Infant and young child feeding in emergencies: Programming adaptation in the context of COVID-19 in Lebanon

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By Bayan Ahmad

Bayan Ahmad is Senior Field Officer at International Orthodox Christian Charities (IOCC), where she is responsible for overseeing IOCC’s health and nutrition programmes. She holds a Master’s degree in nutrition, dietetics and food management.

IOCC gratefully acknowledge the support of UNICEF for funding the project activities and the salaries of staff and for continuously working on building the capacity of their implementing partners. IOCC also acknowledge the Ministry of Public Health Maternal and Child Health Department, the National Infant and Young Child Feeding Committee and the Nutrition Sector for supporting and facilitating the implementation of the programme.

Background

Infants, young children and their mothers are vulnerable, particularly during humanitarian emergencies. Improving infant and young child feeding (IYCF) practices¹ according to the World Health Organization (WHO) recommendations is key to improving child survival and to promoting healthy growth and development. Rates of optimal IYCF practices in Lebanon are very low. Data shows that only 14.7% of infants less than six months of age are exclusively breastfed (Central Administration of Statistics, 2009) and around 13% of infants aged 6-23 months meet the minimum acceptable diet for complementary feeding (UNICEF, 2016). Field experience reveals that the main barriers to optimal breastfeeding in Lebanon include the lack of both awareness and a supportive environment for breastfeeding.

Ten years into the Syrian crisis, Lebanon remains the country hosting the largest number of refugees per capita. According to United Nations High Commission for Refugees estimates, there were 855,172 registered Syrian refugees dispersed across Lebanon by the end of March 2021.² The presence of such a large refugee population places enormous strain on the country’s economy, public services and local infrastructure. In addition, during the year 2020, the country went through severe economic challenges, exacerbated by the COVID-19 pandemic and the blast in the port of Beirut on August 4, 2020 that caused more than 200 fatalities and 6,500 injuries. During this succession of crises, ensuring optimal breastfeeding amongst refugees and the host community became an even greater priority given the importance of breastfeeding as a life-saving intervention.

Misconceptions and inadequate IYCF practices are commonly found among both refugees and Lebanese families. Programme staff often report that the introduction of water for thirst and tea for colic, illness or to relax the baby is customary and commonly initiated soon after birth. The early introduction of complementary foods is also customary with mothers commonly starting to give their infants small amounts of food from three to four months of age. Infant formula is also commonly given to infants soon after birth when mothers feel that they are not producing sufficient milk to meet their baby’s needs. Women’s reasons for discontinuing breastfeeding include breast and nipple pain, latch difficulties, sleep deprivation and exhaustion. These difficulties are often compounded by maternal employment, inadequate family support or the lack of professional advice which are known barriers to breastfeeding success.

IYCF programming by International Orthodox Christian Charities in Lebanon

International Orthodox Christian Charities (IOCC) has been actively involved in nutrition-related activities in Lebanon both in schools and communities since 2001. Activities to improve IYCF practices have been prioritised both in normal times and in emergency situations, with specific IYCF-related activities targeted to both refugees fleeing conflict in Syria and vulnerable Lebanese families.

In 2011, a national IYCF programme was established by the Ministry of Public Health (MoPH), with support from IOCC and World Vision, and a sub-committee on IYCF in emergencies (IYCF-E) was created, mainly supported by IOCC. In 2018, the MoPH, with support from UNICEF and IOCC, developed and launched a National Policy on Infant and Young Child Feeding to guide actions to promote optimal IYCF to support the healthy growth and development of infants and young children in the country. The policy defines the responsibilities of the Lebanese government, its partners and all relevant stakeholders in promoting, protecting and supporting IYCF.

IOCC is a member of the IYCF national committee and works through the national IYCF programme to implement IYCF-related activities. Through its UNICEF-funded project launched in 2020, IOCC provides IYCF counselling and support to 10,000 pregnant and lactating women and through its team of community health educators, IOCC conducts education and awareness activities on optimal IYCF practices in all governorates to reach 9,000 caregivers. Mothers with lactation difficulties are referred to IOCC’s pool of qualified and skilled lactation specialists who provide one-on-one counselling. Lactation specialists also provide support to ensure optimal IYCF practices in hospitals, primary healthcare centres and at community level. In addition, IOCC monitors and supports hospitals in Lebanon enrolled in the Baby Friendly Hospital Initiative programme through on-the-job coaching and monitoring adherence to the ‘10 steps to successful breastfeeding’, identifying and addressing challenges and supporting them towards certification with the Baby Friendly Hospital label from the MoPH. Other activities include the development of materials on complementary feeding and building the capacity of the healthcare providers working in nurseries to use these materials, as well as the monitoring of violations against the International Code of Marketing of Breast Milk Substitutes (BMS).

During the multi-faceted crisis that occurred in Lebanon, including movement restrictions as a result of COVID-19 imposed from March 2020, IOCC worked to adapt existing programming approaches to ensure that the most vulnerable pregnant and lactating women would be able to access IYCF support. Programmatic adaptations were made in line with the WHO, UNICEF and the Lebanese MoPH guidelines, supported by additional funds reallocated from existing programme budgets. This article outlines the programme adaptations made and lessons learned.

Programmatic adaptations

Promotion of optimal IYCF practices at community level

Initially, IOCC educators provided group education sessions on a daily basis, following a pre-defined curriculum of topics. Caregivers were gathered in one location and sensitised on IYCF topics. In the context of COVID-19, IOCC expanded its team of educators to reach more people and adapted its awareness activities to cover both IYCF and COVID-19. IOCC also mobilised volunteers across the country for a duration of two months to help and support the educators in awareness raising activities.

Based on the materials and guidelines developed at national level, existing educators and volunteers worked to raise awareness of IYCF and COVID-19 within their communities, targeting community members with key messages that aimed to limit the spread of the virus, mitigate its impact and correct misconceptions about IYCF in this context. They provided municipalities with preventive information and guidelines on home isolation, guidance on regular hand washing and hygiene, social distancing, the symptoms of COVID-19, when to seek medical care, how to buy groceries and disinfect them, when to use a face mask and how to use it appropriately as well as myth busters around IYCF/nutrition and COVID-19. Educators and volunteers helped to disseminate key national messages through the distribution of flyers and posters to shops, pharmacies and at household level, as well as through social media (including WhatsApp). They also advocated with local authorities and influencers (mayors, mukhtars and religious leaders) to engage in the dissemination of the key messages. Over two months, the volunteers were able to cover more than 120 of the 1,108 municipalities across the country.

Supporting mothers to practice optimal IYCF

As a response to the COVID-19 pandemic, IOCC lactation specialists began consulting and following up with pregnant and lactating women with either confirmed or suspected COVID-19 infection using the IYCF counselling card that was adapted for COVID-19 by UNICEF (Figure 1).

Figure 1: IYCF counselling card adapted to COVID-19

Box 1 provides an example of the support provided to a nursing mother. Support continued to be provided by lactation specialists for mothers with lactation difficulties referred by educators.

As a response to the COVID-19 emergency, alternative modalities to delivering support to mothers were put in place including the following:

• As many education and support sessions as possible were provided remotely over the phone, via social media or remotely through Zoom, Skype and/or WhatsApp.
• Where necessary and possible, individual meetings were conducted face-to-face while using personal protective equipment (PPE), physical distancing and frequent handwashing.
• The number of people attending awareness sessions in person was limited to five and sessions were conducted in open or well-ventilated areas with strict physical distancing measures and a requirement to wear face masks. As a result, the frequency of sessions was increased to enable the same or greater reach. When lockdown measures meant that approval needed to be given before sessions could be held, educators transferred to online modalities.
• The use of PPE, physical distancing and frequent handwashing were adopted during all individual meetings.

In support of the optimal nutrition of children aged 6-59 months, in 2020 IOCC also distributed micronutrient supplements to more than 5,000 vulnerable children in this age group. This was carried out through outreach at the community level conducted by the educators and lactation specialists. Supplementation targeted both refugee and vulnerable host community children and was carried out over this period in coordination with the Mother and Child Health Department of the MoPH and the Nutrition Sector.

Box1: Case study of support provided to a breastfeeding mother during COVID pandemic

Samah, age 35, was unsuccessful in breastfeeding her first two children and was pregnant in her third trimester with her third child when she was diagnosed with COVID-19. Samah was not planning to breastfeed her baby and had heard a lot of myths and misconceptions around the need to avoid breastfeeding during the pandemic and to feed her infant with formula milk as a safer alternative. While still pregnant, Samah was approached by Amal, an IOCC lactation specialist. Amal helped to both improve Samah’s knowledge about breastfeeding and build her confidence in her ability to breastfeed. She provided the mother and her partner with information about the benefits of breastfeeding, breastfeeding initiation and positioning, the importance of exclusive breastfeeding and the prevention and treatment of common breastfeeding problems.

Education and counselling sessions were conducted by Amal remotely through WhatsApp and Zoom. Amal also coordinated with the midwife at the hospital to ensure that Samah was supported to initiate breastfeeding within the first hour after her baby was born and that the baby was placed skin-to-skin on his mother’s chest to encourage him to breastfeed more.

Amal then followed up closely with Samah through video calls following the birth to observe her breastfeeding and provide support several times before she left the hospital. Although Samah experienced nipple soreness and bleeding and the physician suggested she  use formula supplements, she continued exclusively breastfeeding, adjusting the latch and adopting good position to overcome the initial difficulties.

Later, when the time came for Samah to return to work, Amal counselled her, giving guidance on how to express and store her breastmilk and provided her with a manual pump. Samah said,

“We live in a culture where breastfeeding is undervalued and bottle feeding is viewed as the normal and safe way to feed babies, especially during this pandemic. I learned a lot from my experience with Amal. She helped me fix the breastfeeding difficulties I faced and corrected the misconceptions that I had about breastfeeding. She also helped me save money, which was good especially with the worsening economic situation. In addition, online consultations were highly convenient and time savvy; it was easy and fast to communicate with Amal by using WhatsApp. I’m still exclusively breastfeeding my baby. I now in turn raise awareness on breastfeeding and correct misconceptions within my community.”

Protecting IYCF through legislation

Despite the existence of a national law (Law 47/2008) that legislates upon the International Code of Marketing of BMS, IYCF is still undermined, particularly in emergencies. Due to the economic crisis, the COVID-19 pandemic, the heavy refugee burden and, in addition, the blast at the port of Beirut, calls for infant formula donations from the community increased. Several grassroots initiatives and organisations accepted donations and distributed these through a general distribution scheme without having the capacity or knowledge to follow global guidance for humanitarian aid.

IOCC identified the organisations and the formula milk providers involved and contacted them to provide them with legal information to ensure that artificial support was administered in line with the law.³ In addition, as a member of the IYCF national committee, IOCC supported the development of IYCF Standard Operating Procedures (SOPs) to guide and inform national and international agencies on how to ensure appropriate, timely and safe IYCF support for families. IOCC also contributed to the development of an infographic for the SOP to communicate information quickly and clearly, translated this into Arabic and disseminated it across agencies and sectors. IOCC then conducted workshops for organisations and small groups that were providing milk formula distribution to vulnerable families in all Lebanese governorates to inform them about the IYCF SOP, discussing how to provide nutrition support in a way that was in line with the global and international guidance on IYCF-E.

In coordination with the IYCF national committee, IOCC set up a IYCF hotline number to report violations of the BMS Code and to receive referrals for mothers in need of follow-up from lactation specialists. Various channels, including the development of a flyer and social media, were used to promote the hotline to agencies working across different sectors as well as caregivers. Infants and young children less than 24 months of age who were identified as needing support were referred for a full assessment conducted by a lactation specialist and given either skilled IYCF support or artificial feeding support as appropriate.

Discussion

The lockdown measures introduced in Lebanon in March 2020 to reduce the spread of COVID-19 resulted in a rapid change in circumstances for pregnant women, new mothers and their infants. Lactation specialists noticed that the changing and uncertain circumstances, the prevalence of misconceptions and myths surrounding breastfeeding and COVID-19, combined with reduced face-to-face support from family, friends and peers negatively affected women's perceptions and experiences of breastfeeding and their ability to overcome practical challenges. Furthermore, the deterioration of the economic situation and the loss of income associated with the closure of small businesses affected the ability of many families to purchase nutritious foods, altering the economic basis for infant feeding decisions. The prevailing context in Lebanon, where infant formula is regarded as an essential commodity and infant feeding with formula milks is regarded as ‘normative’, also presented extra challenges, driving the soliciting of donations of BMS and feeding equipment for untargeted distribution.

The government, UNICEF and professional health organisations were advised to maintain mother-infant contact and to encourage and support breastfeeding, including when a mother had COVID-19 provided she was well enough and precautions were taken to minimise transmission to her infant during feeding. Global and national guidance was released and IYCF programmes had to adapt quickly in order to provide scaled-up support to protect and promote optimal IYCF in this context.

Achievements

As a result of the programme adaptations by IOCC described in this article, between the end of February and the end of December 2020, lactation specialists were able to reach more than 11,000 pregnant and lactating women to provide them with IYCF counselling and support, as compared to around 3,000 in 2019. IOCC educators and volunteers were also able to reach more than 24,000 caregivers (compared to 1,500 in 2019) with education on IYCF especially in the context of COVID-19. This demonstrates a considerable growth in reach at this challenging time, largely driven by the incredible effort of IOCC volunteers and staff, as well as the use of online platforms which enabled many women to be reached swiftly. In terms of the hotline, over 700 calls have been received since its launch in September 2020 with more than 85% of the calls being referred to a lactation specialist. Five violations of the BMS Code were reported through the hotline.

Challenges

A major challenge with working remotely was internet access. Some caregivers in rural areas had poor connections while others did not have any connection at all. This limited their ability to engage with some activities.

The programme adaptations described resulted in an increased workload, training needs and logistics within IOCC. Staff were provided with regular additional trainings on infection prevention and control measures to ensure they were able to share key messages and answer common questions on COVID-19. Many more materials were also developed, printed and distributed by IOCC which resulted in staff time and budget implications. To support this, the budget reallocations had to be done in coordination with the donor  to support additional activities.

The surge in calls to the IYCF hotline proved challenging during 2020. In response, in 2021, two IYCF monitors were recruited to support the national IYCF hotline and meet the additional surge in needs.

Lessons learned and recommendations

Prior to the COVID-19 outbreak, IOCC worked on a preparedness plan that involved identifying resources, determining roles and responsibilities, developing policies and procedures and planning adaptations to programme activities in order to be able to respond promptly and effectively to a pandemic. This meant that the planned programme adaptations could be implemented swiftly after the first case of COVID-19 was confirmed in Lebanon. This kind of preparedness planning is essential in driving an appropriate emergency response. In future, greater alignment and coordination in mitigation plans across sectors (nutrition, health, food security and livelihoods, agriculture, water hygiene and sanitation, social protection and mental health and psychosocial support) is needed to improve the reach and support of all pregnant and lactating women and their infants and maximise opportunities across all services.

Despite the challenges, the merging of online support with in-person support enabled IOCC to reach a large number of pregnant and lactating mothers with essential IYCF support services in a short space of time. However, breastfeeding and complementary feeding practices in Lebanon remain poor. Along with the worsening economic situation and the increased demand for formula milk, programmes and services to protect, promote and support optimal feeding practices should remain a critical component of the programming and response for young children in the context of COVID-19 and more funding for IYCF-E activities is still needed. There is also a need to invest in the training and mobilisation of more community health volunteers to run IYCF-E activities at community level and lactation specialists to provide specialist counselling and support. Building the capacity and strengthening more health facility staff on IYCF-E counselling in the COVID-19 context is also needed to sustain the gains made and further scale up quality IYCF programming. 

The understanding of myths and misconceptions related to IYCF and the tailoring of messages accordingly, and the inclusion of key decision-makers within the family structure (fathers, mothers-in-law)  and influential members of society (midwives, doctors, dietitians, religious authorities, mayors), in awareness activities were important aspects of the programme. This should be considered by IYCF programmers going forward.

The IYCF hotline number provided another important platform for pregnant and lactating women to access remote support services. The hotline needs to be promoted to reach its full potential. The national IYCF committee, in coordination with the Lebanese government and UNICEF, is preparing a campaign on IYCF that aims to raise awareness on IYCF and promote the IYCF hotline with an official launch planned in June 2021.

IOCC and partner actions to address unethical breaches of the International Code of Marketing of BMS were a critical part of the response. Further advocacy is needed so that Law 47/2008, which aims to protect and promote breastfeeding, and the International Code of Marketing of BMS, are actually enforced in all emergency responses including during and after the COVID-19 pandemic. A legal framework supported by the MoPH is needed to ensure full adherence to the BMS Code to make sure that donations for and the marketing and promotion of formula milk are neither sought nor accepted.

Further recommendations are made for donors, embassies, international organisations, non-government organisations and grassroots organisations in a call for action that was developed by the Nutrition Sector in the response to the Beirut explosion.⁴

Conclusion

Adapting IYCF programme activities in the context of COVID-19 and the economic situation in Lebanon proved challenging. Progress has been made but programmes and services to protect, promote and support optimal early and exclusive breastfeeding and age-appropriate and safe complementary foods and feeding practices should remain a critical component of the programming and response for young children in the context of COVID-19. Coordination with other sectors is also needed to focus on reaching and prioritising pregnant and lactating women and infants and young children.

For more information, please contact Bayan Ahmad at Bahmad@iocc.org.

Central Administration of Statistics (Lebanon) (2009) Lebanon Multiple Indicator Cluster Survey 2009. Accessed at : http://ghdx.healthdata.org/record/lebanon-multiple-indicator-cluster-survey-2009

UNICEF (2016) Baseline survey. Accessed at: https://data2.unhcr.org/en/documents/download/49509