Ali Maclaine, consultant nutritionist
The provision of infant formula and milk for infants and young children is a very emotive subject, especially during emergencies.(1) NGOs have been struggling with how to tackle this problem since the early 1990s, when emergencies in countries such as Iraq revealed that a significant percentage of women had been using breastmilk substitute (BMS) before the crisis occurred.(2) Previously, relief work had focused on countries where the pre-crisis breastfeeding rate was nearly 100%; although breastfeeding practices were often less than ideal, at least that lifeline for infants was there. However, even when relief agencies knew the benefits of breastfeeding and the dangers of BMS, especially during emergencies, they felt that they had to do something to support affected infants, and so often distributed infant formula - untargeted, unmonitored and without follow-up.
Since then, agencies have been developing infant feeding in emergencies (IFE) policies, initiatives and training materials (see Box 1, p. 11). However, the conflict in Lebanon has again highlighted the difficulties in supporting formula-fed infants, while at the same time promoting breastfeeding. This article outlines the background to IFE, then describes the IFE response in Lebanon and the major issues that arose from it. It draws on the findings of a Save the Children mission to Lebanon to monitor IFE and support safe infant feeding practices.
Infant feeding in emergencies
IFE is little understood, even by many health and nutrition staff, never mind other sectors. There is often a belief that it is only about promoting breastfeeding, and as such is a development issue, and so not a high priority in emergencies. In places such as Lebanon, where many women use formula and 'know how to do it', many people do not understand why formula should not be freely distributed during an emergency. Moreover, as infants are often out of sight in shelters or homes it is easy to overlook their needs and potential requirements.
The importance of breastfeeding
The benefits of breastfeeding, in terms of the infant's growth, physical and psychological development and immunological protection, and in regard to the mother's health, are well-established. The World Health Organisation (WHO) recommends that an infant is exclusivelybreastfed (3) for the first six months of life, and continues breastfeeding for two years or more, withtimely and adequate complementary foods. In terms of child survival breastfeeding is crucial: 13% of all under-5 deaths could be prevented if all infants were breastfed - more than any other preventative intervention.(4)
The dangers of artificial feeding
BMS is inferior to breastmilk; it lacks breastmilk's precise balance of nutrients, is more difficult to digest, may be wrongly prepared, does not protect against illness and, if contaminated, (5) may carry infection, leading to higher mortality. Even in the best, most hygienic conditions, artificially- fed babies are five times more likely to suffer diarrhoeal diseases.(6) In an emergency situation, even where bottle feeding is not normally associated with increased mortality in a non-emergency setting, infant feeding methods can become an issue of life or death. Unsanitary, crowded conditions, a lack of safe water and a lack of facilities to sterilise feeding bottles and prepare formula safely and correctly means that artificially fed infants are more than 20 times more likely to die from diarrhoea and other infectious diseases than infants who are exclusively breastfed.(7) Moreover, during an emergency people may not be able to obtain enough formula to feed their baby adequately because they are cut off from markets or because of cost.
(1) Infants are defined as a child below 12 months of age. A young chid is a child aged between 12 and 24 months.
(2) Breastmilk substitute is any food marketed or otherwise represented as a partial or total replacement for breastmilk, irrespective of whether it is suitable for that purpose.
(3) Exclusive breastfeeding means that the infant receives breastmilk and essential medicines only.
(4) G. Jones et al., 'How Many Child Deaths Can We Prevent This Year?', The Lancet, vol 362, 5 July 2003, http://www.who.int/child-adolescent- health/New_Publications/CHILD_HEALTH/CS/CS_paper_2.pdf.
(5) 'Intrinsic contamination of powdered infant formula with E. sakazakii and Salmonella has been a cause of infection and illness in infants ... and death.' Joint FAO/WHO Workshop on Enterobacter Sakazakii and Other Microorganisms in Powdered Infant Formula, Geneva, 2-5 Feb 2004. In unhygienic emergency conditions other contamination can easily occur.
(6) Infant Feeding in Emergencies: A Guide for Mothers, WHO Regional Office for Europe, 1997.
(7) 'The World Health Assembly Reaffirms the Importance of Breastfeeding for Infant World-wide', WHO Press Release WHA/10, May 1994; M. Jacobssen et al., 'Breastfeeding Status as a Predictor of Mortality among Refugee Children in an Emergency Situation in Guinea-Bissau', Tropical Medicine and Interanational Health, vol. 8, no. 11, November 2003.