Infant Feeding in Emergencies: Recurring Challenges

Published Report

By Marie McGrath

The importance of infant feeding in emergencies has been highlighted during recent emergencies in countries such as Iraq and Bosnia, where breastmilk substitutes are commonly used. Anecdotal evidence suggests that, in these situations, infant feeding practices have had a negative impact on child health. The 1999 Kosovo crisis presented an opportunity to investigate the policy and practice of agencies involved in the humanitarian response with regard to infant feeding.

Field research was carried out in Macedonia between 15 June and 31 July 1999 and gathered data on the following:

1. The availability, awareness and implementation of existing policy instruments and guidelines on infant feeding in emergencies;
2. The flow of relief items used for infant feeding and any accompanying violations of the International Code of Marketing of Breastmilk Substitutes;
3. The quality of infant feeding interventions;
4. The infant feeding practices of the emergencyaffected population.

The methodology included a literature search of guidelines and policies relating to infant feeding in emergencies, questionnaires for field and headquarters personnel on infant feeding issues and structured interviews with key field personnel. In two camps, an infant feeding practice survey (including 24 hour recall) of children 2 years and under was conducted. The response rates were affected by the sudden mass return of refugees to Kosovo in June, 1999.

The research found that there was poor awareness, use and implementation of guidelines and policy instruments among emergency personnel operating in Macedonia. UN agencies, International and local NGOs were all affected. Where guidelines were observed, this was often as a result of individual rather than organisational learning. The International Code was contravened in a number of ways including the general distribution of infant formula, complementary foods, bottles and teats and the donation of such products to facilities in the health care system. A number of factors constrained effective implementation of and adherence to MOUs, guidelines and the Code and these included poor levels of interagency coordination and gaps in the applicability of the instruments themselves.

Infant feeding items reached the emergencyaffected population through a wide range of channels. Large proportions of the items were unsolicited donations that passed through a number of agencies before reaching the affected population. Lack of co-ordination and monitoring of these items meant that it was very difficult to trace these flows. This situation resulted in a range of infant feeding interventions with the affected population which varied substantially in quality. Mother and Baby Tents were the focus of infant feeding interventions in camps and the quality of support given was very variable. Breastfeeding support was rarely adequate though MBTs often provided infant formula, bottles, and complementary foods to mothers and infants. Other interventions included postnatal support in maternity facilities which was in some cases undermined by the donation of breastmilk substitutes to these facilities.

The camp surveys of infant feeding practice showed that 88% of the 242 children surveyed had initiated breastfeeding. Among infants under 6 months of age, 60% were exclusively breastfed and 24% predominately breastfed. The main supplementary items in infants under six months were water, tea and cow's milk. Breastfeeding was continued in 50% of children aged 12 - 15 months and 22% of children aged 20 - 23 months. The use of liquid or powdered (non-formula) milk was high. Among infants aged 6 - 12 months who were being breastfed (60%), 74% were receiving liquid or powdered milk. Among the remaining infants aged 6 - 12 months not being breastfed, all were receiving liquid or milk powder and none were receiving infant formula. In Stankovec I camp, the timely complementary feeding rate for infants aged 6 - 9 months was 33%. Among children receiving non-milk foods, biscuits were the main complementary infant food introduced (67%). In Neprostino camp, 47% of all children 2 years and under had fed on a bottle in the previous 24 hours.

A negative impact of the crisis on rates of initiation of breastfeeding was not identified. However the cohort effect was observed. Among infants no longer breastfeeding, a significantly higher proportion (81%) aged 6 - <12 months stopped breastfeeding before the age of 4 months than among children aged 12 - 24 months (32%) (p=0.001, risk ratio 2.53). Perceived inadequacy of breastmilk was the main reason given for cessation in all age groups. The long-term consequences of a reduction in the duration of breastfeeding are unknown but could be detrimental if access to cow's milk or water and sanitation conditions decline. The prevalence of diarrhoea in children 2 years and under was high (54%). More recent data from Kosovo indicate an increased prevalence of childhood diarrhoea and ARI in the returnee population. For a more vulnerable population in less sanitary camp conditions and with fewer international resources available, the negative consequences on infant morbidity and mortality of the aid operation may have been much greater.

Based on the research findings a number of recommendations for policy makers and practitioners are made. The research report and recommendations are available in the document referenced below.

Reference

Meeting the nutritional needs of infants during emergencies: recent experiences and dilemmas - Report of an International Workshop, Institute of Child Health, London, November 1999. For more information contact Anna Taylor, Save the Children, UK, email: a.taylor@scfuk.org.uk

¹Kosovar Albanian Health Survey Report, IRC, Institute of Public Health, Pristina, WHO, CDC, September 1999