Infant Feeding in Emergencies: A Global Crisis
By Carole Dobrich, RN, IBCLC
©2016, Carole Dobrich. Original submitted in partial fulfillment of the requirements for the degree of Bachelor of Science Maternal Child Health: Human Lactation, Union Institute & University, Cincinnati, Ohio
The crisis of human displacement due to war, environmental emergencies, and natural disasters have become far more frequent in the past few decades. The burden of these catastrophes is not only monetary, it also carries a heavy human cost. The health crisis brought about by the devastation increases the morbidity and mortality rate exponentially. When access to food supplies and safe water are scarce the most vulnerable, newborns, infants, and young children are at greatest risk. Free donations of commercially manufactured Infant Milk (CMIM) and an unsafe water supply, can lead to disaster, and death. Education about breastfeeding, and safe preparation of CMIM is needed for both volunteers, and health care professionals. Breastfeeding and breastmilk provide critical nutrients and immune protection. It is a lifesaving practice in emergency situations.
Breastfeeding is the biological normal way to feed an infant. Yet in 2016, levels of optimal breastfeeding in both high- and low-income countries remain low. This has led to a global increase in morbidity and mortality among infants and young children. As the world is changing, there is an increase in both natural and man-made disasters and emergencies. Attention needs to be paid to how the simple practice of breastfeeding can save lives during these emergencies.
Human milk is the complete “super food” that can independently sustain an infant life for the first six months after birth. Human infants have thrived and flourished on human milk for more than 100,000 years. It is species specific and is perfectly adapted to the infant’s growth and developmental needs. A newborn baby is relatively immature at birth, and the kidneys and liver are unable to process high protein feeds. Human milk is relatively low in protein, yet the proteins available are very important for the infant’s immune system. Human milk is highest of all mammal milks in lactose, which is necessary for appropriate brain development. The newborn brain triples in weight during the first two years of life reaching 80% of its final size.
Exclusive breastfeeding colonises the baby’s digestive system with beneficial bacteria helping establish the infant’s microbiota. Infants that are breastfed have a relative abundance of the good bacteria, bifidobacteria and lactobacilli. Human milk oligosaccarides support the growth of these beneficial bacteria. Bifidobacteria and lactobacilli have a symbiotic bacteria-host relationship with humans and inhibit the growth of pathogenic bacteria. Infants who are not breastfeed are colonised with harmful bacteria such as Escherichia coli and Clostridia, and lack the protective human milk properties (Van Best, Hornef, Savelkoul, & Penders, 2015, p. 242).
It has been known for many years that breastfeeding is protective against diarrhea and pneumonia, two of the leading causes of hospitalization and death in children under five years of age. Nearly half of all diarrhea episodes and one third of respiratory infections are preventable by exclusively breastfeeding (Victora et al., 2016, p. 479). Therefore, the risk associated with poor infant feeding practices during emergencies can lead to increased morbidity and mortality.
Many of these illnesses and deaths are preventable by helping mothers initiate and maintain exclusive breastfeeding for the first 6 months, and continue breastfeeding for two years and beyond. Globally 820,000 infants die each year because they are not breastfeed (WHO 2016). In emergencies, support to help breastfeeding mothers continue breastfeeding, and non-breastfeeding mothers to consider re-lactation or induced lactation, while ensuring safe preparation of CMIM practices is essential.
The evolution of infant feeding practices in the past century has been influenced more by economics, agriculture, modernisation, and commercialisation, than public health. The pediatrician, Dr. Cicely Williams published an article in 1933, describing a syndrome related to a protein calorie malnutrition, that she had observed in Ghana. The Gha people called it Kwasiorkor, the Ashanti word for “the disease of the weanling when taken off the breast too early” (Williams, Baumslag, & World Alliance for Breastfeeding Action, 2006, p. vii). In 1939, Williams addressed the Singapore Rotary Club. Her speech was called Milk and Murder and addressed the subject of infant feeding practices surrounding the increased use of CMIM and infant death rate.
“If your lives were embittered as mine is, by seeing day after day this massacre of the innocents by unsuitable feeding, then I believe you would feel as I do that misguided propaganda on infant feeding should be punished as the most criminal form of sedition, and that those deaths should be regarded as murder." (Williams, Baumslag, & World Alliance for Breastfeeding Action, 2006, p. 62)
The above quote has become synonymous with the International Baby Food Action Network (IBFAN). It is also a reminder of how important breastfeeding is and how risky CMIM can be when used for non-medical reasons. Following the Second World War, there was further decline in breastfeeding, and increased use of CMIM. The mother to mother breastfeeding support group, La Leche League (LLL) held its first meeting on October 17, 1956, when breastfeeding rates in the United States, were an abysmal 20%. It took many years for the breastfeeding rates in the United States to climb, even a few percentage points, yet the LLL organization grew worldwide. The CMIM industry also continued growing and marketing their products for profit using false health claims. In 1968 Dr. Derrick Jelliffe described the impact of CMIM industry marketing practices on infant health using the term "commerciogenic malnutrition".
Globally, the CMIM industry grew with the support of the medical profession. Tactics that undermined mothers were used to market the products. The marketing methods used by the CMIM industry included exploiting mother’s anxiety about not producing enough milk, stressing the superiority or equivalence of CMIM to human milk, using images of chubby, healthy looking infants, disguising sales representatives at mothercraft nurses and providing free samples. The key was to gain medical endorsement (Richter, 2001, p. 46). Many of these marketing strategies are still in use in 2016. It is important to note that the American Academy of Pediatrics and many health care professional organizations continue to receive funding and sponsorship from CMIM companies.
The Nestlé boycott began in 1977 and spread worldwide over the next few years. It was a way for the consumer to protest against Nestlé’s unethical marketing of CMIM in third world countries. On May 21st, 1981, at the 34th World Health Assembly (WHA) the International Code of Marketing of Breastmilk Substitutes (the Code) was adopted as a minimum requirement and in its entirety. Of the 118 member states present, all except one country voted in favor. The only county to vote against the resolution was the United States (Brady, 2012, p. 529). “As of March 2016, 135 countries had at least some form of legal measure in place covering some provisions of the Code” (WHO, UNICEF, IBFAN, 2016).
Marketing of CMIM has made its way into all countries and influence on infant feeding has significantly changed to the detriment of both mothers and babies. In countries where breastfeeding is considered a normal part of society, CMIM has also made its way into the culture. Maternal concern about “not enough milk” is fuelled by misinformation. The belief that stress decreases milk supply, has led to mothers supplementing their infants when it may not be necessary, and potentially life threatening, especially in emergency situations.
During the past ten years, there have been too many examples of natural and man-made disasters leading to infant and young child feeding (IYCF) insecurity. There are field exchange reports on the Emergency Nutrition Network website about the experience of earthquakes, refugee camps, hurricanes, and tsunamis related to IYCF ("IYCF (Infant and Young Child Feeding) | ENN," n.d.). Similar experiences seem to be had in many parts of the world.
It is not unheard of following natural disasters, that there is difficulty getting resources to the region. Surprisingly, CMIM donations seem to make their way to the agencies in rapid time. There is also quick distribution of the product by both local and international agencies. This is contrary to international guidelines for infant and young child feeding in emergencies (IYCF-E). It is often believed, by those uneducated about infant feeding during emergencies, that CMIM is needed. The donations of CMIM can obstruct the vital delivery system and delay essential supplies.
Once donations are given out, there is little or no education on how to prepare the product. Instructions on the package are unlikely to be in the language of the disaster country. It is also possible the actual product maybe out of date. Add the complication of limited, or unsafe water, required to both make up the product and also to clean the container that would be used to feed the infant. What has been noted in most of these circumstances is a rapid decline in exclusive, and at times, any breastfeeding. There has also been an increase in diarrheal disease, morbidity and mortality among those infants receiving CMIM. Following the disasters there has been knowledge gained and policies put in place to try and curb the rapid distribution of CMIM.
The lessons to learn about IYCF policies in emergencies, were put to the challenge for the first time on a large scale following the 2010 Haiti earthquake. Infant feeding was set as a priority from the beginning. Haiti’s challenge was that it had poor pre-earthquake IYCF practices and mix feeding was commonplace. There were many orphaned infants and children prior to, and significantly more following, the earthquake. The goal was to improve IYCF practices, reduce morbidity, malnutrition, and mortality during this crisis, and following. The decision was made early in the crisis to set up an IYCF nutrition co-ordinator. The establishment of a separate, dedicated IYCF service which included baby tents, wet nurses, and minimal use of CMIM.
Donations of CMIM were not accepted, and only ready-to-serve CMIM via cup was used if necessary. Clear guidelines for use of CMIM were developed, and some of the indications for use included, orphaned infants, HIV+ mothers who had decided not to breastfeed, non-breastfed infants, and for mothers who were relactating. The document Infant and Young Child Feeding in Emergencies Operational Guidance for Emergency Relief Staff and Policy-Makers was the basis for the action plan(IFE Core Group, 2007). Many lessons were learned from Haiti, and so much is still to be learned. Key lessons learned included the importance of pre‐emergency orientation and international guidance, policy and action plans on IYCF-E. Also the awareness that emergency preparedness is key (Norton, 2011).
Since Haiti, there have continued to be many situations requiring the need to support IYCF-E. Examples of this are: the earthquakes in Christchurch and Nepal, the Australian bushfires, and most recently in Canada, the Fort McMurray wildfires. New Zealand, Australia, and Canada are all first-world countries. They also need to have in place emergency preparedness their youngest citizens. This past May 2016, Fort McMurray was the site of the largest Canadian wildfire evacuation in history. This evacuation of more than 90,000 Albertans included about 3,000 children under the age of two. About 900 of those infants were breastfeeding. (Chase & Pensa Branco, 2016).
Within hours of the initial evacuation, it was recognised that those evacuating families with infants and young children, would need breastfeeding support and safe feeding guidance for non-breastfed infants. The lactation community in Alberta and across Canada pulled together and formed “a humanitarian coalition to mount an Infant and Young Child Feeding in Emergencies (IYCF-E) response”(Chase & Pensa Branco, 2016). This response is based on the same IYCF-E Core Group Operational Guidance Manual (OGM) used during the Haiti earthquake aftermath. The OGM was the foundation guideline that was quickly tailored to suit the specific needs of the local situation. One of the key immediate recommendations from the Alberta Infant & Young Child Feeding in Emergencies Support Group is echoing globally. The request to “cease of appeals for infant formula & baby food donations through the media and other channels” (Chase & Pensa Branco, 2016). The general public need to be informed that the best way to help is through monetary donations rather than donations of inappropriate infant feeding supplies.
The Syrian crisis is an emergency that is affecting families’ world-wide. There are refugee camps across Europe; the most well-known are in Jordan and Greece. The displacement of population is occurring around the world. Canada has accepted more than 25,000 Syrian refugees yet there is much work to be done with the families and IYCF. Many refugees arrive with cans of powdered CMIM which was given to them at the camps. Many of the mothers were breastfeeding prior to receiving the product and then once they have arrived in Canada, have weaned their infants, increasing the health burden and economic cost-association of supporting the incoming refugees.
There are NGOs working to support breastfeeding in the camps in Jordan and Greece. One of those organizations in Chios, Greece is called the Nurture Project International (NPI). NPI is a not-for-profit organization that provides experienced and qualified public health professional volunteers who provide rapid assessment, training, and support to the local communities affected by disaster, crisis, or trauma. This program assists by setting up mother-baby tents which provide safe environments for mothers to rest, eat and receive qualified breastfeeding and nutritional assistance. ("Nurture project international," 2016)
Non-breastfeeding mothers are assessed and offered assistance with relactation, or induced lactation should they wish to re-establish, or establish breastfeeding. Support and instruction on safe preparation of CMIM in the refugee camp is provided. Infants in the refugee camps are fifty times more likely to be hospitalised for diarrhea and 10.5 times more likely to die if not breastfed ("Nurture project international," 2016). Lack of safe water and sanitary conditions make it difficult to safely prepare CMIM. It is also unlikely that the families have the equipment necessary to safely sterilize the bottles and teats to decrease contamination.
One of the other projects the NPI has implemented is the Peer to Peer Mobile Support project. This is an “outside the box” project to ensure families on the move have access to breastfeeding or CMIM feeding support while traveling. The volunteers for this project are provided with counselling, are trained, and are required to have breastfed their own baby for at least six months, or have significant breastfeeding support qualifications. This project uses online applications, social media and WhatsApp. Other possible volunteer positions include field peer support. These volunteers train refugees in peer support so as to help them to develop their own mother groups in their areas.
It is important to be aware of “western culture” rescuer attitudes when volunteering in overseas emergencies. The volunteer experience is usually for a minimum of four to six weeks in an environment that is not politically stable. As this project has not been well established long enough to evaluate the potential negative effects on the volunteers, it is possible to consider the experience of post-traumatic stress disorder (PTSD) following such an experience. That being said having been being well prepared physically and psychologically, the experience of helping families in significant need, is enticing.
Those working in disaster zones, refugee camps, and war-torn areas, have learned to use the limited available resources. Introducing a baby-bottle where there is no clean water, is both irresponsible, and dangerous. Those working on the ground in emergencies, and supporting volunteers behind the scenes, are “outside the box” thinkers. They make the world a better place.
As the world continues to face emerging crises, natural disasters, and human population displacement, infant feeding must be in the forefront of policy makers. It is of extreme importance to support practices that are cost effective and save lives when working with infant and young children in emergencies. Guidelines for all governments and organizations involved in disaster/emergency crisis management must include evidence-based emergency preparedness materials, and training on infant feeding, and breastfeeding in emergencies. Unless measures are put in place by both governmental and non-governmental agencies, disease, despair and death will continue to take hold. Breastfeeding saves lives.
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