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UNICEF, WHO, Whole of Syria Nutrition Cluster the Global Nutrition Cluster, the IFE Core Group, and partners call for ALL involved in the response to the Emergency in Syria to protect, promote, and support the feeding and care of infants and young children, their caregivers, especially pregnant, postpartum, and breastfeeding women. This is critical to support maternal and child survival, growth and development, and to prevent malnutrition, illness and death.
This statement has been issued to help secure, coordinated, multi-sectoral and young child feeding (IYCF) to support and provide care for infants and their caregivers during the emergency response.
The recent escalation of hostilities in Syria has increased humanitarian needs for the areas directly affected by the escalations in hostilities, with echoed indirect effects on other people living in Syria specially in Aleppo, Idleb and Hama Governorates. UN OCHA notes that the security situation in Syria remains volatile, unpredictable, and rapidly evolving in many parts of the country, particularly in the northern and northwestern regions. Escalating hostilities continue to impact civilians, civilian infrastructure, and humanitarian access and operations. In Aleppo city, reports indicate significant civilian casualties, including women and children.
As of 5 December, UN OCHA reports that at least 178,000 people have been displaced due to the recent escalations in northern Syria, including 128,000 newly displaced and 39,000 displaced at least twice. Figures are still being reconciled, noting that UNHCR and NGOs operating in the northeastern part of Syria estimate that between 60,000 and 80,000 people have been newly displaced there, including more than 25,000 currently hosted in collective centers.
Public health concerns are escalating due to the presence of unburied bodies, lack of potable water, and the pre-existing risk of waterborne diseases such as suspected cholera. According to UN OCHA flash updates (as of 3rd December), the conflict has severely disrupted health and nutrition services. Several healthcare facilities, including one of main hospitals and a maternity hospital in Idleb city have been damaged, with 35 health organizations unable to continue their operations in Aleppo as of early December 2024. This has led to the closure of key health facilities, including hospitals and primary health care centers, affecting over 1.7 million procedures and nearly one million treatment courses in Aleppo. Provision of health services such as trauma care, maternal health, and disease surveillance is severely limited by the displacement of health workers and the prevailing insecurity.
Currently, Syrian communities are simultaneously hit with an on-going cholera outbreak and significantly overwhelmed health facilities. With harsh winter arriving which maybe coupled with heavy rain, floods and snowing. Even before the ongoing escalation of hostilities, Syrian women and children have been subjected to physical injuries, lack of health-care services, lack of shelter, food shortages, unsanitary conditions, risk of communicable diseases, protection threats and high levels of stress and uncertainty.
Women and children, especially pregnant girls and women, infants and young children and postpartum women, are populations that are extremely vulnerable in Syria. During such emergencies, the importance of breastfeeding and increase of the morbidity and mortality risks associated with not breastfeeding are more pronounced.
In all emergencies, the youngest children are at the highest risk of illness and mortality. Infants who are not breastfed are especially vulnerable as they are not receiving the protection and benefits of breastmilk. For babies and young children in humanitarian and fragile settings, access to early childhood development (ECD) services is a matter of life and death. Supporting them and their caregivers is essential to ending preventable newborn and under-five deaths and fostering healthy brain development.
In Syria where the rate of exclusive breastfeeding ranges from 19%-29% and a high percentage of children are partially or fully dependent on commercial infant formula. The dietary intake of infants and young children aged 6-23 months is extremely poor with majority of children 6-23 months (68%) in Syria experiencing child food poverty. With the deteriorating access to nutritious foods, essential services and feeding practices, the diets of young children are the risk of deteriorating further.
At least 1 in 4 children in Syria suffers from anemia, emphasizing the detrimental effects of sub-optimal diets lacking essential nutrients. On maternal nutrition, 1 in 4 women aged 15-49 years suffers from anemia, with an even higher prevalence observed among teenage girls, where 1 in 2 girls is anemic. Additionally, 1 in 10 women is wasted, contributing to increased risks during pregnancy. Diarrheal episodes among children have surged, affecting one in four, amid an Acute Watery Diarrhoea outbreak in 2023-24. Recurrent diarrhoea is associated with 50 per cent of undernourishment. Measles outbreaks in several governorates further compromises child nutrition status. Measles vaccination in Idleb and Aleppo Governorates are sub-optimal, ranging between serious and extreme (Syrian Humanitarian Needs Overview (HNO), 2024).
Breastfeeding is lifesaving. It provides children with hydration, comfort, connection, high quality nutrition and protection against disease, shielding them from the worst of emergency conditions. This ability has been described as empowering and healing by some breastfeeding women. Breastfeeding also has important consequences for maternal mental health, physical health, and caregiving capacity, as well as long-term child development and educational attainment.
Between the ages of 6 and 23 months – the complementary feeding period – breastfeeding and access to a diverse range of nutritious foods provide children with the essential nutrients, vitamins, and minerals they need to develop to their full physical and cognitive potential, with benefits that endure well into adulthood. The complementary feeding period is also a critical opportunity to prevent all forms of childhood malnutrition, including stunting, wasting, micronutrient deficiencies, overweight, obesity and diet-related non-communicable diseases. In addition, lifelong food preferences, tastes and habits are often established in childhood.
Globally Recommended Maternal Infant and Young Child Feeding Practices
1. Early initiation of breastfeeding (uninterrupted skin-to-skin contact immediately after birth and putting baby to the breast within 1 hour of birth)
2. Exclusive breastfeeding for the first 6 months (no food or liquid other than breastmilk, not even water unless medically indicated)
3. Introduction of age-appropriate, safe, and nutritionally adequate complementary feeding at 6 months (180 days) to 2 years of age; that meet recommended minimum meal frequency and dietary diversity (5 or more food groups) while continuing to breastfeed; and
4. Continued breastfeeding for 2 years or beyond
5. Responsive feeding for children 6-23 months of age, defined as “feeding practices that encourage the child to eat autonomously and in response to physiological and developmental needs, which may encourage self-regulation in eating and support cognitive, emotional and social development”
6. Ensure pregnant and breastfeeding women, have priority access to food and non-food items
Interventions to support mothers, caregivers and their children should consider:
1. Support mothers to initiate and continue breastfeeding as a priority to help protect their health and well-being and that of their infants. Although stress can temporarily interfere with the flow of breast milk in some women, it is not likely to inhibit breast milk production, provided mothers and infants remain together and are supported to initiate and continue frequent breastfeeding. This support entails practical support with attachment and positioning for breastfeeding, confidence building, facilitating skin-to-skin contact and keeping mother and infant together (e.g., provide baby carriers/slings). It is recommended to draw upon existing breastfeeding support organisations and individual lactation specialists from Syria and surrounding countries in the region.
2. Keep mothers and babies together, even if one becomes ill - Mothers should continue to breastfeed even if they are pregnant or become sick. Antibodies in the milk of the mother, even if she is sick, will help protect their babies from any diseases. If a sick mother is holding or feeding a baby (whether breastfeeding or using commercial infant formula), she must follow hygiene practices, wear a mask and wash her hands before and after feeding the child.
3. Support and protect nutritional needs of children during Cholera Outbreaks - Referral of suspected cholera case to cholera treatment centre (CTC) is vital because of high risk of cross infection with other children and the need of correct rehydration of the child with acute watery diarrhea (AWD). A strong referral system to be established and maintained between ORC/DTC and OTP/TFC. Rehydration solution for malnutrition (ReSoMal) Should not be given if children are suspected of having AWD or have profuse watery diarrhoea. Such children should be given standard WHO low osmolarity oral rehydration solution that is normally made, i.e. further diluted/standard rehydration solution. Therapeutic foods already contain adequate zinc, therefore children with severe acute malnutrition and profuse AWD/Cholera receiving F-75, F-100 or RUTF should not receive any additional zinc supplement. Breastfeeding is protective against cholera and should continue to be prioritised, recommended, and supported through an outbreak and separation of mothers and their infants should be avoided if at all possible.
4. Support and protect the nutritional needs of infants and young children who are not breastfed and minimise the risks they are exposed to. Infants who are exclusively dependent on infant formula are highly vulnerable in the current situations and should be urgently identified, assessed, and supplied with a comprehensive package of essential support. This package should include adequate Breast Milk Substitute (powdered infant formula or ready to use infant formula) supplies, equipment and supplies for hygienic storage, preparation and cup feeding, practical training on hygienic preparation and storage, and counselling on responsive feeding for the entire length of time that the child requires. The support should also provide for ongoing, regular follow up at designated shelter and reception areas and within other service provision in Syria. Mothers who are not exclusively breastfeeding should be encouraged and supported to increase their confidence on supporting their infants and return to exclusive breastfeeding. Orphaned infants and other vulnerable infants who are not being breastfed should be supported with re-lactation and wet-nursing support as a first line intervention.
5. In accordance with the Whole of Syria Nutrition Sector Standard Operating Procedure (SOP) on Donations, Targeted Distribution and Procurement of Breastmilk Substitute (2017) and international standards and guidance, do not call for, support, accept or distribute donations of Breastmilk Substitutes, including commercial infant formula, other milk products, commercial complementary foods, and feeding equipment (such as bottles, teats, and breast pumps). However, If the procurement of Breast milk substitute is needed, the required commercial infant formula - Ready to use infant formula (RUIF), procured by UNICEF or other partners should be in line with the WHO International Code of Marketing and Breast Milk Substitutes, ‘the Code’, UNICEF Guidance on the Procurement and Use of Breastmilk Substitutes in Humanitarian Settings and (subsequent WHA resolutions) and provided as part of a sustained package of coordinated care based on assessed need and should be Code-compliant. All partners must report the code violations to the nutrition cluster coordinators, immediately for necessary action, and support. All code violations must be recorded and responded to adequately, in the best capacity available in the response. For infants 6-23 months of age and above, breast feeding continues to be the recommended practice. For those who are not breastfed, acceptable milk sources include full-cream animal milk (cow, goat, buffalo, sheep, camel), Ultra High Temperature (UHT) milk, reconstituted evaporated (but not condensed) milk, fermented milk, or yogurt, and expressed breast milk. Any animal milk given to infants <12 months should be boiled and left to cool before giving the milk. Milk products should never be included in general distribution and should be accompanied by key messages and guidance on infant and young child feeding in emergencies.
6. Ensure the availability and continuity of nutritious, appropriate and fresh food for children, pregnant, postpartum and breastfeeding women, and families. Where there are identified shortfalls in local access and availability of foods, facilitate access to age-appropriate and hygienically prepared, complementary foods for children 6-23 months. Facilitate access of nutritious foods for older children, and for their caregivers, with particular attention to pregnant, post-partum and breastfeeding women. All partners must promote access to food and shelter through coordinated support from other sector agencies and partners. Women and children must be included as vulnerable groups within all national and partner supported social safety nets. Direct cash support must be considered in hard-to-reach and affected populations.
7. Provide support to mothers and caregivers to access early childhood development (ECD) services and enable them to provide responsive feeding and care to infants and young children - Provide critical ECD services including creating safe spaces for babies and young children to play and learn, training caregivers and frontline workers to provide nurturing environments, and counselling caregivers to bolster their own well-being. Additionally supporting mothers and caregivers to provide responsive feeding to infants and young children to enable them encourage children to eat, provide food in response to their appetite and satiety signals and feed them with care. Counselling on responsive feeding can promote self-feeding, improve nutrient intake, and reduce the risk of undernutrition and overweight.
8. Ensure pregnant and breastfeeding women, and other caretakers of young children have priority access to non-food items including appropriate accommodation, clothing, water, protection, mental health and psychosocial support, gender-based violence related support, and other interventions to meet their essential needs. Consider how women in transit can be supported to minimise distress during their journey. At all service points, provide safe and comfortable spaces for mothers to feed and care for their infants and young children.
9. Identify higher risk infants, children, and mothers and respond to their needs. These include (but are not limited to) pregnant and post-partum women; newborns; low birth weight infants; malnourished children, including infants under 6 months of age; children with disabilities; children experiencing issues with feeding; 0-23 months and unaccompanied children; maternal orphans; institutionalised; mothers who are malnourished or severely ill; mothers who are experiencing mental health crisis; instances where mothers are separated from their children. All vulnerable infants, young children and mothers identified must be supported with adequate care services or linked with care-providers through strong referral systems.
It is the collective responsibility of all nutrition cluster partners, other sectors, and stakeholders to report any randomly distributed commercial infant formula. We encourage you to report. We encourage you to orientate your staff to raise awareness of the contents of this position statement.
Please contact Whole of Syria – Nutrition Cluster teams for more information. Contacts below:
Regina Mbochi, UNICEF
Whole of Syria Nutrition Sector Coordinator
Email: rmbochi@unicef.org
Dr. Neha Singh, Save the Children
Whole of Syria, Nutrition Sector Co-Coordinator
Email: neha.singh@savethechildren.org