Infant and Young Child Feeding in Emergencies (IFE) Essential Orientation

WHA RESOLUTION The Sixty-third World Health Assembly URGES Member States: (8) to ensure that national and international preparedness plans and emergency responses follow the evidence-based Operational Guidance for Emergency Relief Staff and Programme Managers on infant and young child feeding in emergencies, which includes the protection, promotion and support for optimal breastfeeding, and the need to minimize the risks of artificial feeding, by ensuring that any required breast-milk substitutes are purchased, distributed and used according to strict criteria;

Origins of Ops Guidance Concept dos and donts emerged 2000 IFE Interagency Group, Version 1.0, 2001 –Version 2.0, May 2006 –Version 2.1, February, 2007 English, French, Spanish, Portuguese, Arabic, Russian, Chinese, Japanese, Kiswahili, Bahasa (Indonesia), Farsi

Dos and donts Need for clear, concise, practical guidance on IFE Pull various components of a response together Non-technical Not just nutrition and health staff, but including logistics, watsan, military,……… 1-2 pager………………………26 booklet

Operational Guidance Key audience: Emergency relief staff incl national governments, UN agencies, national and INGOs, donors International Code for Marketing of Breastmilk Substitutes embedded All emergencies in all countries and to non- emergency contexts (preparedness). Target group: infants and young children 0-2 years of age and their caregivers.

Structure of the Ops Guidance Key Points Sections 1-6 –1. Endorse or develop policies –2. Train staff –3. Coordinate operations –4. Assess and Monitor –5. Protect, promote and support IFE interventions –6. Minimise the risks of Artificial Feeding Section 7 - Key Contacts Section 8 – References Section 9 - Definitions

Section 9 Definitions Standard, internationally recognised –Infant, Exclusive breastfeeding –Infant Formula, Breastmilk substitute (BMS) –Optimal infant and young child feeding (IYCF) –AFASS criteria – acceptable, feasible, affordable, sustainable, safe Standard definitions built upon –Infant complementary food –Home modified milk

Section 9 – Definitions, contd Created definitions –Nutrition and health emergency response: For an agency to be part of the nutrition and health response, they must have staff actively involved in the healthcare system who are responsible for targeting the BMS, monitoring the infants, and ensuring the supply of BMS is continued for as long as the infants concerned need it.

1 Endorse or Develop Policies 1.1 Agency central level endorse/develop policy addresses protection and support of IFE –Makes specific reference to what should be included. 1.2 Disseminate it, integrate it, reflect it in procedures Working examples – DFID, World Vision Country Level – National policy on IYCF in which IFE is specifically addressed

2 Train Staff 2.1 Basic orientation for all national and international staff on IFE 2.2 Technical training for health and nutrition staff 2.3 Seek specific expertise national and international level on breastfeeding/infant feeding counselling and support

3 Co-ordinate Operations 3.1 UNICEF co-ordinating agency (cluster approach) or designated agency with the necessary expertise –Policy coordination – specific policy for emergency operation based on national and agency policies –Intersectoral coordination – food aid, watsan, reproductive health –Action plan – identifies responsible agencies and mechanisms for accountability –Dissemination of policy and action plan, including operational agencies, donors, media –Evaluation of emergency response once an operation is over

4 Assess and Monitor 4.1 Key information on IYCF always be collected in initial rapid assessment (4.2 – details) -Conspicuous infant formula, infants not breastfed pre-crisis 4.3 Additional key qualitative and quantitative information - Water availability and quality, fuel, potential support givers - Nutritional adequacy of food ration, infant feeding practices Maintain records and share experiences

5 Protect, promote and support IFE Integrated Multi-Sectoral Interventions Integrated multi-sectoral –Many direct and indirect supports of IFE, eg reproductive health, shelter, water and sanitation, food aid delivery –IFE not just a standalone intervention

5.1 Basic interventions Meet nutritional needs of the general population. –Prioritise pregnant and lactating women with supplementary foods (5.1.1). –If foods are lacking, then multiple micronutrients should be given to pregnant and lactating women and children 6-59 months (NB Refer to guidance for malaria endemic areas) (5.1.2) Address infant complementary feeding from the outset –Supplement food ration with local foods, micronutrient fortified blended foods, e.g. CSB, WSB (5.1.3) –Commercial baby foods – consider cost and nutritional value and risk of undermining infant feeding practice (5.1.6)

5.1 Basic interventions, contd Establish the population you are dealing with: –Demographic breakdown at registration of U2s (0-<6m, 6-<12m, 12-<24m) Registration of newborns within 2 weeks of delivery Refugees and displaced populations –Rest areas, secluded areas for breastfeeding –Screen new arrivals to identify any IYCF problems and refer

5.2 Technical Interventions Training of health/nutrition/community health staff knowledge and skills to support mothers and caregivers Integrate breastfeeding and IYCF into all levels of healthcare, e.g. maternity services, growth monitoring, selective feeding programmes More targeted detailed support –Services to support orphans and unaccompanied children –Correct preparation of unfamiliar infant complementary foods

5.2 Technical Interventions, contd Address HIV/AIDS –Primary prevention, e.g. through condom provision (5.2.6) –Individual HIV status unknown, support optimal IYCF (5.2.7) Testing and counselling in place: –Individual HIV negative, support optimal IYCF (5.2.7) –HIV positive women support informed decision about infant feeding choice applying AFASS criteria and supported to see this through (5.2.8)

Infant feeding and HIV/AIDS in emergencies Risk of infection or malnutrition from using BMS likely to be greater than risk of HIV transmission through breastfeeding. –EBF for first six months of life, with continued breastfeeding will give best chance of SURVIVAL –Decision based on individual circumstances but should take greater consideration of the health services available and the counselling and support she is likely to receive (WHO, 2006) –Mixed feeding is the worst option as gives highest transmission rate.

6 Minimise the risks of any artificial feeding 6.1 BMS donations and supplies BMS donations are not needed Avoid soliciting or accepting donations of BMS Any unavoided donations: – collected by designated agency –dealt with under guidance of UNICEF/coordinating agency and the government

6.1.4 One agency supply BMS to another, only if both working as part of the nutrition and health emergency response and the provisions of the Code and the Ops Guidance are met. Both the donor and recipient agency are responsible to ensure provisions are met and continue to be met.

6.2 Establish and implement criteria for targeting and use Infant formula –Targeted to infants requiring it (criteria, 6.2.2) –Assessed health/nutrition worker trained in BF and IF issues –Individual training on safe preparation –Follow-up at distribution site and at home (not less than twice a month)

6.2.4UNICEF or designated nutrition coordinating agency responsibility to train and support agencies in training staff and mothers on safe preparation of infant formula in given context Assess whether AFASS prior to establishing a household based programme. Where safe preparation cannot be assured,, on-site preparation and consumption should be initiated. Ongoing assessment is critical to ensure conditions continue to be met.

6.3 Control of procurement Donor agencies considering funding of BMS and milk products: Ensure that the provisions of the Ops Guidance and the Code are met Cost implications to meet associated needs Interventions to support non-breastfed infants should always include a component to support breastfed infants Equal consideration should be given to skills based as to commodity based interventions

6.3.2 Type and source of BMS Generic (unbranded), locally purchased. Manufactured and packaged in accordance with Codex Alimentarius standards. At least six months shelf life on receipt of supply. Type of infant formula appropriate for the infant, including age. Follow on milks, growing up milks, not necessary. UNICEF does not supply infant formula.

6.3.3 Labels – detailed requirements laid down by the Code Infant formula supply is continued for as long as the infants need it: –Breastfeeding is re-established, or –At least six months of age and some source of milk/animal source food available (6-24 months of age) Use of bottles and teats is discouraged. Use of cups promoted..

6.4 Control of Management and Distribution Infant formula purchased by agencies working as part of the nutrition and health emergency response may be used or distributed by the healthcare system. Distribution should be discrete and not part of food aid distribution. WHA 47.5: No donations of free or subsidised BMS in any part of the healthcare system.

6.4.2 BMS, milk products, bottles and teats should never be part of a general or blanket distribution. Dried milk products should not be distributed as single commodity, only distributed if pre- mixed with milled staple food. Single tins of infant formula should not be given to mothers unless part of an assured continuous supply. No promotion at point of distribution – displays, leaflets with brands, etc.

7 Key Contacts 7.1 Violations of the Code – report to WHO and International Code Documentation Centre (ICDC) 7.2 IYCF and/or coordination of IFE, contact UNICEF 7.3 UNHCR milk policy, contact UNHCR 7.4 Feedback on Ops Guidance and share field experiences, contact IFE Core Group via ENN

In conclusion….. Field driven policy guidance Challenge is implementation Responsive and timely updates Feedback on use

Current IYCF data DHS MICS Punjab Swat/Buner Save the Children Mar 2010 Exclusive BF 0-5 mths37%49%45-50% Timely initiation within 1 hrs29% 13-24% Non BFed children 0-5 mths3.4%around 7-8% % Bottle feeding with nipple27% Prelactal food given 0-5 mths66%

MacRAM, post flood 50% of lactating women have reduced breastfeeding their children 15% stopped breastfeeding completely Families have reduced provision of complementary foods for their children Distribution of dry milk, infant formula, bottles and teats were reported in all provinces, most in Sindh