Infant Feeding in Emergencies: Experiences from Rwanda

Frances O'Keefe field worker Gisenyi - Concern Worldwide

Between October and December last year escalating civil conflict led to hundreds of thousands of Hutu refugees returning from refugee camps in eastern Zaire to Rwanda. Due to the scale and speed of the return many children became separated from their mothers. SCF, who were engaged in tracing activities at the time, estimated that 1,800 unaccompanied children were present out of a total exodus of 450,000 persons. Of these about 50 were below 2 years of age. It was the younger children who caused the greatest difficulties with regard to feeding, as they required exclusive breastfeeding if they were to have a good chance of survival.

Concern Worldwide operated a transit centre for unaccompanied children in Gisenyi in north-western Rwanda. If children were healthy they were referred to an MSF centre where efforts were made to trace families or find appropriate carers. Some infants were admitted who were accompanied by older siblings (the maximum age 14 years). The infants who were admitted were usually referred by agencies such as SCF-UK and ICRC. Approximately 4-6 infants per week were taken care of in the Concern centre.

Unaccompanied babies seen by Concern lost their mothers to the violence in eastern Zaire. There were some reports of instances where young babies had been found alive and abandoned at massacre sites. Other mothers were sick and malnourished (the region has a high HIV prevalence) prior to the journey back to Rwanda and died during their journey home or soon after their return. Children frequently suffered exhaustion, dehydration and starvation during the journey home.

A number of issues pertinent to infant feeding practices in emergencies arose during this programme:

• The practice of wet nursing was unacceptable because of the high prevalence of HIV. Mothers, potential wet-nurses, carers and staff would not accept this practice.
• There was little choice about which artificial milk products to use. Guigoz and Nestle were the only available brand products and were available for purchase in local shops. Dried Skim Milk, which was not considered an alternative option because of the availability of formula milk, became available later on. There was a lack of non-generic formula feed products through all supply networks e.g. donors, UNICEF. Another artificial milk for malnourished children - Nutriset, was available but not suitable for infant feeding.
• Feeding bottles were used for accurate measuring and preparation of formula feed. Jugs or other appropriate utensils were not available locally. Local populations were not familiar with using bottles and there was the danger that, although only used for milk preparation, their use would have a longer term impact/influence on the feeding practices of carers. A cup and spoon was used as the method of feeding with infants fed on demand.
• There was a general lack of guidelines available for infant feeding practices at field level.
• Since no relatives were available, accurate chronological age was difficult to assess. This problem was exacerbated by poor nutritional status and made it difficult to calculate the appropriate feeding regimen.
• One carer for each infant was an essential element of the programme. Important aspects such as patience, emotional support and stimulation could then be put into practice.
• Carers were reluctant to give infants additional weaning foods before six months. The concept of provision for individual needs for this age group was not accepted.
• Medical care was as important as the provision of suitable nutrition in the Concern centre. This was particularly relevant to the older infants who suffered infections etc.

A higher success rate in terms of mortality was generally achieved with the youngest infants (1 to 6 months) in comparison to older infants (7 to 12 months). It was not apparent why this was the case but it was felt that this may have been due to rapid referral and the fact that the infants were quickly started on suitable formula. A higher mortality rate was reported for older infants. A possible reason for this was that older infants survived longer under the harsh conditions when hiding in the forests, where inappropriate foods (poisonous bark, diluted milks) were eaten, possibly causing infections and clinical complications. The young infants who endured these situations may not have survived at all. In fact the young babies admitted to the Concern centre may have spent less time separated from their mothers, giving them a better chance of survival.

If and when relatives were found, the problem of inappropriate foods available at household level remained. Formula feeds were either unavailable or unaffordable in rural areas.