Nutrition in Emergencies – Training materials

Objective: to reflect on risks of artificial feeding, infant formula and milk products use in emergency situations and appreciate possible mitigation solutions.

Group exercise (participants either works in pairs or as round table)

Please read the following examples of interventions and discuss whether this is a suitable intervention or not, stating why.

Are any of the proposed interventions a potential Code violation?

Scenario 1:

After an earthquake devastated a capital city, many people are homeless and have lost all their belongings. They live in makeshift camps or evacuation centers. Many mothers had been feeding their babies both breastmilk and artificial milk before the earthquake. They are requesting milk for their babies, as they are used to mixed feeding. Since the earthquake, there are reports that mothers are having difficulty breastfeeding, particularly those with infants under six months of age. Your team is preparing to distribute kits to the victims including tarpaulin, soap, cooking set, blankets etc. A colleague proposes to include two boxes of powder infant formula, together with a baby bottle in each kit to answer to the needs of those mothers.

Do you agree with this proposition? Why? If not, what could be done?

Model answer:

This is not a good idea. The Operational Guidance on IYCF-E recommends that there is no untargeted distribution of breastmilk substitutes such as powder infant formula (PIF). Untargeted distribution of PIF with no guarantee of supply for as long as the infant needs it is a Code violation (WHA resolution 47.5 and 63.23[1]). Giving a mother infant formula in this way will decrease her breastmilk production further, as the more the baby suckles, the more breastmilk is produced. After those two boxes are finished, the mother will have no access to additional milk. The hygiene, access to safe water and sanitation in the camps are likely to be poor. This means that the use of powdered infant formula poses a large threat to the health of the children, putting them at risk of diseases such as diarrhea, pneumonia, malnutrition and even death. Baby bottles are difficult to clean and pose an additional risk of infection. Rather than PIF supplies, these mothers need skilled breastfeeding support. Where the infant is less than six months of age, support to establish/re-establish exclusive breastfeeding is the best option.

Scenario 2:

You are in charge of a health clinic in an emergency setting. The Director of your organization (an international staff) says that a food manufacturer from his home country wishes to donate 5 MT of infant formula. He proposes to accept this, so you can provide it to those infants who have lost their mothers. The staff can make a thorough assessment of whether breastfeeding is indeed not possible, and each child can be followed individually to assess his/her health throughout the whole period where infant formula is provided. Will you agree with this proposition? Why? If not, what could be done?

Model answer:

The Operational Guidance on IYCF-E recommends that donations of infant formula (and any other BMS, bottles and teats) are not accepted in emergencies. Donations are often in the wrong language and are supplied disproportionate to need. It is unlikely that you will need 5 MT of infant formula for the individual cases that present to your clinic. Any supplies should be purchased, labelled in the local language and meet Codex Alimentarius requirements. Note that distribution of donated supplies through a health facility is a Code violation. The quantities of infant formula that need to be purchased should be based on the assessment of needs, taking into account that the children enrolled in the program receive the formula for as long as needed. This donation should not be accepted. See below for guidance in situations whereby after an individual assessment an infant or young child is categorized as eligible for BMS.

Scenario 3:

You are part of a team that assesses the needs of the population in an emergency to then derive recommendation on what actions need to be taken. A person from the Child Protection team informs you that the disaster has caused a lot of deaths and that many children are orphaned or separated from their parents. Among them, there are even small infants and young children, for whom they have not been able to find family to care for. The person says there is an urgent need for infant formula for the young infants. What will you recommend?

Model answer:

From the UNICEF SOPs on the management of BMS in humanitarian settings: infants and young children under the age of two who, after an individual assessment are determined to be classified in one of the categories below, are eligible for BMS:

1)      Infants and young children who were orphaned or whose mother has been absent for a long period of time before the humanitarian situation and there is no option to wet-nurse,

2)      Infants and young children who have become orphaned or whose mother is absent for a long period of time in the course of the humanitarian situation and there is no option to wet-nurse,

3)      Extremely rare situations where the mother and/or infant has a medical condition during which breastfeeding is not possible and there is no option to wet-nurse. (ref. WHO and Ebola)

4)      Infants and young children who were not breastfed at the time the humanitarian situation developed regardless of the reason (including infants whose mothers are in the process of re-lactating but whose milk supply is not yet sufficient, and for whom there is no option to be breastfed (including through re-lactation or wet-nursing).

This is a situation where there is indeed a need for BMS (guidance is available of the choice of the type of BMS and how to estimate needed quantities from UNICEF SOPs on BMS and the IYCF-E toolkit of Save the Children) and all the associated supports and care, since those infants do not have the possibility to be breastfeed. As reflected in the Operational Guidance on IYCF-E, there are considerable supports necessary to minimize the risks of artificial feeding. You will need to urgently notify the designated coordinating government body on IYCF-E or any agency taking the lead on IYCF-E, UNICEF and WHO. The designated agency for managing artificial feeding will need to work with Child Protection to register and manage these cases appropriately.

For more on minimizing the risks of artificial feeding go to the IYCF-E toolkit of Save the Children here

Scenario 4:

The food distribution team of the national disaster management agency plans to include milk cartons in a general food distribution. You tell them about the dangers of milk distribution, that it can negatively affect breastfeeding and consequently cause diseases and even death. The food distribution team says this is not an issue here, because the milk is intended for children older than 2 years old only, not for children of breastfeeding age. It clearly says on the carton in English it should not be used as a breast milk substitute. In addition, the milk cartons are ready-to-use, so no dilution with water is needed. The cartons are presented as 1 liter cartons. Do you agree? Why?

The Operational Guidance on IYCF-E recommends that there is no general distribution of milk and milk products. There is a strong risk that this milk will be used as a breast milk substitute. Mothers may not be able to read the instructions on the carton, especially if it is not in the local language. Once open, liquid milk is a rich medium for bacterial growth. It is likely that cartons will not be immediately consumed and without refrigeration, will quickly become contaminated. If such a distribution is already happening, it is better to recommend the milk is used in family cooking (e.g. to fortify porridge) with strong messaging regarding infant feeding.