Infant and Young Child Feeding
in Emergencies (IFE)
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
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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.
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.
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Pakistan, 2010
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Safe and appropriate infant and young child feeding in emergencies
Optimal infant and young child feeding recommendations
Early initiation of
breastfeeding (within
1 hour of birth)
Exclusive
breastfeeding
(0-<6m)
Continued breastfeeding
(2 years or beyond)
Complementary feeding (6<24m)
Complementary
foods
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Early initiation of breastfeeding
Exclusive breastfeeding within one hour of birth saves infant
and mothers’ lives
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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 skinto-skin contact
• Implement Baby-Friendly Hospital Initiative (BFHI) 10 steps to successful
breastfeeding
• Promote early initiation of breastfeeding through antenatal services
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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
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Complement not substitute…………
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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)
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Complementary feeding is more than just food……
Frequency
Amount
Texture
Variety
Active
World Viision, Kenya 2009
Hygiene
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Frequent
feeding
Adequate
amounts of
food
Appropriate
consistency
A variety of
different
foods
Responsive
feeding
Hygienically
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Continuum of Infant and Young Child Feeding in South Sudan
Source: Southern Sudan 2010 Household Survey abridged report, April 2011
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
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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
4%
Water, sanitation, hygiene
3%
Antenatal steroids
3%
Newborn temperature management
2%
Vitamin A
2%
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Causes of death in children under 5, 2000-2003
UNDERNUTRITION
underlies 53% of under
five deaths
Maternal and
child
undernutrition
contributes to
35% U5 deaths
Adapted from Bryce et al, Lancet 2005; Black et al, Lancet 2008 & Caulfield et al, Am J
Clin Nutr 2002
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Risk of death if breastfed is equivalent to one
The younger the infant, the more vulnerable if not breastfed
Age (months)
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WHO Collaborative Study, Lancet, 200016
U2s contribute to global burden 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.
Protection and support of optimal infant and young child feeding is
essential in both prevention and treatment of acute malnutrition
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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
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Why
Artificial
artificial
feeding
feeding
is always
is always
risky
risky
No active protection
Infant formula
powder is not
sterile
Increases food
insecurity and
dependency
Bottle and teats
Bottle feeding
extra source of
increases risk
infection
Costly in time,
resources and
care
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Reasons
forrisky
risky feeding
Reasons
for
feedingpractices
practices
A proportion of
infants may not
be breastfed
when an
emergency hits
Pre-emergency
feeding
practices may be
sub-optimal
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During an
emergency,
inappropriate aid
may increase
artificial feeding.
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Risks of untargeted distribution fuelled by donations
Yogyakarta Indonesia post-2006 earthquake
Relation between prevalence of diarrhoea and receipt of donated infant
formula, Yogyakarta
post-2006
earthquake.
Relation
between Indonesia
prevalence
of diarrhoea
and receipt of donated
infant formula in children U2
Source: Hipgrave, et al: Accepted
Public Health Nutrition Journal, 2010
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Artificially fed infants are highly
vulnerable in emergencies
Mixed fed babies lose protection and
invite infection
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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
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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
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Artificial feeding intervention
•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.
Myanmar, 2008. A young infant
and mother identified as in
need of skilled support to
establish breastfeeding and
minimise the risks of artificial
feeding.
•A last resort, when other safer options have
been first eliminated.
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Breastfeeding is a lifeline in emergencies
Nutritional
Immunological/Physiological
Psychological
Practical
Physical
Maternal
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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 ageappropriate, safe and
appropriate
complementary foods
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Enabling access to
services
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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.
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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
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What are infant
feeding
recommendations
where HIV is
prevalent?
Consider HIV-free child survival
(risk of HIV transmission and
non-HIV causes of death)
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WHO recommendations on infant feeding and HIV (2010)
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
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WHO recommendations on infant feeding and HIV (2010)
If
Mother is HIV-infected & on ARVs
then
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
unless
Replacement feeding is acceptable,
feasible, affordable, sustainable and
safe (AFASS)
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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.
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True or false?
1. If a mother’s HIV status is unknown, she should replacement
feed until she knows it is safe to breastfeed
2. An HIV-infected mother should breastfeed for 6 months only,
then quickly switch to replacement feeding
3. HIV-infected infants have a better chance of survival if
breastfed
4. HIV-infected mothers should be discouraged from
breastfeeding if there are no ARVs available
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True or false?
1. If a mother’s HIV status is unknown, she should replacement
feed until she knows it is safe to breastfeed
2. A HIV infected mother should breastfeed for 6 months only,
then quickly switch to relacement feeding
3. HIV infected infants have a better chance of survival if
breastfed
4. HIV-infected mothers should be discouraged from
breastfeeding if there are no ARVs available
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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.
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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.
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Violations of the
International
Code
International
violations inCode
emergencies
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”
The companies who
produce BMS
Those involved in
the humanitarian
response
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
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The Sphere Project
• 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
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Minimum response in every emergency
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Minimum response on IFE
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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
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What must you do to
protect and support
safe and appropriate
IFE?
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Be ready with frontline assistance for mothers and children
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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.
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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
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Skilled breastfeeding support
Breastfeeding counselling is an emergency response
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Prioritise pregnant and
lactating women for
shelter, food, water and
security
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Offer ‘safe places’ for breastfeeding and feeding support
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Skilled support for challenging cases
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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
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Locate technical capacity
Wet nurse relactates an abandoned
baby (Myanmar, 2008)
Unaccompanied infants with no source
of breastmilk (Rwanda, 1994)
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Make sure every newborn initiates breastfeeding within 1
hour of birth
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Ensure access to safe and adequate complementary foods,
appropriate to needs and context
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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
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Collaborative effort on IFE
Current members and associate members:
WHO
WFP
www.ennonline.net/ife
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International Code in emergencies
Emergency preparedness: Strong, enforced national legislation
Protection: Uphold provisions of the International Code
Accountability: Monitor and report on Code violations
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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
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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
•Use BMS to prepare a fortified blended food for use as
complementary food for infants over 6 months
•Use BMS in institutional nutrition support, eg., elderly, orphans
•Use in preparation of biscuits and cakes that can be distributed
to flood affected population
•Use BMS in animal 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, 2011
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Communicate clearly on IFE
Should be…
•Consistent
•Technically sound
•Strong
•Responsive
•Innovative
•Press offices and general media
are key influences
www.ennonline.net/
resources
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Be prepared and prepare others
Orientation of key ‘players’:
•Nutritionists & breastfeeding
counsellors
•Health and nutrition staff
•Media and press agencies
•Donors
•Military
•Water and sanitation staff
Capacity development and
training of nutrition and health
staff
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DoD photo by: TSGT PERRY HEIMER
Key messages
•
•
•
•
•
•
•
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 and resource
intensive
Donations and untargeted distribution of milk
increase morbidity in children
HIV-free child survival, not just HIV
transmission, is the consideration
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We gratefully acknowledge the support of the IFE Core Group
in the development of this content
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