoea and U5 death. CDC investigators of the outbreak found that the greatest risk for hospital admission for diarrhoea was not being breastfed. Many of those admitted had developed severe malnutrition, and had a history of recurrent diarrhoea. REF: creek et al, Role of infant feeding and HIV in an outbreak of severe diarrhoea and malnutrition among young children, Botswana, 2006. Creek et al, 2006

Reasons for risky feeding practices
A proportion of infants may not be breastfed when an emergency hits Pre-emergency feeding practices may be sub-optimal During an emergency, inappropriate aid may increase artificial feeding. There are many reasons why risky feeding practices may prevail in an emergency. Like we just saw, a proportion of infants may be artificially fed when an emergency hits. A population may have sub-optimal feeding practices, for example, low exclusive breastfeeding rates and mixed feeding, few iron and zinc rich complementary foods. Risky feeding practices may be reinforced or brought about by the emergency itself, e.g. untargeted distribution of infant formula leading to increased artificial feeding rates. The risks associated with sub-optimal practices are much greater in an emergency. So protection of appropriate feeding is needed, irrespective of whether they are pre-existing or ‘caused’ by the emergency. 19

Risks of untargeted distribution fuelled by donations
Yogyakarta Indonesia 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, Yogyakarta Indonesia post-2006 earthquake. Here is an example of negative impact of aid on child health following the 2006 earthquake in Indonesia. Donated infant formula was distributed to all children. This led to a significant increase in the prevalence of diarrhoea in children under 2. The rate of diarrhoea in children U2 who had received donations was more than double that of children who had not. 20

Artificially fed infants are highly vulnerable in emergencies
Mixed fed babies lose protection and invite infection This means that artificially fed infants are highly vulnerable in emergencies. Breastfed babies that use artificial feeds (called mixed feeding) are also at risk. Introducing artificial feeds – especially to infants < 6m – reduces the benefits of breastfeeding, and exposes the infant to all of the risks of artificial feeding. Especially in an emergency environment, even a little artificial feeding will carry risk. 21

What are infant feeding recommendations where HIV is prevalent?
Consider HIV-free child survival (risk of HIV transmission and non-HIV causes of death) One of the questions many ask, is what are infant feeding recommendations in emergency affected populations where HIV is prevalent To answer this, HIV-free child survival is a key consideration. This looks not just at the risk of HIV transmission but the risk of mortality from non-HIV infectious disease. This consideration of child survival, not just HIV transmission, is reflected in the current WHO recommendations. This is especially important to consider in emergencies, given the risky environment of an emergency for a non-breastfed infant.

HIV status of mother unknown or HIV negative
WHO recommendations on infant feeding and HIV (2007) If HIV status of mother unknown or HIV negative then 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 WHO recommends that: If the HIV status of a mother is unknown or she is HIV negative, then recommended feeding practices are the same as optimal feeding practices for the general population.

Mother is HIV-infected
WHO recommendations on infant feeding and HIV (2007) If Mother is HIV-infected then 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 If the mother is HIV-infected, then feeding practices as for the general population are recommended, unless replacement feeding meets all the AFASS conditions. The most appropriate infant feeding option for a HIV-infected mother should depend on her individual circumstances, including her health status and the local situation, but should take greater consideration of the health services available and the counselling and support she is likely to receive. unless Replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS)

This offers the best chance of child survival.
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. This means that in a population where the HIV status of a mother is unknown or she is HIV negative, then recommended feeding practices are the same as for the general population irrespective of the HIV prevalence. These recommendations give the best chance of child survival to infants and young children.

What is IFE concerned with?
Protection and support Breastfed infants: early initiation, exclusive and continued breastfeeding Non-breastfed infants: minimise the risks of artificial feeding All infants and young children: appropriate and safe complementary feeding Well-being of mothers: nutritional, mental & physical health Breastfed infants: early initiation, exclusive and continued breastfeeding Non-breastfed infants: minimise the risks of artificial feeding All infants and young children: appropriate and safe complementary feeding Well-being of mothers: nutritional, mental & physical health Given all these considerations, we can now appreciate more closely what IFE is about. At the very beginning of this session, we began by saying that IFE is concerned with protection and support of safe and appropriate infant and young child feeding in emergencies. More specifically we’ve now learned that this concerns protection and support of breastfed and non-breastfed infants and young children. For breastfed infants, this means early initiation, exclusive and continued breastfeeding For non-breastfed infants, this means minimising the risks of artificial feeding For all infants and young children, this means appropriate and safe complementary feeding The well-being of mothers is critical to the well-being of infants and young children. So the needs of mothers - or primary caregivers – is also a key consideration in IFE. How can we meet these needs? To help, there are some key policy guidance and frameworks and strategies to be aware of. 26

Key global legislation, frameworks, strategies & initiatives
The International Code of Marketing of Breastmilk Substitutes (International Code) The rights of women and children UNICEF conceptual framework Operational Guidance on IFE International law and frameworks The Sphere Humanitarian Charter and Standards Millennium Development Goals There are many strategies and frameworks, collaborations and policy guidance, to guide our thinking and help meet our responsibilities towards IFE. They are complementary, draw and build upon each other to build a protective policy framework. Three of these are especially relevant to IFE – the International Code, Sphere, and the Operational Guidance on IFE that we will refer to. Bonus information (use depends on audience and time): Article 24 of the Convention of the Rights of the Child specifies that parents have the right to access to education and are supported in the use of basic knowledge of child health and nutrition, including the importance of breastfeeding. It specifies that international cooperation is needed to realise this right. The UNICEF conceptual framework of the causes of malnutrition has been widely applied to emergency contexts. It considers infant and young child feeding and care as one of the underlying causes of malnutrition.1] The benefit of strategies targeting infant and young child feeding are reflected in all eight of the UN Millennium Development Goals, in particular MDG 4 (reduce child mortality). The WHO/UNICEF Global Strategy on Infant and Young Child Feeding was adopted by the World Health Assembly in The Strategy identifies our obligation to provide appropriate feeding support for infants and young children in emergencies and the development of the knowledge and skills base of health workers working with carers and children in such situations. The Sphere humanitarian charter and standards specify the minimum acceptable levels to be attained in humanitarian response. Infant and young child feeding is reflected in key Sphere indicators in nutrition, food security and food aid that determine whether Sphere standards have been reached. Innocenti Declaration 2005 called for government and donor commitment to increase resources for infant and young child feeding as a key child survival strategy and to implement the Global Strategy. Global strategy for Infant and Young Child Feeding Innocenti Declaration (2005) Baby friendly initative 27

The International Code of Marketing of Breastmilk Substitutes
The International Code = World Health Assembly (WHA) Resolution (1981) + subsequent relevant WHA Resolutions 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 BMS is referred to as the Code or the International Code. The Code of Marketing of BMS was adopted as a WHA Resolution in Subsequent relevant WHA resolutions have equal weight. The are collectively known as ‘the Code’. The Code is intended to protect the mothers/carers of both breastfed and non-breastfed infants and young children from commercial influences on their infant feeding choices. It does not ban the use of infant formula or bottles, but controls how they are produced, packaged, promoted and provided. The Code prohibits free/low cost supplies in any part of the health care system. Governments encouraged to incorporate the Code in legislation. However compliance with the Code does not depend on legislation - adoption and adherence to the Code is a minimum requirement worldwide. The Code is even more critical in emergencies. 28

International Code violations in emergencies
Violations of the International Code 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 a opportunity to open or strengthen a market for infant formula & ‘baby foods’ or as a public relations exercise The companies who produce BMS Those involved in the humanitarian response Products that meet the Code definition of a breastmilk substitute are said to be within the scope of the Code. For the purpose of the Code, a breastmilk substitute is: “any food being marketed or otherwise represented as a partial or total replacement of breastmilk, whether or not suitable for that purpose.” Violations of the Code may be perpetrated by companies who see it as a marketing opportunity, or by those involved in the humanitarian response. So active upholding the provisions of the Code is essential in emergencies. Often violations of the International Code in emergencies are unintentional but reflect poor awareness of the provisions of the Code 29

The Sphere Project Infant and young child feeding is included in Sphere indicators to meet minimum standards on food aid, 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 was launched in 1997 by a group of humanitarian NGOs and the Red Cross. It aims to improve the quality of assistance to people affected by disaster and improve the accountability of states and humanitarian agencies to their constituents, donors and the affected populations The Sphere Project has developed a humanitarian charter and a set of standards that specify the minimum acceptable levels to be attained in humanitarian response. Infant and young child feeding is included in Sphere indicators to meet minimum standards in food security, nutrition and food aid Infant and young child feeding is a key consideration for other sectors, e.g. WASH, health, security Upholding the International Code and the next policy guidance we review, the Operational Guidance on IFE, are central to meeting Sphere standards in emergency response.

Minimum response in every emergency
The OG on IFE is a brief non-technical guidance for all those involved or concerned with emergency response anywhere in the world. There are many challenges to meeting our responsibilities towards IFE and The Operational Guidance on IFE was developed to help to put global policies, strategies and frameworks into practice, informed by emergency experiences over the past 10 years. The OG is built on the WHO guiding principles for infant feeding in emergencies and the Global Strategy on IYCF, in particular. The International Code is integrated in the Operational Guidance on IFE and built upon to respond to the particular challenges of upholding the provisions and spirit of the Code in emergencies. The Operational Guidance on IFE and IFE content, including training modules and resources have been developed in an international interagency collaboration called the IFE Core Group. These materials and more supporting content are housed at the ENN, the coordinating agency. In every emergency, there are risks from sub-optimal feeding practices. The degree of risk will depend on the situation (including the nutritional status of the population affected, the water and sanitation conditions, the food security of the population, etc). So every emergency needs a minimum response on IFE. This minimum response is reflected in the Operational Guidance on IFE.

What must I do to protect and support safe and appropriate IFE?

Look at every situation through the eyes of a mother and child
To appreciate what needs to happen in a minimum response, try to look at every situation through the eyes of a mother and child. Can you spot the mother with the baby on her back in this scene? (TOP, FACING LEFT) If you were that mother, how would you feel? How could you improve the situation for mothers like her? (Example: Separate distribution point for water for mothers with U2’s, or priority for mothers with children U2 at general distribution sites). Look at every situation through the eyes of a mother and child

Be ready with frontline assistance for mothers and children
What sort of difficulties do you think this mother is facing, having walked miles to reach a displaced camp, for example? (Tired, hungry, dehydrated, scared, missing family). How can the ’aid effort’ immediately respond? (Food, shelter, fluid, register for services e.g. food ration, rapid assessment of the infant, support for breastfeeding, e.g. breastfeeding corner, put in touch with services as needed, e.g. family tracing). Be ready with frontline assistance for mothers and children

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. A stressed mother can successfully breastfeed. Acute stress can temporarily affect ‘let down’ or release of breastmilk. So this may make the mother think she has not enough breastmilk. Reassuring support will help decrease a mother’s stress and increase her confidence. Reassuring support, protection, shelter will all help. Breastfeeding helps reduce stress in mothers. Breastmilk production is not affected by chronic stress.

Feed the mother and let her feed her baby
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. A malnourished mother can sucessfully breastfeed. A moderately malnourished woman can still successfully breastfed her baby. However this is at the expense of her own nutritional stores, So she will need nutritional support to replenish and protect her own nutritional status, and to sprotect the micronutrient content of her breastmilk. Breastmilk production may be reduced if a woman is severely malnourished. The quality of milk (in terms of micronutrients) may also be affected. Then the woman herself needs immediate therapeutic feeding and care. Even in such cases, the woman needs support to continue to offer her baby the breast, so as to maintain the milk-making process while she recovers her own nutrition. Feed the mother and let her feed her baby

Offer ‘safe places’ for breastfeeding and feeding support
Offer ‘safe places’ for breastfeeding and infant feeding support. This is important to set up early in emergency response, to identify any problems and respond sooner. Grab opportunities to work across sectors to achieve this, for example, psychosocial services may have child centred or child safe spaces that you can combine services with. Offer ‘safe places’ for breastfeeding and feeding support

Prioritise pregnant and lactating women for shelter, food, water and security
Pregnancy is a physiologically demanding but normal process Undernourished mothers/breastfeeding low birth weight infants (LBW) have increased needs As we saw earlier, moderately malnourished mothers need nutritional support and feeding support. Severely malnourished need therapeutic care and feeding support

Make sure every newborn initiates breastfeeding within 1 hour of birth
Just imagine the difference that optimal breastfeeding could make in an emergency. Take a newborn infant, born into a situation of insecurity and poor sanitation, with dirty water, scant food and no shelter. Extreme weather conditions, lack of skilled birth attendance and medical care, and premature birth increase risks even further, both for the infant and the mother. Skin-to skin contact from immediately after birth and initiation of breastfeeding within one hour reduces deaths by nourishing and actively protecting the infant, and helping to stabilise his/her body temperature. It also reduces the risk of post-partum haemorrhage in mothers. 39

Ensure access to safe and adequate complementary foods, appropriate to needs and context
It is important to provide for the complementary feeding needs of U2s in every emergency. As we saw earlier, one important part of this is providing safe and appropriate complementary foods. There are many strategies that are used in emergency contexts to provide access to complementary foods, that will depend on the situation. Here are some examples: L to R: Food and meal preparation demonstrations using local foods, in Dadaab, as part of IYCF programme A mother in Guatemala prepares porridge from soy-fortified bulgur. Distribution of a type of lipid nutrient supplement to vulnerable children in Niger. As well as prioritising access to complementary foods, it is important to enable the many other elements of complementary feeding, including support for continued breastfeeding, supplying resources for hygienic preparation of food, resources and responsive feeding.

Locate technical capacity
In some emergencies, simple measures and basic interventions may be all that is needed to protect and support safe and appropriate IFE. In others, technical interventions on IFE may be needed to deal with more challenging needs of both breastfed and non-breastfed infants and young children. For example, skilled breastfeeding support may be needed to support relactation or to support the mother of a severely malnourished infant. If infants are not breastfed, then skilled support is needed to minimise the risks of artificial feeding in this environment. This may be at an individual level, for example an orphaned infant, or at a population level, for example where a considerable proportion of infants are not breastfed. In the first example here, a wet nurse who was supported to relactate an abandoned baby in Myanmar during the cyclone response in 2008. The second example is of unaccompanied infants during the Rwanda crisis that needed urgent support. Wet nurse relactates an abandoned baby (Myanmar, 2008) Unaccompanied infants with no source of breasmilk (Rwanda, 1994)

Coordination is critical
UNICEF lead coordinating agency on IFE within UN system IASC Nutrition Cluster Core Commitments to Children In collaboration with government & other agencies Specification detailed in the Operational Guidance on IFE Coordination on IFE is a critical part of a minimum response on IFE. Within the UN system, UNICEF is the lead agency on IFE, both within the IASC Nutrition Cluster approach and reflected in UNICEFs Core Commitments to Children. This role is in collaboration with the government and other UN agencies, NGOs. What coordination involves is included in the Operational Guidance on IFE.

Do not seek or accept donations of BMS, bottles & teats
Donated (free) or subsidised supplies of breastmilk substitutes (e.g. infant formula) should be avoided. Donations of bottles and teats should be refused in emergency situations. Any well-meant but ill-advised donations of breastmilk substitutes, bottles and teats should be placed under the control of a single designated agency. Operational Guidance on IFE, v2.1, Feb, 2007 We saw earlier the impact of untargeted donations on child health in Indonesia. In some emergency contexts, donations of infant formula, milk, bottles and teats are common and as well as exposing infants and young children to risk, take up valuable time and resources in the aid effort. There are many examples of Code violations in emergencies that arise through donations. Informed by experiences in emergencies over the last 11 years and more, the Operational Guidance on IFE has a clear position on donations – do not solicit or accept them in emergencies, and report on Code violations. Contacts for reporting are included in the Operational Guidance on IFE, and a Code monitoring form is available on the ENN website, 43

International Code in emergencies
Emergency preparedness: Strong, enforced national legislation Protection: Uphold provisions of the International Code The International Code has a key role in protection in a minimum response on IFE. Key emergency preparedness is developing strong national Code legislation – this strengthens the weight of the Code and makes it more possible to hold people to account for violations. Many violations of the Code in emergencies have been associated with donations. So avoiding donations – and having clear plans to handle donations that do arrive – will help uphold the provisions of the Code. Monitoring and reporting on Code violations is an essential contribution to developing accountability in emergency response. The ICDC (International Code Documentation Centre, in Penang), produced ‘Focus on the Code in emergencies’ in It is a great documentation and reference on the experiences of Code implementation – and the many violations that happen – in emergencies. FOCUS is available from in Resources library. Accountability: Monitor and report on Code violations 44

Do not distribute milk powder or liquid milk as a single commodity
Dried milk products should be distributed only when pre-mixed with a milled staple food and should not be distributed as a single commodity Dried milk powder may only be supplied as a single commodity to prepare therapeutic milk (using a vitamin mineral premix such as therapeutic CMV) for on-site therapeutic feeding. 6.4.2 Operational Guidance on IFE, v2.1, Feb, 2007 There is no distribution of free or subsidised milk powder or of liquid milk as a single commodity Key Indicator. Food Aid Planning Standard 2. Sphere, 2004 Both the Operational Guidance on IFE and Sphere have a clear position regarding distribtion of milk in emergencies. This position is also reflected in the UNHCR guidance on handling milk and milk products in refugee settings. 45

Communicate clearly on IFE
Should be… Consistent Technically sound Strong Responsive Innovative Press offices and general media are key influences Communication is central to strong coordination. This is an example of a poster developed in Indonesia, by a communication team (CREATE) informed by mother focus groups. For them, the cost of artificial feeding was a strong message. A guide for the media has been developed by the IFE Core Group, and is available on the ENN website. resources

Orientation of key ‘players’:
Nutritionists & breastfeeding counsellors Health and nutrition staff Media and press agencies Donors Military Water and sanitation staff Capacity building and training of nutrition and health staff Be prepared and prepare others To achieve a minimum response on IFE, orientation of key players is key – not just nutrition staff, but health, reproductive…… For those staff directly involved with mothers/caregivers and children, then training is essential. There are key resources out there to help with this (see later, Module 2 on IFE). This is a good preparedness activity, e.g. integrating IFE into health staff training curriculum. Emergency preparedness should not be a ‘standalone’ exercise – many elements should be part of routine infant and young child feeding programming. DoD photo by: TSGT PERRY HEIMER

Minimum response on IFE
Coordinated timely response informed by assessed need Protective, well communicated policy & legislation Simple measures across sectors that 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 In summary, there are many elements to consider in a minimum response on IFE, at many different levels. A minimum response on IFE involves coordination, assessment, policy development, basic protection and support across sectors, and technical capacity to meet needs, strong communication, capacity building, emergency preparedness, and accountability – both for actions taken, and for failure to protect and support IFE. These are reflected in the Operational Guidance on IFE, so it a key reference to guide you. Note for presenter: If time is short, then use the information on the previous slides to prepare for discussion that could centre on this summary slide, where each element is discussed in more detail with a group, for example.

The best emergency preparedness is a confident, well mother capable of nourishing her child.
The best emergency response is one that works with her to protect and support her confidence and capacity. The best emergency preparedness is a mother with confidence and capacity to optimally feed her child. The best emergency response is one that works with her to protect and support that confidence and capacity and does not undermine it. Venezuala, after the flood 49

Are you ready? Emergency preparedness not a ‘standalone’ exercise, many elements reflect strong routine IYCF programming. Can you think of emergency preparedness activities, given the considerations of a minimum response on IFE? Examples: Development of national policy on IFE/integrate IFE into IYCF policy, identify skilled breastfeeding support capacity in country, eg La Leche League, BFI, produce preparedness plans for dealing with individual cases of artificially fed infants, develop key contacts and meet with other sectors to cross-check provision for U2s, eg reproductive health and whether early initiation of BF included, support programmes to optomise IYCF – strong practices are the best preparedness for emergencies, legislate for the Code and monitor and report on violations. Note for presenter: Can insert logo of agency, for example, as background to this slide. 50

Access resources at www. ennonline.net/ife
Key Resources & Initiatives This is just a selection of resources. There are also useful working materials, such as a generic IFE policy, model joint statement on IFE, form to monitor violations of the Code, guide for the media on IFE. Module 1 is useful resource for orientation of all those concerned with emergency response. It includes an online self-learning package, modelled on the provisions of the Ops Guidance on IFE and going into the detail of many of the issues touched on in this presentation. Module 2 includes the details of how to assess and support optimal IFE in individual cases, especially with regard to breastfeeding and including low birth weight infants, and moderately and severely malnourished infants. Chapter 8 deals with severely malnourished infants <6m and Chapter 9 wityh managing non-breastfed infants. A recent content produced by members of the IFE Core Group, funded by the Nutrition Cluster, is a training content on IYCF to integrate into CTC/CMAM programming. This has been piloted in Sierra Leone and Zimbabwe and is available from the ENN. Access resources at www. ennonline.net/ife

Current members and associate members:
Collaborative effort on IFE Current members and associate members: WHO The Operational Guidance on IFE and IFE content, including training modules and resources have been developed in an international interagency collaboration called the IFE Core Group. These materials and more supporting content are housed at the ENN, the coordinating agency. WFP 52

The IFE Core Group gratefully acknowledge the support of UNICEF-led IASC Global Nutrition Cluster to their coordinating agency, the Emergency Nutrition Network (ENN), to develop this content

EXTRAS

An emergency can happen anywhere
An emergency is extraordinary situation of natural or political origin that puts the health and survival of a population at risk. An emergency can happen anywhere 55

42 countries account for 90% U5 deaths
Six countries - India, Nigeria, China, Pakistan, Democratic Republic of the Congo and Ethiopia -account for half of under five deaths worldwide, while 42 countries account for 90%. Almost all deaths are from low income countries or poorer areas of middle income countries (Black et al, 2003). These countries reflect where many emergencies happen and where the risk of illness and death in children that are already vulnerable escalates further. 42 countries account for 90% U5 deaths 6 countries account for 50% of U5 deaths

Integrated, multi-sectoral interventions
11 Key Points Policy Training Co-ordination Monitoring Integrated, multi-sectoral interventions Minimise risks of artificial feeding Practical Steps These are reflected in the provisions of the Ops Guidance on IFE are summarised in 11 key points and detailed in 6 practical steps.

Every agency should develop a policy on IFE.
Key points of the Operational Guidance on IFE Appropriate and timely support of infant and young child feeding in emergencies (IFE) saves lives. Every agency should develop a policy on IFE. Training and orientation of all technical and non-technical staff in IFE UNICEF is likely co-ordination agency on IFE in the field. Integrate key information on infant and young child feeding into routine rapid assessment procedures 58

Simple measures put in place early in response Integrated support
Key provisions of the Operational Guidance on IFE Simple measures put in place early in response Integrated support Include foods suitable for older infants and young children Avoid donations or subsidised supplies of breastmilk substitutes, bottles and teats Technical personnel must decide whether to accept, procure, use or distribute infant formula Breastmilk substitutes, other milk products, bottles and teats must never be included in a general ration distribution. 59

HIV and infant feeding in emergencies
The risks of infection or malnutrition from using breastmilk substitutes are likely to be greater than the risk of HIV transmission through breastfeeding. Therefore, support to help all women to achieve early initiation and exclusive breastfeeding for the first six completed months and the continuation of breastfeeding into the second year of life are likely to provide the best chance of survival for infants and young children in emergencies. Operational Guidance on IFE, 5.2.8, v2.1, Feb 2007. The WHO 2007 recommendations and the concern with child survival (rather than solely HIV transmission) are reflected in the recommendations of the Ops Guidance on IFE. Some provisions are extracted here.

Simple measures and basic interventions
Shelter, water, food, security to U2 households Registration of vulnerable groups, e.g. orphans Supportive places to breastfeed Priortise pregnant and lactating women Complementary feeding needs Newborns: early initiation of breastfeeding Frontline support: breastfed & non-breastfed infants Here is an outline of basic interventions in an emergency to protect and support safe and appropriate IFE. We have touched on these in our discussions. Most of these are not ‘standalone’ interventions on IFE, but should be integrated into programming. Also, many are not ‘nutrition’ interventions but are cross-sectoral. For example: Early initiation of breastfeeding & reproductive health services Priority for water and sanitation, and shelter These basic interventions a reflection of the provisions of the Operational Guidance on IFE. So this is a key guidance to refer to as you prepare for and respond to any emergency.

What actions can you take?
Look at your country situation Identify challenges Assign actions and responsibilities Get ready Consider this slide if want to incite action…….. Look at your country situation Identify your challenges Assign actions and responsibilities Get prepared…………..

Use this case study to explore different elements of a minimum response on IFE.

Emergencies are highly infectious environments
Summary points Emergencies are highly infectious environments Breastfeeding and complementary feeding are life saving interventions U2s are highly vulnerable, the younger the child the greater the risk Non-breastfed infants are particularly at risk of malnutrition, illness and death Artificial feeding is risky, difficult & resource intensive Donations and untargeted distribution of milk increase morbidity in children HIV-free child survival, not just HIV transmission, is a key consideration 64

Infant and Young Child Feeding

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