Strategy Meeting on Infant Feeding in Emergencies

Summary of international meeting

Media/communication Working Group in the foreground and Implementation/Capacity building Working Group in the background

On 1st and 2nd November, 2006 an international strategy meeting on Infant Feeding in Emergencies (IFE) was held by the IFE Core Group in Oxford, UK, organised by the ENN. The meeting was funded by UNICEF, IBFANGIFA and CARE-USA. ENN's role was supported by USAID/OFDA and IFE Core Group contributions.

The IFE Core Group members comprise ENN, UNICEF, WHO, UNHCR, WFP, IBFANGIFA, CARE USA, Fondation Terre des hommes, coordinated by ENN since 2004. The IFE Core Group have been working in two areas of IFE - policy guidance that is embodied in the Operational Guidance on Infant and Young Child Feeding in Emergencies for programme and emergency relief staff and capacity building in the form of two training modules (Modules 1 and 2). Since 2005 major concerns of the IFE Core Group have been the difficulties in putting the guidance and training modules into operation, reflected in the poor co-ordination, poor policy awareness and limited technical know-how observed in recent emergency responses. In order to address these concerns, an international strategy meeting was held to:

• identify key constraints to supporting and protecting appropriate infant feeding practices in emergencies, and
• develop strategy directions and practical steps to address constraints

The meeting was attended by sixty or so delegates from around the world, including UN agencies, NGOs, academia, donors, professional bodies, trainers and individuals with field and/or training expertise in infant feeding. Regional field staff attended from Indonesia, Lebanon, Kenya, Mexico, and India.

The following is a summary of some of the key elements of the presentations, plenary discussions and outcomes of the meeting

Day 1

The first day comprised field presentations and plenary discussions on the challenges and opportunities of IFE related to policy and guidance (morning) and implementation (afternoon). Presenters were asked to summarise key points, analyse, highlight key issues, and propose recommendations.

Challenges related to policy and guidance

David Clark, Legal Advisor on the Code with UNICEF NY, opened with a presentation on the politics and policy around the International Code of Marketing of Breastmilk Substitutes (the Code). He also highlighted the risks of artificial feeding, citing recent experiences from Botswana where contaminated water led to a significant rise in infant mortality in infants on replacement feeding (see this issue of Field Exchange). He reiterated that the Code protects both breastfed and artificially fed infants and its better implementation and enforcement would improve infant and young child feeding in emergencies. The Operational Guidance articulates well the application of the Code in emergencies - this needs to be widely distributed, internalised and implemented.
The two presentations that followed highlighted the reality of Code and Operational Guidance implementation in the field. First Ali Maclaine, Save the Children UK (SC UK) detailed the inappropriate infant feeding interventions and widespread Code violations they documented following the conflict in Lebanon in 2006 (see field article this issue). Many key recommendations for action were made; infant and young child feeding (IYCF) should be assessed in the initial phase of emergencies with standardised assessment tools, UNICEF must uphold its role in monitoring and coordinating infant feeding in emergencies. She highlighted the need for training and orientation for staff on IFE.

A second presentation by Sri Sukotjo of UNICEF Indonesia described how following the May 2006 earthquake, UNICEF found that widespread distribution of infant formula in Yogyakarta reduced breastfeeding rates. Infants who were formula fed had increased incidence of diarrhoea after the earthquake. Limited awareness, knowledge, skill and commitment on IYCF nationally prior to the crisis contributed to this situation. Advocacy, circulars, guidelines and health education materials on infant feeding did not stop the flow of infant formula or encourage breastfeeding. On a positive note, UNICEF Indonesia demonstrated that well designed breastfeeding support in emergencies can make a difference - evidence based advocacy and support for mothers through breastfeeding counsellor training was shown to successfully raise exclusive breastfeeding rates. UNICEF also managed to successfully negotiate with one government donor agency and prevent one unsolicited large donation of infant formula.

Asummary of a recent WHO HIV and Infant Feeding Technical Consultation (Geneva, October 25-27, 2007) was presented by Zita Weise Prinzo, WHO Geneva. One of the key outcomes of the consultation is a new recommendation for duration of exclusive breastfeeding for HIV positive mothers in situations when AFASS (acceptable, feasible, affordable, sustainable and safe) criteria are not in place for replacement feeding. Current 2000 UN recommendations advise HIV-positive mothers to exclusively breastfeed during 'the first months of life' and discontinue once AFASS criteria for replacement feeding are met. Pending finalisation of the exact wording, the WHO technical consultation concluded that, based on the new evidence, exclusive breastfeeding is recommended for HIV-positive women for the first six months of life, unless/until AFASS criteria are met for replacement feeding. Participants at the Oxford meeting welcomed this alignment with recommendations for the general population since it may help with addressing some of the confusion in the field, caused by the 2000 recommendation. Participants also considered the wording of this recommendation critical, and after some discussion on both days, the plenary proposed a specific wording which delegates who participated in the WHO technical consultation agreed to feedback to WHO as a recommendation of the IFE meeting.

Fathia Abdallah, UNHCR shared the experience of revising the UNHCR Policy Related to the Acceptance, Distribution, and Use of Milk Products in Refugee Settings (2006). This was updated from the 1989 joint UN version, in close collaboration with ENN, the IFE Core Group and significantly informed by the Operational Guidance. She proposed that the 2006 UNHCR policy on milk product handling in refugee settings could and should form the basis of a joint UN policy to cover non-refugee settings.

Challenges and opportunities for implementation

The afternoon session began with a summary of the inter-agency standing committee (IASC) nutrition cluster system by Flora Sibanda- Mulder, UNICEF NY. The nutrition cluster aims to strengthen emergency preparedness, strengthen coordination and set standards and policy. At the field level, the cluster aims to identify gaps, create stronger collaboration, improve strategic field level coordination and prioritisation and strengthen accountability through country cluster leads. A 'toolkit' of interventions that includes IFE is being developed to facilitate the cluster approach. Experience from delegates so far showed that the success of the nutrition cluster depends to a large extent on the capacity of the cluster leads in-country and the co-ordination in Lebanon was particularly lacking. UNICEF is looking at building a resource of technical experts with IF expertise to fill this gap.

Presentators from Lebanon, Latin America and the Carribean (LAC), India and Kenya highlighted the challenges of IFE in their regions and how they have been working to address these.

Iman El-Zein, IBFAN Arab World in Lebanon described how infant formula, often with labels violating the Code, was widely and indiscriminately distributed. Furthermore, she described their frustrated attempts to support breastfeeding mothers that was prevented by lack of official support by the coordinating agency, and the expectation by aid facilitators and mothers of receiving commodities rather than counselling. Recommendations highlighted the need for good cooperation and co-ordination between local NGOs, INGOs and the UN, good leadership and trained health personnel.

Marcos Arana, of IBFAN LAC described dealing with natural disasters in his region that tend to follow a seasonal pattern. Despite their predictability, very few strategic efforts have been made by authorities to include IFE in national or regional programmes of disaster preparedness. Spontaneous solidarity often takes the form of food donations, which often include infant formula, and is not under the control of the health system. Successful initiatives that IBFAN LAC have developed in the region include developing audio cassettes and media information kits; training, including diploma courses, and Spanish translation and adoption of the IFE modules.

Dr Bethou Adhisivam, JIPMER, Pondicherry shared the findings of a study he carried out to assess the impact of breastmilk substitutes donated during the tsunami in four coastal villages in Pondicherry, India (see research summary this issue).

Finally, Anne Njuguna, CARE Kenya shared her experiences of training on IFE in the Dadaab refugee camps, using IFE materials translated and modified to suit the local setting. Training was largely based on the UNICEFWHO 40-hour breastfeeding counselling training materials. Challenges included the high turnover of staff, lack of basic needs among refugees, difficulties of assessment due to language and technical skills and traditional and cultural practices (such as wet nursing being taboo). Recommendations given included the need to incorporate qualitative research into programmes and the need for simpler training modules to target local health workers.

Ian Bray, Media Officer with Oxfam GB, offered some insight into how we need to approach our work with the media to make a difference to public responses to IFE. Journalists look for stories that are dramatic, immediate, simple, personalized and that have authority. Geographic proximity, magnitude, conventionalism and novelty are important to them. The main two questions to ask are "So what?" and "Why now?" The best way to educate journalists on an issue is to give them a good story.

One of the main limitations cited in using the training modules by NGOs has been lack of time for adequate training. Caroline Wilkinson, Action Contre Le Faim (ACF) described how they have been trying to address this by developing a training CD for their nutrition field staff. The IFE CD comprises a series of mini modules developed by a lactation counsellor, guided by the nutrition and psychology team, and using the training modules developed by the IFE Core Group. External experts are currently reviewing its use.

Key Conclusions from Day 1

The Operational Guidance and the International Code are not just about protecting and supporting breastfeeding but also about minimising the risks of artificial feeding and ensuring appropriate infant and young child feeding. However NGOs continue to distribute infant formula in emergencies particularly when there is a high prevalence of formula fed infants pre-crisis. Availability of skilled breastfeeding support is insufficient or non-existing.

New or updated IFE Policy guidance and training materials do exist. However there seems to be a huge gap between what is known at technical/policy level and the reality in the field. In particular:

• Recent experiences in Indonesia, Lebanon, India have shown significant violations of the principles highlighted in the Operational Guidance
• Health professionals remain poorly trained on IFE issues
• Coordination at field level remains a serious problem, although the recent cluster lead initiative may help in the future
• There is little documentation of actual use of training materials in the field to help evaluate their application.

However there are examples of some excellent recent work that we need to draw upon (Dadaab, Lebanon, Indonesia, India, Mexico).

Does it really matter? New evidence presented at the meeting shows that, yes, it does.

• Inappropriate IFE practices were the most significant risk factor associated with very high levels of diarrhoea and death in Botswana
• Infant formula distribution during emergencies in Indonesia, Lebanon and India impacted negatively on infant feeding practices
• Indonesia and Dadaab, Kenya examples showed that breastfeeding counselling can improve feeding practices in emergencies.

What can be done? The real challenge is to better integrate and mainstream IFE into agency and government policies and programmatic response. There is a need to significantly raise the issue of IFE on the agenda globally, reaching out to the media, donors, and the military. Advocacy materials do exist but they are not widely known and used. A huge effort is needed on capacity building at all levels.

Since the challenges of IFE identified during the 1999 Kosovo crisis , there is more awareness generally of IFE, more policy guidance and materials available, some positive experiences and new compelling data on outcomes. However we have still not been able to impact the acute emergency response. A balanced approach to supporting both breastfed and artificially fed infants remains a challenge. To move forward we need stronger commitment from all key actors and more funding.

Participants in the Oxford IFE meeting, 1-2 November, 2006

Day 2

The second day comprised four working groups to identify strategic directions and critically, come up with action points assigning/suggesting agency responsibilities and timeframes. Recommendations of the working groups were presented to the plenary and unless contested, were agreed as recommendations of the meeting.

The four working groups were:

• Policy and coordination
• Implementation and capacity building
• Engaging with the media/effective communication
• Impact assessment/lesson learning

Despite considerable advocacy effort by IFE Core Group members for donors (22 bilateral and private invited) to attend, donors were poorly represented and only one attended for the first day. This was identified as a considerable gap by the plenary. As a result, a scheduled fifth working group on working with donors was absorbed into the other four working groups.

Working groups - practical steps forward

The following is a selection of some of the key steps agreed, with responsible agencies given in brackets. A full listing of outcomes with agencies and timeframes assigned to tasks is given on the ENN website.

• The Operational Guidance should be elevated as official guidance, building on the Global Strategy and Innocenti Declaration on Infant and Young Child Feeding. The UN Standing Committee on Nutrition (SCN) endorsement should be pursued. (ENN/ UNICEF/ACF)
• Key sections of the Operational Guidance are to be reviewed to clarify particular provisions pertaining the Code (ENN/SC UK/IBFAN /UNICEF)
• Agencies should endorse the Operational Guidance via ENN. (All/ENN). Fifteen agencies signed up to support the Operational Guidance at the meeting.
• UNHCR to set in motion the development of a joint UN policy on handling milk products that can be used by other agencies and expanded to cover other emergency settings (UNHCR/ENN).
• The ENN were invited (and accepted) to become a member of the UN nutrition cluster to represent the IFE Core Group and keep IFE high on the agenda.
• Strengthen the connection between the Operational Guidance and Sphere (ENN) and work to ensure that IFE (and specifically managing infants under 6 months) is included within existing training and materials, including: - Valid International training manual on Community Therapeutic Care (ENN) - WHO manual on managing severe malnutrition (WHO). - Emergency Staff Capacity Building Project (Mercy Corps International)
• Develop a media/advocacy kit for internal distribution/press distribution. This will include key messages, questions and answers, key statistics and possibly an audio /visual aid. (UNICEF)
• Advocate for WABA (World Alliance for Breastfeeding Action) to have IFE as key theme for the World Breastfeeding Week 2008 (IFE Core Group/IBFAN).
• Compilation of case studies from recent emergencies, into an ENN document (ENN).
• Explore development of an ENN Special Supplement on IFE (ENN)
• Explore linking IFE to other sectors, such as reproductive health and child survival (All)

Immediately following the meeting, the IFE Core Group met to address the specific outcomes of the two-day meeting. This included clarification of the ENN/IFE Core Group role in relation to the UN nutrition cluster, prioritisation of the workplan and resources available, and an invitation to ACF and SC UK to join the IFE Core Group.

All presentations from the meeting are available at http://www.ennonline.net A full report will be soon available from the ENN. For further information, contact: Marie McGrath, ENN, email: marie@ennonline.net

¹Meeting the nutritional needs of infants during emergencies: recent experiences & dilemmas. Report of an International Workshop, Institute of Child Health, London, November 1999. http://www.ennonline.net/docs/IFEWorkshopReport1999.pdf