Working together for the nutritional health of vulnerable populations 1

The overall objective of the Health and Nutrition Cluster Response is to reduce avoidable morbidity and mortality associated with the conflict and subsequent displacement Objective 3: To prevent excessive nutrition-related morbidity and mortality of vulnerable groups including acutely malnourished children pregnant and lactating women (PLW) & elderly Indicator: Number of vulnerable groups including children pregnant & lactating women (PLW) and elderly reached out with interventions to support, protect and promote appropriate nutrition 2

Why this presentation? Enhance understanding of the importance of protecting, promoting & supporting safe & appropriate infant & young child feeding (IYCF) Inform what the current context in eastern Ukraine means for IYCF Identify the need for nutrition-specific & nutrition-sensitive WASH approaches, targeting infants & young children 3

Importance of protecting, promoting & supporting safe and appropriate IYCF  Children <2 years most vulnerable to illness & death -Critical period for physical, mental & emotional development -Age-specific nutrition needs; risk of infection; complete dependency on others for care  Nutritional & psychosocial deficits during this time period can result in lifelong impairment & disability 4

Recommended IYCF Practices Recommendations of the Ukraine MoH. WHO & UNICEF for infants & young children to achieve optimal growth, development & health: Exclusive breastfeeding until the age of 6 months, commencing within 1 hour of birth Introduction of nutritionally age-appropriate, adequate & safe soft, semi- solid & solid complementary foods starting at 6 months Continued breast-feeding up to the age of two years or beyond Appropriate & timely support of IYCF-E saves lives 5

Context in GCAs of eastern Ukraine Suboptimal young child feeding practices -Low rates exclusive breastfeeding, infants <6 months (mean 13.8%; 25.8%) -Mixed feeding –breastfeeding & infant formula (intro mean 3.1 mo; 4.2 mo) -Use of teas & water for infants <6 months (intro mean 3.1 mo) -High use of bottles/teats (mean 68.1% %) -Early introduction of complementary foods (mean 4-5 mo) -Duration of continued breastfeeding (mean 31.8%; 53.5% at 1 year) Indiscriminate distributions of infant formula by agencies No elevated wasting in children 6-23 months (prevalence below 1%) (Save the Children - UNICEF IYCF-E Assessment June 2015: IDPs. Kramatorsk; Sloviansk; Svytahirsk) 6

…GCAs context Lack of refrigerators, especially in some collective centres Most have access to running water (97.6%) Most have facilities to boil water (98.8%) Preparing food & drinks for infants -bottled or tap water (Kramatorsk & Slovianske) well use (Sviatohirst)  Sub-optimal water quality in conflict affected areas Erroneous, belief bottled water is safe for babies because it is sterile Access to soap, primarily through self-purchase Hygiene products requested: diapers, soap, baby creams, shampoo, wet wipes, children’s laundry detergent + teething gel (Save the Children - UNICEF IYCF-E Assessment June 2015: IDPs. Kramatorsk; Sloviansk; Svytahirsk) ? Prevalence of blue baby syndrome (methaemoglobinaemia) & water- borne diseases eg hepatitis A, cholera in Ukraine

‘Nutrition-sensitive’ & ‘Nutrition-specific’ Nutrition-specific interventions address the immediate causes of under-nutrition, like inadequate dietary intake and some of the underlying causes like feeding practices and access to food Nutrition-sensitive interventions can address some of the underlying and basic causes of under/malnutrition by incorporating nutrition goals and actions from a wide range of sectors. They can also serve as delivery platforms for nutrition- specific interventions 8

Understanding inter-sectoral linkages The Under-Nutrition Causal Framework Adapted from Unicef 2013 Outcome Under-Nutrition Immediate Causes Inadequate Dietary Intake Underlying Health / Nutrition Causes Inadequate Care for Mothers and Children Insufficient Access to Food Inadequate health services & unhealthy environment (incl poor WASH) Inadequate health services & unhealthy environment (incl poor WASH) Food Care Health Disease (incl diarrhoea, helminth infections & conditions such as environmental enteropathy

Integrating IYCF into WASH 10

Inadequate dietary intake Appetite loss Nutrient loss Malabsorption Altered metabolism Increased energy & nutrient needs Disease (increased severity & duration) Weight loss Growth faltering Lowered immunity Increased susceptibility Infection - Malnutrition Cycle

F-diagram 12 (adapted from Perez et al., 2012)

IYCF – WASH Linkages WASH & nutrition activities have several possible linkages and can achieve common outcomes o Poor water & sanitation is an underlying cause of malnutrition o Improper sanitation facilities, waste disposal & water/food management can lead to food/water contamination o Poor personal & food-feeding/water hygiene practices increase the risk of diarrheal diseases o Poor WASH may lead to changes in the intestinal flora, causing longer time for poorly nourished or ill children to recover, or promote relapse o Hygiene kits can contain items to support young children’s nutrition 13

Use of infant formula Infant formula should only be used for medical reasons, based on assessment & ongoing growth support by a health professional o Lacks breast milk’s precise infant-specific balance of nutrients & appropriate temperature o Do not contain antibodies to protect against illness o Increase risk of infection, compared to exclusively breastfed babies, via bacteria & parasites that can contaminate water supplies, infant formula & feeding equipment during preparation & use o Can be incorrectly prepared o More difficult to digest o Mixed feeding (formula + breastmilk) causes mother to make less breastmilk, as breastmilk production works on a demand-supply basis Breastmilk is the most nutritious and safe food for infant and young children 14

Use of bottles & Teats Feeding bottles with teats should not be used o May make it more difficult for the baby to learn to attach well at the breast due to “nipple confusion” o They decrease suckling, therefore mother produces less milk o Compromises breastfeeding frequency, intensity & duration, as well as increased risk of dental disease & otitis media o Bottles & teats are difficult to clean o When bottle feeding is associated with unhygienic conditions and poor preparation of infant formula, it puts the infant at increased risk of diarrhoea o Increases risk of infant not receiving adequate stimulation & attention during feeds 15

Safe complementary feeding Timely introduction of complementary foods –at 6 months Continued breastfeeding until 2 years of age or beyond Safe storage, preparation, cooking & serving of foods & liquids Optimal handwashing practices, esp at critical periods, with soap & water 16

Integrating IYCF into WASH Understand the situation –background nutrition/IYCF data & policies Consider caregivers of children <2 years as priority targets for WASH activities Integrate IYCF considerations into assessments, policies, strategic plans, programme activities & monitoring, in collaboration with Nutrition Sector Train staff on the links between infection, IYCF & under/malnutrition Know & promote the benefits of breastfeeding, safe feeding & hygiene Be informed, & provide information, on how to minimize the risks associated with unsafe & inappropriate feeding o Know the guidelines in ‘The Code’ & ‘The Operational Guidance’ o Support the controlled & safer use of infant formula o Refer formula fed infants, for targeted support o Report untargeted distributions of infant formula, to the Nutrition sector Coordinator 17

…integrating IYCF into WASH Distribute hygiene kits for infants & young children with nutrition- supportive nutrition items eg diapers, baby creams, shampoo, wet wipes, children’s laundry detergent and soap + teething gel Provide clean water & cups for non-breastfed infants …taking care not to undermine breastfeeding eg BF mothers receive goods of same or greater value Collaborate with nutrition sector on development of targeted hygiene messaging and education/training Provide hygiene items to caregivers attending nutrition/IYCF education sessions Ensure appropriate WASH facilities at health/nutrition services (eg baby- friendly spaces) 18

Nutrition Sub-Cluster Key IYCF Messages 19

THANK YOU! 20