Best Practices in Breast Feeding during emergencies Dr Sudarshini Fernandopulle (MBBS, MSc, MD) Consultant Community Physician SF/2009

Challenges to Breast Feeding in an Emergency Priority given to other basic needs such as shelter, clothing, provision of food for adults etc. Belief that under stressful conditions and/or limited access to food mothers are unable to breast feed Disorganized environment lack of privacy for breast feeding Inadequate support from skilled workers SF/2009

Un-Controlled Donations Large supply of infant formula at homes, health centers & distribution points – SF/2009

SF/2009

Maliban donates infant milk food for tsunami victims Maliban in collaboration with the government of Sri Lanka has once again provided assistance to the children of tsunami survivors, by making a contribution of infant milk powder to the value of Rs. 20 million. The donation was handed over… at the President’s House. Source: Daily News, Sri Lanka. Indian Ocean Tsunami, Sri Lanka, 2004/5 SF/2009

“We distributed children's clothes and about 40 mothers showed up with their babies, we…taught them how to use the milk powder we had received in big quantities.” Source: Real Medicine Foundation News. Sri Lanka, Indian Ocean Tsunami 2004/5 SF/2009

“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 traumatised and no longer able to properly breastfeed. Over 60 mothers brought their children aged ½ year to 3, 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.” Source: IsraAID Press release. Sri Lanka, Indian Ocean Tsunami, 2004/05. SF/2009

Incorrect messages in media Tsunami Victims Relief in Sri Lanka Please donate urgently for the one million+ Tsunami victims who have lost everything and need your help immediately to survive. Critically urgent supplies eg. Infant formula and feeding bottles and medical supplies will be airlifted…The remainder will be shipped in 40 foot container and arrive in Sri Lanka in approximately 21 days. Source: McGill Tribune, Canada. Indian Ocean Tsunami, Sri Lanka, 2004/5 SF/2009

Mechanisms for successful breast feeding Breast milk production Suckling the breast (correct attachment and positioning) Main reasons for breast feeding problems are due to failures in either or both mechanisms. SF/2009

Factors influencing milk production: Suckling makes more milk. SF/2009

Oxytocin reflex Good feelings and sensations helps the oxytocin reflex to work and milk to flow SF/2009

Suckling releases Prolactin and Oxytocin hormones Suckling releases Prolactin and Oxytocin hormones. Prolactine produces milk for the next feed. Oxytocin acts on smooth muscles on the lactiferous sinuses and milk is expressed to baby’s mouth. Frequent suckling is essential to maintain breast milk production. SF/2009

Dietary recommendations for infants and young child feeding during emergencies 0-6 months: All infants including those born to the affected population should receive EBF during the first six months. SF/2009

Exclusive Breast Feeding for 0-6/12 Babies should start BF within an hour of birth EBF and demand feeding until completion of six months EBF means giving only BM and no food, no water, no drinks and no teats. Medication on doctor’s recommendation only. Support women and build their confidence for EBF. SF/2009

…cont 0-6/12 If getting both breast milk and formula feeds continue only breast feeding (to minimise risk of infections) Every effort should be made to identify ways to breast feed infants whose mothers are absent or incapacitated Those already stopped breast feeding re-lactation should be attempted before considering the use of infant formula. SF/2009

Advantages of breast feeding during an emergency Prevents infections Provides optimal nutrition to baby Strengthens bond between mother and child providing crucial physical and emotional support for the child. SF/2009

Reasons for Higher risk of infections in an emergency Lack of safe water and sanitation Poor personal hygiene Unhealthy/unclean environment No access to health services Psychological trauma SF/2009

6-24 months: Start CF on completing six months while continuing to BF for two years or longer Support women to BF for two years or longer. BM produces half baby’s nutrition requirement -6 to 12 months 1/3rd during second year 10% during third year Encourage children to eat CF 6 – 9 m – 2 to 3 times a day 9-23 m 3-4 times a day with 1-2 snacks Non breast fed – 4-5 meals Support families to prepare and feed CF SF/2009

Supportive care for women Should be provided to all those breast feeding Create an enabling environment for BF BF corners One to one counseling Mother to mother support groups Mental and emotional support especially for the traumatised women Support those on mixed feeding to increase BF Skilled help SF/2009

Skilled support for BF mothers Assess need of individual mothers Help to BF Ensure effective suckling by correcting positioning and attachment Build mother’s confidence and help milk flow Increase milk production by: encouraging frequent and longer feeds Ensure mother gets enough to drink Remove interference Keep mother and baby together Mobilize family support Encourage age appropriate feeding SF/2009

Additional support needed Expressing BM Cup feeding Kangaroo care Help traumatized mothers Support to LBW babies Support to malnourished babies Support to malnourished mothers BF babies Re-lactation Breast conditions SF/2009

Correct positioning SF/2009

Good and poor attachment SF/2009

Supportive care for women Extra food Food supplementation Micronutrient supplementation Family support Family Planning Priority in receiving food Priority and adequate water Priority to use toilets and bathing SF/2009

Other measures to support BF during emergencies Developed a circular on Protecting, promoting and supporting Breast feeding during Emergencies Developed IYCF guidelines during emergencies Trained health staff on IYCF during emergencies SF/2009

Indications for formula feeds: If mother is not available If child was on formula prior to emergency and re-lactation failed Scientific evidence for inadequate breast milk in an infant less than six months on EBF Urine output less than six months Inadequate weight gain (average of 125 grams per week during first six months while on EBF) SF/2009

Formula feeds The quantity, distribution and use of breast milk substitutes at emergency sites should be strictly controlled Those responsible for feeding infant formula should be adequately trained and equipped to ensure safe preparation and use SF/2009

….cont Feeding infant formula to a minority of children should in no way interfere with protecting and promoting breastfeeding for the majority. The use of infant feeding bottles and artificial teats in emergency settings should be actively discouraged and cup feeding promoted instead as cups are easier to keep clean. SF/2009

Risk of formula feeds Higher risk of diarrhoea Aggravates malnutrition Higher risk of death No guarantee of continued supplies SF/2009

If on formula feeds Use cup instead of bottle First six months – formula one 6-12 months – formula 11/ After one year - full cream/goat or cow’s milk recommended SF/2009

Breast feeding sick infants Continue BF Keep mother and baby together If baby can suckle encourage the mother to do so If cannot suckle feed with expressed BM If unable to feed expressed BM teach mother to express BM to maintain BM production Teach mother to cup feed when discharging Give ORS through cup SF/2009

Illness of mother Do not stop Breast feeding Treat mother Keep mother and infant together and encourage BF Mobilize family support to help with BF If mother cannot breast feed help to express breast milk Help mother to increase production as she recovers Monitor weight gain and urine output SF/2009

Maternity care Identify pregnant women near term early Early initiation and EBF Strengthen BFHI SF/2009

Thank you SF/2009