Letter asking for guidance on BMS for orphans in Rwanda, by Ros O'Loughlin (and response by ENN)

Dear Field Exchange,

I read with great interest the articles on infant feeding in the first issue of Field Exchange. I was at the time working in a centre for unaccompanied Rwandan refugee children in Kisangani, Zaire (now Stanleyville, Democratic Republic of Congo).

The number of children under one year of age was small, only 5 or 6, but we were faced with the problem of how to feed them. I was disappointed that the articles only pointed out the problems that I knew too well but offered only limited solutions. We were using diluted Nutriset milk. Wet nursing was not an option as the children were only with us for an average of 3 weeks before repatriation to Rwanda.

I would like to have seen some practical advice in the form of recipes given, e.g., using Nutriset milk or dried skimmed milk. I realise that these would not be ideal, however, when faced with that situation and with no alternatives one must improvise.

Yours etc.,
Ros O'Loughlin,
Naas, Ireland.

Dear Ros

Thanks for taking the time to let us know what kind of thing you would like to see in Field Exchange. It appears that your are not alone in your request for guidance on infant feeding emergencies.

We did seek advice on which of existing DSM, oil, sugar mixes in current guidelines, if any, would be appropriate for the small number of infants for whom breast milk is not an option. We discovered without too much surprise that there was a lot of controversy around the topic.

I'll summarise the different views. There appears to be a consensus that, because of the problem associated with the quantities and proportions of minerals and vitamins in DSM/oil/sugar recipes, they should be used only in the most exceptional circumstances, if at all.

There is also the view that with so much known about formula preparation it should be possible to do better than giving such mixes even in an emergency situation. The opinion is held that if a young infant cannot be breastfed and if a safe alternative source of breast-milk cannot be found, than a good pre-formulated 'breast-milk substitute', prepared according to the latest US or EU recommendations or the CODEX ALIMENTARIUS guidelines, is the next best thing. This should be distributed in generically labelled containers, and fed with a cup, not a bottle.

On the other hand, there are those who believe that there is a place for recipes in extreme situations as a last option. From this viewpoint

• breastfeeding would be the first and best option followed by, in decreasing preference,
• wet-nursing
• local purchase of infant formula
• importation of generic infant formula and, lastly
• emergency measures to fill any 'gaps' in the flow of supplies.

It is in the last category that home-made recipes would fit, thereby averting the types of situation where infants are fed CSB because nothing else was available.

Most current guidelines provide recipes for DSM/oil/sugar mix. One thing is certain exact quantities of each commodity must be used. 'Rounding up' amounts to the nearest teaspoon must be avoided.

We did not recommend mixes as there is not yet a consensus on what constitutes an adequate DSM/oil/ sugar mix for this age group. There is an ad hoc group on infant feeding attempting to achieve consensus on this topic and we will report on any developments.

Coming back to your own situation - you used F100 (Nutriset milk). The problem with recommending the use of such a product for the breastfeeding age group is the wider public health damage which could conceivably occur if breast- feeding practices are changed by the introduction of artificial milks. Also for the proper use of this commodity it is better that F100 is NOT perceived of as a breast-milk substitute rather than a liquid diet specifically formulated for (older) severely malnourished patients.

Nevertheless, the F100 diet is designed to support rapid growth and to be absorbed by the damaged intestine; as such, in an emergency, it could be used (diluted into 2.8, instead of 2.0, litres) for younger children for a short time, although it has not been tested in this role. It is VERY low in iron, so that any infant given this diet is likely to develop iron deficiency. DSM/oil/sugar mixtures are also deficient in iron as well as most other vitamins and minerals. F75 is totally inappropriate for infants and not designed to allow normal growth. It should never be used for infant feeding.

Editors.