Postscript to 'Infant feeding in the South Asia earthquake aftermath'

Maaike's observations concur with many of our experiences around infant feeding in emergencies (IFE) in previous humanitarian interventions. Failure to include breastfeeding support in early interventions, dilemmas on how to manage non-breastfed infants and untargeted distributions of milk products were all features of the aid intervention in FYR Macedonia, documented during the 1999 Kosovo crisis¹. Maaike in her article refers to the Operational Guidance on Infant and Young Child Feeding in Emergencies (2001)². The original concept for the Ops Guidance largely emerged from discussions around the 1999 IFE research from FYR Macedonia, which found poor awareness, use and implementation of guidelines and policies by local and international emergency staff. Even more importantly, it highlighted how decisions that can have a significant influence on infant feeding, e.g. acceptance and distribution of unsolicited breastmilk substitute (BMS) donations, were often taken by logisticians, programme managers and non-health agencies. The Ops Guidance was developed by an inter-agency working group on IFE (including the IFE Core Group) to provide concise, practical, but mainly non-technical, guidance on how to ensure appropriate infant and young child feeding in emergencies. It targets all, from nutrition and health workers, logisticians and programme managers to policy makers.

However, it is not for lack of guidance and policies that we were, and still are, falling short. The need for training specifically to address IFE was identified at an International Meeting on Infant Feeding in Emergency Situations meeting in 1998, out of which grew an interagency collaboration (IFE Core Group 3³) to address this. Over the last eight years, there has been considerable work by the IFE Core Group to develop specific technical guidance and training materials to help agencies and staff protect and support infant and young child feeding in emergencies. To date, two training modules have been developed (Modules 1 and 2) that are referred to by Maaike. Both evidence and experience- based, the modules complement the considerable resources developed by the World Health Organisation that include complementary feeding in the breastfed and non-breastfed child, and infant and young child feeding in the context of HIV/AIDS⁴ - guidance that wasn't around eight years ago.

Over the past year, members of the IFE Core Group have focused on promoting and targeting the training materials and this was a contributory factor to their use in the training in Pakistan. A creative approach by the Pakistani team overcame one of the criticisms of these resources: their African focus through the images used. While lack of funding has prevented the IFE Core Group from developing different versions of the modules for different regions or continents, the team in Pakistan showed that a simple adaptation could be made. Their work now provides a valuable resource and inspiration for others in the region and for the future development of the materials.

As for the Ops Guidance, is it actually being used in the field? Maaike's account from Pakistan suggests limited implementation. Lack of awareness of policies and guidance undoubtedly remain a negative factor, particularly amongst agencies not usually involved in health related interventions, military-related aid and individual responses, leading to inappropriate actions like the donation of infant formula. Moreover, collaboration between the IFE Core Group and agencies in the 2006 revision of the Ops Guidance and on agency policies on milk product handling in emergencies suggest that even agencies that are aware of the guidelines and policies are struggling to implement the recommendations on the ground. A prime example cited by Maaike is that of managing orphans in emergencies when there is no wet nurse.

Interestingly, case material collated by the IFE Core Group during the development of Module 2 identified feeding of orphans as a key IFE concern in the field and additional material was developed specifically to address this issue. However, implementation remains constrained partly due to difficulties (and perhaps fear) of handling and being seen to handle infant formula in an emergency context. It is a huge challenge to provide the most nutritionally appropriate BMS to those in need and, at the same time, protect breastfeeding. What often happens is that whilst agencies with 'knowhow' deliberate in the field, those less equipped and/or aware of the issues and risks of artificial feeding in emergency contexts feel compelled to step into the void and start distributing commercial formula or milk products. Sometimes, the less politically sensitive home-prepared breastmilk substitutes are chosen. But they also carry risks linked with their preparation in emergency contexts, and are less nutritionally complete⁵.

Maaike's article suggests that support of infant and young child feeding in emergencies is still considered an optional extra in early emergency interventions, something to be considered once a situation has stabilised. At the same time she emphasises the importance of having the main elements of the emergency response in place before any disaster strikes. Knowledgeable staff at the MOH in Pakistan and in-country, and the existence of national legislation implementing the International Code on the Marketing of Breastmilk Substitutes were key in establishing an appropriate response to IFE. The commitment to IFE of the MOH was reflected in their seeking guidance from international agencies on issues like the procurement of BMS and the protection of breastfeeding, and their willingness to distribute documents like the DG Health's letter. At the same time, the international community were pivotal in supporting the MOH technically, for example inputing into the DG Health's letter, and as a source of manpower. Less obviously, many committed individuals and agencies worked hard, often 'behind the scenes', to successfully place infant feeding and nutrition high on the agenda.

Thirty UN agencies and NGOs signed up to support the Ops Guidance when it was produced in 2001. Documented suboptimal implementation of this guidance in the field in Pakistan coincides with the revision of the Ops Guidance (available April 2006). It has made the IFE Core Group revisit what agency 'support' actually means, and how to monitor this support. We feel that to truly 'operationalise' the guidance, we now need to identify and address the factors currently hampering implementation within agencies. Towards this end, we propose and will pursue in autumn 2006 an inter-agency working meeting to address these issues from which, we hope, will emerge a united 'struggle consensus', with steps towards finding solutions.

Marie McGrath, ENN
Lida Lhotska, IBFAN-GIFA
Mary Lung'aho, CARE

View the article that this postscript relates to

¹Meeting the nutritional needs of infants during emergencies: recent experiences and dilemmas - Report of an International Workshop, Institute of Child Health, London, November 1999. See summary in Field Exchange no 10, Infant Feeding in Emergencies: Recurring Challenges, Marie McGrath

²See online at http://www.ennonline.net/ife/index.html

³The IFE Core Group comprises UNHCR, WFP, WHO, UNICEF, ENN, IBFAN-GIFA, TdH, and CARE, with working collaborations with ACF and IFRC and co-ordinated by the ENN.

⁴See resources at http://www.who.int/child-adolescent-health

⁵Extract from Operational Guidance (version 2). Part 6.4.7. It is difficult to obtain nutritional adequacy with home-modified animal milks, particularly regarding micronutrients...Thus home-modified animal milk should be used in non-breastfed infants below 6 months only when there is really no other feasible alternative option, such as generic or commercial infant formula. See Bull WHO, 2004. Are WHO/UNAIDS/ UNICEF - recommended replacement milks for infants of HIV-infected mothers appropriate in the South African context? P.C. Papathakis & N.C. Rollins, http://www.scielosp.org/pdf/bwho/v82n3/v82n3a05.pdf