Letter on relevance of IFE guidelines in developed countries, by Sarah Saunby

Recently, ENN was party to an exchange of questions and discussion between field staff and 'experts' relating to decisions on the use of readymade therapeutic products versus those made from modular ingredients in the management of severe malnutrition. Those involved have agreed to share this exchange with the Field Exchange readership as they feel this is an issue that needs 'airing'. The ENN would welcome contributions from the Field Exchange readership on this topic. Email any comments to marie@ennonline.net (eds).

Questions from the field

Dear Field Exchange,
When we think about Infant Feeding in Emergencies (IFE), it's generally associated with some crisis in a developing country; a tornado, earthquake, tsunami or conflict induced displacement. The UK shouldn't really need to give much consideration to international guidance on IFE, because things like this just don't happen in the UK.

So when I heard, following the recent UK floods, that in South Yorkshire alone, 14,000 people had been evacuated from their homes and that 86,000 homes had disrupted power supplies with 32,000 homes being completely without power, I wondered what systems, if any, were in place to protect vulnerable babies in the UK. In emergencies, children under five are more likely to become ill and die from malnutrition and disease than anyone else. In general, the younger they are, the more vulnerable they are. Inappropriate feeding increases their risks¹. Are UK infants immune to this risk?

The WHO/UNICEF Global Strategy on Infant and Young Child Feeding (2003) describes how artificially fed infants already constitute a risk group and should receive special attention from the health and social welfare system. Therefore, situations like this really highlight the importance of breastfeeding. In emergency shelters or homes without power supply, how easy is it to maintain safety guidelines set out by the UK Food Standards Agency, Department of Health and infant formula manufacturers for preparing infant formula, i.e. mixing powdered formula with water at 70 degrees centigrade (the temperature necessary to kill harmful pathogens) and cleaning and sterilising bottles and teats. A recent report in the UK Guardian newspaper highlighted the acute risks that formula feeding presents to infants where there aren't the resources to safely support it². Whilst we clearly don't have the same problems as in developing countries, the current situation across South Yorkshire and other areas of the country shows that there are occasionally problems to be overcome³.

In a BBC Radio Sheffield interview, one man described how he was woken in the middle of the night by emergency crews who told him he and his family had 5 minutes to get ready and leave their home. For a breastfeeding mother, so long as the mother and baby are kept together, the baby's food needs are pretty much catered for. But for those mothers artificially feeding, how must they have felt to have to leave their homes so suddenly without any necessary equipment or means to feed their infant

If local authorities and other agencies are donating supplies of food that includes infant formula milk, are they following the UK Law, WHO and UNICEF code and resolutions Operational Guidance on IFE⁴ and International Baby Food Action Network (IBFAN)⁵ guidelines in ensuring breastfeeding is protected and not undermined by emergency relief efforts and distribution of breastmilk substitutes? Are those aid workers / staff aware that such guidelines even exist? Any appeals being made on behalf of victims should be for money rather than donations. Many health workers and parents are unaware that infant formula is not a sterile product to start with.

Is this covered as part of the 'major incident' preparations? Is the importance of keeping a mother and her infant together understood and training given in assisting mothers with relactation, if necessary? Are health workers and agency staff equipped to advise breastfeeding mothers whose infants are around six months of age, to manage mothers in a stressful situation, and to advise on cup feeding?

In many flood-affected areas, people have been left without mains supply water, drinking water supply or any bowser (portable container) water, and bottled water is the only option. In one UK county, 340,000 people lost their water supply. Many types of bottled waters (mineral, spring and table) may be unsuitable to mix with powdered feeds because the solute levels (sodium, nitrate, sulphate and fluoride) are too high to feed babies with. Have mothers, who normally use powdered formula, been informed that the ready to feed cartons of infant formula may pose less of a risk than powdered feed during this time, particularly where the clean water supply has been affected and has she been helped with supplies?

If it is felt that the that Infant Feeding in Emergencies guidelines are not that relevant in this country, then it really is time to think again. My feeling is that this highlights just how important it is in the UK, as well as the rest of the world, and I would urge the UK Government and other agencies to ensure systems are in place to protect this vulnerable group at such a difficult time.

My real concern is for those people in disadvantaged groups who are already experiencing inequalities in health. They are likely to be the most affected in these circumstances as they are more likely to have health problems, have lower incomes (ready-tofeed cartons of formula are usually more expensive than powdered formula), less likely to be able to afford house insurance (to replace any damaged items such as sterilisers, bottles and teats), and may be less likely to have their own transport to collect water from depots.

Yours sincerely,
Sarah Saunby
Sheffield Area Contact, Baby Milk Action & BfN Registered Breastfeeding Supporter UK

A more detailed version of this letter has been posted online, along with other details and information on infant feeding issues in the UK, at http://boycottnestle.blogspot.com/2007_07_01_archive.html

¹http://www.ennonline.net/pool/files/ife/module1-manual.pdf Infant Feeding in Emergencies, Module 1 for emergency relief staff WHO, UNICEF, LINKAGES, IBFAN, ENN, 2001

²http://www.guardian.co.uk/comment/story/0,,2090780,00.html The Guardian Formula milk is even more deadly in disaster zones, by Marie McGrath, Wednesday May 30th, 2007

³http://news.bbc.co.uk/1/hi/uk/6239828.stm BBC News Floods force thousands from homes. Tuesday, 26 June 2007

⁴Operational Guidance on Infant and Young Child Feeding in Emergencies, v2.1, Feb 2007. Applies worldwide. Available at www.ennonline.net/ife

⁵IBFAN is a global network to strengthen independent, transparent and effective controls on the marketing of the baby feeding industry. The UK IBFAN organization is Baby Milk Action, http://www.babymilkaction.org