Save the Children’s IYCF programme and linkages to Protection, Food Security and Livelihoods in Haiti

A breastfeeding mother who received support in the baby tent

By Lucia Pantella

Lucia holds a M.Sc. in Humanitarian Programme Management at the Liverpool School of Tropical Medicine. She conducted her field research on the emergency response of Save the Children in the aftermath of the earthquake in Haiti. She is currently working with Save the Children Sweden in the Gaza strip. She previously worked on protection in Eastern Chad and in Sri Lanka.

Lucia would like to acknowledge Vicky Sibson, Emergency Nutrition Adviser at Save the Children UK, for her support and guidance during the research period and all the staff of Save the Children for their participation in this study. Thanks to Professor Barry Munslow and Tim O'Dempsey, at the Liverpool School of Tropical Medicine. A special thanks to all the mothers in Port au Prince, who took part in this research and who try, day after day, to find better living conditions for their children. Thanks also to Kathiana Malvoisin, who helped with the translation and introduced the author to a beautiful, chaotic and devastated city.

This article reflects the views and perspectives of the author as independent researcher from Save the Children, as a hosting organisation.

The Haiti earthquake of January 12th 2010 made headline news worldwide given the extent of damage and of loss of life, as well as the profound impact on already vulnerable children and families. While the exact number of deaths and injuries caused by the earthquake may never be known, the Government estimates that 222,750 people (2% of the population) were killed and 300,572 were injured¹. The majority of the 3 million people affected by the disaster were concentrated in Port-au-Prince, which suffered the main burden of human loss and destruction.

Pre-crisis child nutrition situation in Haiti and separated children

Although Haiti's infant mortality rate had significantly declined from 105/1000 in 1990 to 60/1000 live births in 2006, prevailing figures in 2010 were still unacceptably high. A nutritional survey in 2009 found low rates of acute malnutrition (less than 5%), yet 23% of Haitian children suffered from chronic malnutrition. Micronutrient deficiencies, such as anaemia, iodine and vitamin A deficiency affect a large number of children and women, causing a range of cognitive and physical problems. A relatively high low birth weight rate (25%) was also a concern, as was HIV prevalence (despite low prevalence rates)².

Pre-earthquake Demographic Health Survey (DHS) data reflected low exclusive breastfeeding (EBF) rates for children under 6 months - only 40.6% of infants under 6 months were exclusively breastfed, while in Port-au-Prince the rate was even lower (21.7%)³. Mixed feeding⁴ was common in infants under 6 months. According to the DHS (2006), orphans and vulnerable children represented 20% of the 4.3 million children in the country, of whom 4.3% were 0-24 months⁵. The same survey revealed that children aged 12-24 months were slightly more underweight (low weight for age) than children 24-59 months of age, but the difference in undernutrition prevalence was much greater in urban (ratio of 1.39) compared to rural areas (1.06).

Whereas the majority of orphans and separated children in Haiti lived with extended families, a considerable number were hosted in residential care centres (orphanages). At the time of the earthquake, most of these were not registered under the IBESR (Institut du Bien Etre Social et de Recherche), which is the governmental agency in charge of child protection in Haiti. These have been described as ghost institutions, where little is known about the identity of hosted children and the quality of care provided. The total number of institutionalised children in Haiti was still unknown at the time of the earthquake, with estimates suggesting around 50,000 children hosted in almost 450 centres, half of which were located in the Port-au-Prince metropolitan area. Despite being called 'orphanages', the majority of the hosted children living in residential care centres had at least one parent alive⁶.

Save the Children's (SC) initial emergency response

In response to the vast needs of the people affected by the earthquake, SC scaled up and mounted one of its largest emergency programmes to date. It involved six sectors: Child Protection, Education, Health and Nutrition, Water, Sanitation & Hygiene (WASH), Shelter and Food Security and Livelihoods (FSL). Targeting 800,000 people, 70 international and 815 national staff were involved in the delivery of relief interventions at the peak of the SC response (May 2010).

SC's early infant and young child feeding (IYCF) response

The vulnerability of infants and young children related to IYCF practices was a key concern in the Haiti post-crisis situation, given the poor short term availability and access to food, increased risks of waterborne diseases, death of mothers and extreme psychosocial trauma impacting on IYCF and care practices. Therefore, SC's nutrition emergency response was considered one of the key areas for life saving intervention and included four main components:

• Protection, promotion and support of optimal IYCF practices through breast-feeding counselling and nutrition education in the Points de Conseil en Nutrition pour Bébé (PCNB) or 'baby-tents', and artificial feeding management. This included the targeted provision of Ready-to-Use-Infant-Formula (RUIF), mass sensitisation campaign promoting exclusive breastfeeding and warning of the danger of breastmilk substitute (BMS) use, and efforts to control unsolicited BMS donations through radio messages and a media campaign.
• Treatment of moderate and severe acute malnutrition for children under 5 years and mothers through the community based management of acute malnutrition (CMAM) approach
• Blanket Supplementary Feeding Programme (BSFP) to prevent deterioration in the nutrition situation amongst the most vulnerable
• Prevention of micronutrient deficiencies through micronutrient supplementation.

SC's IYCF intervention was based on the Operational Guidance on Infant and Young Child Feeding in Emergencies (Ops Guidance on IFE)⁷. It was fully integrated in the nutrition programme, which in turn was part of the wider Health and Nutrition Response. An IYCF adviser was appointed to coordinate the intervention and a considerable amount of resources were made available to support the Ministry of Health (MoH) in developing national guidelines on the 'babytents' (nutrition contact points where IYCF support was delivered), in partnership with the Nutrition Cluster members at country level.

During the month of February 2010, SC's IYCF programme scaled up rapidly and 15 baby-tents were set-up in different municipalities of Port au Prince metropolitan areas. (See Box 1 for an outline of baby tent activities). IYCF activities also took place in Leogane commune and in the SE Department of the Country, including Jacmel.

SC's Family Tracing and Reunification (FTR) Programme

Considering the scale of the disaster and the preexisting large number of separated children, SC set up a Family Tracing and Reunification (FTR) programme in partnership with other agencies of the Child Protection sub-cluster. SC was nominated as the coordinating body for the Separated Children Working Group in collaboration with UNICEF. The aims of the group were to identify separated children, register them in a database, reunite those children whose families could be traced and were willing to take them back, and provide interim care for the others.

Research objectives and methods

The aim of the study was to investigate the impact of SC's IYCF response to the earthquake in Port au Prince and to identify linkages that resulted with child protection and FSL sectors, in order to better address the needs of the youngest children affected by the earthquake.

The mother of an artificially fed infant received infant formula supplies

The research team was composed of an independent Master Research Student at the Liverpool School of Tropical Medicine supported by the SC UK Emergency Nutrition Adviser, the Haiti IYCF adviser and a Haitian translator.

The field research was conducted in May and June 2010 focusing on the emergency response of SC in Port-au-Prince metropolitan area. Data were collected in ten internally displaced people (IDP) camps and informal sites where health and nutrition interventions were run. Residential care centres and stabilisation centres were also visited and the researcher attended regularly coordination meetings at the United Nations (UN) Logistic base.

Qualitative methods were used to collect primary information. These included 51 semistructured interviews, four focus group discussions, non-participant and participant observations and gathering life stories. Surveybased secondary data and monitoring reports were extensively used to collect quantitative data and triangulate information.

Nutritional Risks and SC's IYCF Response: did it work?

Exclusive breastfeeding status

A focus group discussion with mothers

Despite access to counselling, one quarter (24%) of newborn infants' mothers attending the babytents were reluctant to exclusively breastfeed. While this compares favourably to a pre-emergency exclusive breastfeeding rate of 40.6%, a higher rate was anticipated. Mothers stated that the insufficiency of their own diet prevented them from producing enough good quality milk. While research demonstrates that dietary insufficiency rarely affects the amount or quality of breastmilk that a woman produces, this maternal perception represents a powerful barrier to enabling a lifesaving intervention for newborns. Moreover, there was a general belief that all emotions pass through the breastmilk, and that stress makes milk dry-up. After the earthquake, this belief fuelled concerns amongst health and nutrition agencies and the MoH that there may be a reduction in the already low level of breastfeeding.

In general, the majority of mothers reported that employment was not a major determinant of reduced duration of EBF. In fact, most of the women living in the camps belong to the lowest socio-economic groups and were either unemployed, or involved in informal markets and petty trade activities. Mothers who wanted to continue breastfeeding had a number of options, e.g. petty trading closer to their dwelling, working flexible hours, or bringing their infants to the workplace. Manual expression and storage of breastmilk was not a practical option for most mothers due to the requirement for refrigeration facilities.

Discussions with breastfeeding mothers suggested that the increase in the prices of food and of infant formula post earthquake and the reduction of income as a result of the earthquake made mothers more receptive to behaviour change messages encouraging exclusive breastfeeding. For many women, exclusive breastfeeding was a coping strategy after the earthquake to feed their children. The breastfeeding support offered in the baby-tents was highly valued by the majority of mothers living in the camps.

The challenges of complementary feeding (CF)

Ensuring adequate CF for children between 6 and 24 months was perceived as a major challenge for mothers and caregivers attending the baby tents. Putting into practice the advice received during the nutrition education sessions regarding appropriate food to introduce during the CF period and the methods of preparation was not always easy and feasible. Caregivers were particularly constrained by the post-earthquake deterioration in living conditions and facilities for food preparation, and the lack of appropriate complementary food in the relief effort. Buying fresh vegetables, fruits and meat was a challenge for many mothers living in the camps.

Priorities for the cluster led nutrition emergency response in Haiti included a blanket supplementary feeding programme (BSFP) to 12,000 children less than 5 years of age and to pregnant and lactating women (PLW). The programme was designed to prevent deterioration in the nutritional status of mothers and children in the aftermath of the earthquake and to prevent a rise in acute malnutrition. However, the BSFP could only start in April 2010 for administrative/supply reasons. Children from 6 to 35 months received one sachet of a high energy Ready-to-Use- Supplementary Food (RUSF)⁸ per day for 90 days, while children from 36 to 59 months and PLW received rations of Corn Soy Blend (CSB), oil and sugar.

Although the RUSF is designed to treat moderate acute malnutrition, in Haiti it was used partly to compensate for the inadequate complementary feeding support. According to SC staff, in many cases the aim of the BSFP was not fully understood by the beneficiaries, who complained about the reduced amount of food distributed compared to the normal round of general food distribution which they had received only for the first three months after the earthquake. BSFP rations were also shared among members of the family, reducing the nutritional benefits to children and PLW.

Artificial feeding management

The most innovative nutritional intervention in the Haiti emergency was the management of artificial feeding at scale that included RUIF as an emergency BMS. RUIF is a BMS that is already constituted and does not require the addition of water. It is therefore potentially less risky in an emergency environment, but is not a guarantee of safety and requires careful targeting and management. RUIF was chosen due to inadequate conditions (especially hygiene), resources (including water) and controls to manage powdered infant formula (PIF) supplies at household level. Labelling was tightly controlled in order to avoid any marketing which may affect the messages promoting breastfeeding, and to ensure Code adherence. In Haiti, the RUIF was supplied to and distributed by Nutrition Cluster partners following compulsory staff training through the PCNB/baby tents, according to the National Directives developed following the emergency, See Box 2 for criteria for RUIF use in Haiti.

There was also a risk that without a clear BMS provider, primary caregivers would have been encouraged to use artificial infant formula and other BMS supplies arriving through unsolicited donations. To tackle the latter, the Nutrition Cluster worked intensively on advocacy to minimise the risks of any artificial feeding through handling BMS donations and supplies, but also monitoring and intervening in case of identification of inappropriate use of BMS by the cluster members. SC was designated by the nutrition cluster members to manage the RUIF in Haiti.

The nutritional risks of separated children

Separated children less than 24 months were considered more at nutritional risk because they were not breastfed. However breastfeeding counsellors and nutritionists working in the PCNB/baby-tents also raised concerns about the capacity of the extended family to provide adequate care to fostered children, especially infants. There were reports of a number of defaulting cases (children not attending the programme for at least one week period) among orphaned children enrolled in the artificial feeding programme and receiving RUIF supplies. In one of the stabilisation centres, a key informant reported that they regularly treated cases of abandoned children who were severely malnourished.

Nutritional risks in residential care centres

A can of ready to use infant formula

Residential care centres posed a challenge for the nutrition sector in terms of conducting nutritional screening to refer malnourished children for appropriate treatment and management of artificial feeding (including RUIF supply) to non-breastfed infants. Assessment findings and staff observations from visits revealed that IYCF practices in residential care centres were sub-optimal and risks of malnutrition high. Moreover according to a post-earthquake rapid assessment conducted by CRS, WASH facilities in centres were reported to be inadequate in 63% of cases⁹.

Shortly after the earthquake, one agency, supported by UNICEF and WFP, intervened in the orphanages, providing RUSF for children from 6 to 35 months and high energy biscuits for children from 36 month to 15 years. However, infants under 6 months were not targeted with the RUIF. A rapid nutrition assessment in those centres based on a purposive sample of 1,000 children between 6 and 59 months, revealed that the proportion of acutely malnourished children was around 6%, including 1.5% with severe malnutrition. This reflects that after the earthquake, residential care centres faced nutritional problems and could not guarantee adequate levels of nutritional support for their resident children. UNICEF also reported cases of malnutrition in the orphanages and the need for infant formula for babies less than 12 months.

Four months after the earthquake, MoH representatives expressed frustration regarding lack of prompt nutrition assistance in these centres and insisted that nutrition cluster members and the IBESR¹⁰ establish an intervention with urgency. However, there were significant challenges to such an intervention with reservations particularly about the risks of inappropriate use of RUIF without systematic monitoring mechanisms in place. In the aftermath of the earthquake, the number of infants in the orphanages was very volatile, as was the number of orphanages. Since most of them were not registered under the IBESR they were, in effect, ghost institutions, where little was known about the identity of hosted children and the quality of care provided. There were concerns that supplying RUIF to these centres would encourage mothers and caregivers to abandon their infants there. This fear prevented the Nutrition Cluster from intervening to supply RUIF. Moreover, issues related to registration of children, inaccuracy of information on the case-load, infants being adopted, and difficulties with coordination between agencies and sectors were significant obstacles to extending the artificial feeding intervention to residential care centres.

Cross-sectoral linkages in SC's emergency response

The importance of integrated programming is a key strategic principle of SC's interventions. The research considered the Emergency Standard Operating Procedures (ESOPs) developed by the SC UK Office which provides a number of recommendations for potential cross-sectoral linkages. Four areas for multisectoral programming which could enhance the effectiveness of the IYCF response in Port-au- Prince, were identified:

1. Multi-programming catchments areas
2. FSL support for PLW
3. Referral system for separated children
4. Intervention in residential care centres

The degree to which these linkages were made in Haiti was explored in this study.

Multi-programming catchment areas

Despite an attempt to conduct a multi-sectoral assessment at the beginning of the response, decisions about programme location activities were made separately by each SC sector and were informed by the gaps left by other organisations. This resulted in geographic dispersion and fragmentation of SC activities in the metropolitan area, reducing the potential for integration and the possibility of offering multiple services to affected people, while referral systems with other agencies from different clusters were not in place.

A strategic decision to integrate health and nutrition in Port-au-Prince was made at the very beginning of the response, which linked the mobile health clinics to PCNBs/baby-tents. This played an important role in reaching a large number of mothers and caregivers.

Programming FSL support for mothers and caregivers

SC's FSL recovery strategy for the first phase of the emergency included a nutritional component, providing vouchers for complementary foods (food aid) and cash transfers for vulnerable households, with a particular focus on households headed by PLW. However, the strategy was not implemented in Port-au- Prince, since it would have required a high level of integration and coordination among the sectors that was not possible in the aftermath of the earthquake. Moreover, there were issues of practicability related to time and logistics constraints (including the identification of appropriate suppliers), and scale-ability due the large number of affected people in densely populated areas. Thus, linking a nutrition intervention and a FSL intervention was postponed to the second phase of the response. This involved FSL support targeting children affected by severe and moderate acute malnutrition but did not include direct interventions to support optimal IYCF practices for mothers.

Referral system for separated children

Although FTR and IYCF target groups partly overlapped (i.e., separated/orphaned children under 12 months), there was no system for information exchange between the two programmes. On the one hand, data about the age of separated children registered in the FTR database were not stratified by month (recommended in the Operational Guidance on IFE), while in the baby-tents, breastfeeding counsellors collected information only on children separated from their mothers, but not those separated from other family members. This limited the possibility of setting-up a referral system between the two sectors. Moreover, training for child protection staff regarding the needs, risks and appropriate responses to the nutritional needs of separated children of different breastfeeding ages was limited. Lack of awareness of the existence of the artificial feeding programme for children under 12 months who could not be breastfed, meant FTR officers did not refer any child to the baby-tents. Conversely, in none of the 10 baby-tents of Portau- Prince visited by the researcher were nutrition staff aware of SC child protection work, despite the baby tent staff daily contact with orphans and separated children. SC's staff considered difficulties related to lack of time and the need to scale-up the initial response quickly to be the main reasons for the failed linkages.

Intervention in Residential Care Centres

As part of the inter-agency FTR emergency response programme, SC participated in an initiative to register all children in residential care centres and trace the families of those who had been separated after the earthquake. However, a number of difficulties with caregivers were encountered in the registration and reunification process. Interviewed FTR personnel reported that some caregivers were reluctant to take the child back because they did not have enough means to provide adequate food for them. Also, it was hope that a nutritional intervention would facilitate the child protection intervention in the residential care centres by overcoming the resistance of the caregivers to collaborating with the family reunification programme. However, lack of timely needs assessment data, poor coordination between institutional and nongovernmental actors (IBESR and MoH, and nutrition and child protection clusters) and the absence of an operational strategy for an IYCF intervention in the orphanages meant this did not happen.

Suggestions for programme design in future emergency responses

The response to the Haiti earthquake demonstrates considerable progress in addressing the needs of infants in an emergency. Resources and knowledge were applied from previous IFE responses, such as in Myanmar, Lebanon and the Philippines. In spite of the major difficulties encountered by the humanitarian system, there were strong coordinated efforts to implement the Operational Guidance on IFE and to intervene quickly to protect and support optimal IYCF in this risky context. It is possible that the nutritional survey conducted in the months of May-June 2010, which revealed low levels of global acute malnutrition in children amongst both the displaced and non displaced communities, with no significant changes compared to the pre-earthquake situation¹¹ was in part due to the success of the IYCF response.

However, the extreme nature of the Haiti emergency, in terms of mortality, level of destruction, logistic challenges, chaos and the pre-existing high number of orphaned and separated children had profound implications for the IYCF response. The research suggests that many of the IYCF limitations experienced in families and reflected in programmes could have been overcome by developing multisectoral programming, especially with child protection and FSL both at the organisation and cluster levels.

Based upon previous experience of SC¹² and through the analysis of SC's IYCF programme in Haiti, the researcher identified three main areas where lessons can be drawn on for SC and in general for the sector for improving the effectiveness of the nutrition response in future emergencies. Key lessons identified are:

Meeting basic needs of pregnant and lactating mothers

Promoting exclusive breastfeeding for infants less than 6 months and advising on adequate CF, without concurrently providing access to accompanying measures such as food aid, shelter and WASH, reduced the acceptability and feasibility of the services provided in the baby tents, thus limiting the impact of the IYCF intervention.

A baby tent session

A timely BSFP could have achieved a greater impact (soon after a disaster) if there had been an adequate communication strategy which clearly specified the target and the purpose of the intervention both to eligible and non-eligible recipients.

Other support interventions such as food distribution, fresh food vouchers or conditional cash transfers (CCTs) need to be considered and integrated with the IYCF programme.

For cash based interventions, the level of conditionality (for example, provision of cash upon attendance at exclusive breastfeeding promotion sessions), the delivery and monitoring mechanisms, the link to income generating activities, and feasibility and scale are issues to be considered while planning the intervention. Also, if any FSL intervention for PLW is implemented, it should be implemented in conjunction with nutrition education messages to enhance the sustainability of behaviour changes.

Supporting small-business activities for breastfeeding mothers of children over 6 months through grants and micro-loans could be a programmatic option to support the IYCF technical intervention. The feasibility of manual expression of milk should be explored in contexts where storage is possible; some mothers in Haiti were practising breastmilk expression although on a small scale.

Cash-based support programmes for caregivers of maternal orphans need to include elements that minimise risks of exploitation by opportunist foster caregivers. This could be achieved by establishing a system to identify those families who are genuinely willing to take care of children and need support. Monitoring of these interventions also require the strong participation of the community through community based child protection committees who are responsible for identifying suitable foster carers (in partnership with Child Protection and FTR officers).

Addressing the nutritional needs of separated children and children in residential care

Assessment of artificial feeding need at population level including the estimation of caseload for BMS supplies should be conducted in collaboration with FTR programmes, and by establishing systems for exchange of information at the very beginning of the emergency response. To inform this process, registration of separated children by FTR working groups (both in the community and in residential care centres) should seek to distinguish children <6 months, 6-<12 months, 12-<24 months and children aged 24-<59 months (2-5 years), in order to identify the size of potential beneficiary groups.

In situations of emergency and distress, lack of nutritional support for parents and caregivers often contributes to family separation and neglect. Creating synergies through effective referral systems with the child protection and FSL sector could improve coverage and impact of the IYCF intervention, as well as reduce risks of family separation and promote family reunification.

Nutritional and health care intervention strategies for residential care centres need to be developed, while minimising the risk of proactively supported centre-based solutions rather than community based mechanisms for separated children. In this regard, the Operational Guidance on IFE policy guidance should include recommendations on IYCF interventions in residential care centres.

Improve the organisational capacity to promote cross-sectoral integration

Integrated programming demands strong leadership and clear guidance from the initial stage of the emergency response, through facilitating systematic multi-sectoral assessments based on a holistic understanding of children's needs and adoption of strategic decisions.

Multi-sectoral rapid assessment teams comprising people with different skills for example in child protection, health and nutrition, may facilitate the identification of vulnerable groups. FTR officers need to be involved in home visits and follow-up for motherless and separated children who require artificial feeding support as these children may also be exposed to higher risks of abuse, neglect and exploitation.

The strategic choice of integrating health and nutrition from the very beginning of the response through linking mobile clinics to baby-tents, facilitated the rapid scaling-up of the nutrition intervention including the IYCF component. In contrast, lack of referral system between FTR and IYCF programmes did not allow for addressing interlinked needs of separated children.

Conclusions and recommendations

This researcher's findings demonstrated that the complementary sectoral strengths of nutrition with child protection and FSL sectors were not maximised and the emergency response targeting the youngest children was weakened as a result. The importance of pursuing integrated programming from the very beginning of the relief operation should become a key strategic principle, not only for organisations working in multiple sectors such as SC, but also for the whole cluster system to ensure coordinated and effective response. The researcher makes a number of recommendations to those involved in coordinating and implementing direct and allied programming related to IYCF in emergencies, and those working in related policy and resource development:

There is a need to advocate at both national and global cluster level for a prompt and systematic exchange of information and collaboration between the Separated Children Working Group (Child Protection sub-cluster) and IYCF Working Group (Nutrition cluster) to set-up effective referral mechanisms, especially for children under 24 months of age among all partners. It is important to ensure that information on FTR services (such as the call centre for separated children) is disseminated at the nutrition cluster level and that information on IYCF services (including artificial feeding management cases) is disseminated to child-protection sub-cluster actors. UNICEF, as the cluster lead agency for the GNC and responsible agency for child protection, is well placed to enable information consolidation and exchange. At the same time, agencies that work both in the nutrition and CP sectors can support this process through development of internal tools and mechanisms. This is arguably best achieved through emergency preparedness.

The FTR Standard Operating Procedures at organisation and cluster level should include a specific reference to the nutritional needs of children under 24 months and that the data on accompanied and unaccompanied infants and young children under two years are stratified by age (0-<6 months, 6-<12 months, 12-<23 months, 24-<60 months) to inform programming. Multi-sectoral joint assessment would enable a more holistic perspective.

FSL interventions should have a clear nutrition objective to support IYCF interventions, targeting specifically PLW and children under 2 years. This should be emphasised in future update of the Operational Guidance on IFE and specified in relevant FSL policy guidance.

The Early Recovery/Livelihood cluster should include PLW and families fostering separated children in FSL support programmes. These activities need to be realised in partnership with nutrition and child protection actors, to ensure appropriate targeting mechanisms and consistent communication messages, reducing risks of exploitation.

A breastfeeding mother who received support in the baby tent

The provisions of the Operational Guidance on IFE should be reflected in revisions of the Interagency Emergency Child Protection Assessment Toolkit¹³, including a specific focus on residential care centres.

A rapid assessment tool to assess the nutritional needs of infants and young children in residential care is needed. The institutional care capacity maps (tools of Interagency Emergency Child Protection Assessment Toolkit) needs to specify that the presence of children under 24 months in residential care centres be referred to the designated IYCF coordinating agency/relevant working group at country level. The evaluation questionnaire for residential care centres developed by the Child Protection sub-cluster should be revised in cooperation with nutrition actors to collect relevant information on IYCF.

Interventions in residential care centres to manage artificial feeding and to support adequate complementary feeding need a specific well planned strategy and may require:

• Provision of a BMS on a regular basis (closely monitored)
• Nutrition education for caregivers (including coaching and training)
• Nutritional surveillance (that could be linked with a vaccination campaign)
• Family tracing for non orphaned children and nutritional support for re-united children
• Referral to services outside the institutions, through establishing referral mechanisms.

Finally, it is essential to engage in donor advocacy for multi-sector funding mechanisms, (e.g. Flash appeals and Consolidated Appeal Process) both at the organisational and cluster level, to facilitate multi-sectoral integrated programming to protect, promote and support optimal and timely IYCF responses.

For more information, contact: Lucia Pantella, email: lpantella@yahoo.com

Weblinks to Global Clusters

Global Nutrition Cluster: http://oneresponse.info/GlobalClusters/Nutrition

Protection Cluster: http://oneresponse.info/GlobalClusters/Protection/

Child Protection Working Group (CPWG): http://oneresponse.info/GlobalClusters/Protection/CP/

¹IASC (Inter-Agency Standing Committee), 2010. 6 Months Report. Response to the Humanitarian Crisis in Haiti Following the 12 January Earthquake. Achievements, Challenges and Lessons Being Learnt. Draft 2. Unpublished.

²According to Unicef, 1.9% of adults (15-49 years) in Haiti live with HIV/AIDS (Source: UNICEF. http://www.unicef.org/infobycountry/haiti_statistics.html)

³EMMUS, 2006. Enquête Mortalité, Morbidité et Utilisation des Services, Haïti, 2005-2006. Calverton, Maryland, USA. Ministère de la Santé Publique et de la Population, Institut Haïtien de l'Enfance et Macro International Inc.

⁴Combines breastfeeding with artificial feeding or other kinds of food such as bean puree, banana flour, maize porridge and dry skimmed milk

⁵Ibidem

⁶Source: Interviews with Residential Care Centres staff. PaP, May/June 2010

⁷Version 2,1, 2007. http://www.ennonline.net/resources/6 and addendum (2010): http://www.ennonline.net/pool/files/ife/insertoperational-guidance-6-3-2-addendum-2010-final.pdf

⁸Supplementary Plumpy

⁹CRS (Christian Relief Service), 2010. Haiti Protection Assessment Report, Unpublished

¹⁰Institut du Bien Etre Social et de Recherche), which is the governmental agency in charge of child protection in Haiti

¹¹MoH, (Haiti Ministry of Health), 2010. Rapport Final Enquête Nutritionnelle Anthropometrique, Enfants de 6 à 59 mois, République d'Haiti, May- June, 2010. Unpublished.

¹²SC UK (Save the Children UK) 2008a.A Review of Save the Children's Cyclone Nargis (Myanmar) Infant Feeding in Emergencies response: September 15th-26th 2008. Unpublished.

¹³http://oneresponse.info/GlobalClusters/Protection/CP/Pages/Resources.aspx.