Infant Feeding in Emergency Situations
Karleen Gribble, PhD
New South Wales, Australia
From: Leaven, Vol. 45 No. 2-3, 2009, pp. 44-49
EDITOR'S NOTE: Originally published in Essence, the Australian Breastfeeding Association (ABA) magazine, September 2009, this article is reprinted in Leaven with the gracious and express permission of the author, Dr. Karleen Gribble.
Bushfires, droughts, floods, earthquakes, tsunamis, epidemics, and wars can have a severe impact on the health and well being of the entire community. Emergencies remove what is normal and often cause a disruption to food supply and population displacement. Infants under 12 months of age are particularly vulnerable during emergencies because they need access to a consistent, reliable and safe food supply for their nutritional needs and protection from disease. We know from previous experience that the health of infants in emergencies is paramount but history has shown that sometimes emergency aid can do more harm than good.
What's the problem?
During disasters the risks associated with the use of infant formula are enormous. According to the World Health Organization (WHO), in emergency situations artificially fed babies have a 1300% increased risk of death from diarrhoeal disease as compared to babies that are breastfed.1 This risk is related to the diseases that flourish in the unsanitary conditions that often exist in emergency situations and the clean water and fuel required for safe artificial feeding is usually scarce. In addition, babies who are artificially fed are inherently more vulnerable to disease because they do not receive the disease-fighting antibodies that are in breastmilk. In past emergencies, 12–75% of all babies have died and so any factor that increases disease transmission and reduces the ability of babies to withstand disease may well result in their death.2, 3
Operational guidelines on infant feeding in emergencies
Poorly controlled distribution of breastmilk substitutes undermines breastfeeding and while some babies may have been artificially fed prior to the emergency, easy access to breastmilk substitutes increases early weaning and therefore infant mortality. There is consensus amongst the major health and aid agencies on how infant feeding issues should be addressed in emergency situations:
Women breastfeeding their children need to be supported. This involves giving appropriate information, practical assistance and encouragement to continue breastfeeding, especially if they are experiencing difficulties. The recommendation that mothers be supported to exclusively breastfeed their babies for six months and then continue to breastfeed for up to two years or beyond is even more important in emergency situations. Breastfeeding is a robust physiological process and psychological trauma does not impact milk production, although this is a common misconception.
Mothers who have weaned their babies should be encouraged and provided with assistance to relactate as a first choice intervention. When mothers allow their babies to suckle at their breasts frequently throughout the day and night, they can expect to begin producing milk again within a short period (a few days to a few weeks).
In cases where there are babies whose mothers have died or cannot be located, the option of wet nursing should be explored. In such instances babies may be breastfed by a woman who is already lactating or a friend or relative may relactate or induce lactation by allowing the baby to suckle at her breasts frequently through the day and night.
EDITOR'S NOTE: In March 2007, the LLLI Board of Directors adopted a policy regarding the donation of human milk. Please see page 13 of this Leaven, or online at http://www.llli.org/leaderpages/PSRm.html#14
The use of artificial formula should only occur when: mothers have weaned and relactation is not possible; or baby has lost his/her mother and wet nursing is not an acceptable solution. Babies being fed with a breastmilk substitute need ongoing support and assistance to limit the risk associated with artificial feeding. Such assistance should include ensuring that the mother has access to a constant supply of breastmilk substitutes and the necessary resources for preparation. It should also include education on preparation and close monitoring of the use of the infant formula and health of the baby. Women who are relactating or inducing lactation may need some breastmilk substitute supplements and assistance until their milk supply is sufficient.
Distribution of breastmilk substitutes should be tightly controlled and carefully monitored and only provided to babies with a clear need. When infant formula is used in this way it can save lives.
The use of bottles and teats during emergencies is not recommended because of the high risk of contamination and difficulty with cleaning. It is recommended that a cup be used where necessary.
Despite these operational guidelines large donations of infant formula, bottles, and teats continue to be inappropriately distributed during most disaster situations, compromising infant welfare. Infant formula may be necessary in some situations as a last resort but its use must be tightly controlled and carefully monitored as generous or disorganized distribution of infant formula is extremely harmful. UNICEF, WHO and the International Red Cross are active in alerting non-government organizations to the need to support breastfeeding and to be extremely careful in the distribution of breastmilk substitutes.
Why would an aid agency do something that might be harmful?
While donations and assistance in times of crisis are welcomed, there is a role for both aid agencies and donors to ensure that babies are not harmed by the provision of infant feeding products such as formula, feeding bottles, teats, or commercial complementary foods as part of aid programs. Inappropriate distribution of breastmilk substitutes usually occurs when staff is unaware of the dangers of infant formula and the importance of supporting and protecting breastfeeding in emergencies. In many cases, members of staff may have extrapolated the experience in their home country of breastmilk substitutes as "just fine" into the emergency situation. This is easy to understand because infant mortality rates in most Western countries are low and the increased risk of death in non-breastfed babies relatively small. This underlines the need for all health care professionals to be aware of the protective effect of breastfeeding on infant health, particularly when infection rates are high during epidemics such as the recent Human Swine Flu (H1N1 influenza) outbreak.
The unsolicited donation of milk powders has been a big problem in past emergencies. Controlling the supply of unsolicited formula donations and the disposal of excess donations is expensive and difficult logistically. Thus, donations of infant formula should be avoided. Donors can best assist mothers and babies by making recipients of their contributions aware of the need to protect and support breastfeeding by adequately training staff on this issue.
What can you do?
It is difficult to see how large scale overseas events in developing countries might have relevance in a Western context. However, the events that followed Hurricane Katrina in New Orleans highlight the vulnerability of large populations living in major cities without essential services and infrastructure. Nobody is immune from an emergency situation; even Australia is frequently exposed to the threat of floods, cyclones and bushfires. While emergencies in Australia are usually short-term with rapid response, small infants can only be without food and clean water for a few hours. High temperatures can cause infants to rapidly dehydrate so it is important to be prepared and have a plan for any emergency. This may be as simple as being caught in a car on a closed freeway for hours with no access to formula or clean water.
For further information about infant feeding in emergencies, please visit the following Web sites:
health-e-learning.acrobat.com/p28814510/ (a link to watch
If you feel strongly about playing a role in emergency preparedness and/or response you can offer support by:
being alert for appeals for donations of breastmilk substitutes, bottles, and teats and acting to stop them
identifying agencies that support breastfeeding in emergencies and offering them your help
supporting "on the ground" staff by not soliciting or accepting donations of breastmilk substitutes
supporting fundraising and sending money instead of breastmilk substitutes
educating the public on how to protect and support breastfeeding in emergencies.
1 World Health Organization 1997, Infant Feeding in Emergencies, A Guide for Mothers. Retrieved online from http://www.euro.who.int document/356303.pdf
2 O’Connor M.E., Burkle F.M., Olness K. Infant feeding practices in complex emergencies: a case study approach. Prehospital and Disaster Medicine 16: 231-238.
3 Yip R., Sharp T.W. Acute malnutrition and high childhood mortality related to Diarrhoea, lessons from the 1991 Kurdish refugee crisis. Journal of the American Medical Association 1993; 270: 587-590.
Emergency stories from the field
One aid agency press release included a photo of a Western aid worker in a refugee camp demonstrating how to make up infant formula. In this photo mothers sit with their babies and toddlers on their laps. One child is clearly breastfeeding. The text reads:
"A delegation has begun teaching mothers how to properly use infant formula to feed their children. As a result of the Tsunami many women were traumatized and no longer able to properly breastfeed. Over 60 mothers brought their children, aged six months to three years, to the camp. They wished to learn how to properly maintain hygiene while feeding their children with the infant formula provided by our feeding centre. Word has spread, and every day new parents arrive."
These well meaning aid workers are endangering the lives of the babies they are trying to help. The mothers are likely to believe that their babies need to be fed formula in order to stay healthy because they have seen health workers demonstrate its use.
An article in the Sydney Morning Herald (31 December 2004) reported how post-Tsunami, a neighbour cares for a motherless baby:
"Her mother and brother are dead, her father is in hospital and her home, by the beach, has been washed away. Six-month-old Senaka knows nothing of these things. She is being breastfed by a family friend who is also nursing her own baby. 'There's nobody else to do it. The mother is gone. I have to look after her. I have enough milk,' she said."
A health worker reported, "Younger children require exclusive breastfeeding if they are to have any chance of survival" (Puoane et al. 2001).
An aid worker describes how a baby whose mother died during childbirth was assisted by a stranger and her childless aunt: "An infant was brought to us whose mother had also died, it was already wasted. I asked a lactating woman to feed this child in addition to her own. The next day a young woman was brought to the hospital and introduced as the younger sister of the dead mother. She agreed without any resistance to breastfeed her related child. These two women saved the infant's life. The orphan had to be fed frequently. With every feed it attached first to the aunt's breast to suck. As soon as the sucking became slightly weaker, the baby was attached to the breast of the other lactating woman to satisfy the baby. It took at least 2–3 weeks until the young woman was able to fully breastfeed the infant. The two women became quite close to each other. The baby developed well. This young woman managed in spite of the difficult circumstances with the help of her family." (Emergency Nutrition Network 2003).
From an academic journal, a report of the systematic support of breastfeeding of malnourished babies in a refugee camp: "Aid workers were faced with infants of less than six months at high risk of death. Although formula feeding was likely to prevent death it meant almost always the end of breastfeeding. The then formula fed infant would be at high risk of relapse due to infection and underfeeding. We employed a 'supplemental suckling' technique. One hour after each breastfeed each infant was breastfed again but at this time one end of a nasogastric tube was placed alongside the mother's nipple in the infant's mouth while the other end was below the surface of infant formula. As the infant suckled, it also sucked on the tube and obtained formula. The infants rapidly gained weight and stimulated the breast more and more as they regained their strength so that after about ten days the supplemented suckling could be stopped and they continued to gain weight at an accelerated rate on breastmilk alone." (Golden et al 2000).
Experience of a peer counselor, Hurricane Katrina, USA, 2005: "A mother had been stuck on a rooftop with many family members and her two-week-old baby who was bottle fed. They had no access to safe water for five days. Her baby was immediately hospitalized when they arrived in Austin [Texas, USA], but she died several days later. The nutritionist of a relief organization supplying food aid asked the mother if there was anything else she could help her with. The mother asked for help drying up her breastmilk as her breasts were still sore. The nutritionist asked the mother why she hadn't breastfed her baby while she was stuck on the rooftop. But the mother had felt quite unable to do this. What amazes me is that no one with the mother in New Orleans knew to have the mother put her baby to her breast. So many generations had not considered breastfeeding as a way to feed babies that the memory was lost. The baby was lost, also."
EDITOR'S NOTE: Dr. Gribble references ABA's resources for the World Breastfeeding Week at http://www.breastfeeding.asn.au/news/index.html. She writes that "...organisations are able to download and/or order the poster and business cards for emergency workers and adjust them for local conditions and some LLL Leaders and Groups may also find them useful."