1. Infant and Young Child Feeding in Emergencies. Operational Guidance.
VERSION 3.0 – UPDATE

2. The Operational Guidance on IFE
Aim
To provide concise, practical guidance on how to ensure appropriate infant and young child feeding in emergencies (IFE)
Scope
Applies to emergency preparedness, response and recovery worldwide
Target Groups
Infants and young children aged 0-23 months and pregnant and lactating women (PLW)
Intended for
Policy-makers, decision-makers and programmers working in emergency preparedness, response and recovery across sectors and disciplines.
Aim
The OG-IFE aims to provide concise, practical guidance on how to ensure appropriate infant and young child feeding in emergencies.
Scope
The OG-IFE applies to emergency preparedness, response and recovery worldwide to minimise infant and young child morbidity and/or mortality risks associated with feeding practices and to maximise child nutrition, health and development.
Target groups
The target groups are infants and young children aged 0-23 months and pregnant and lactating women (PLW).
Intended for: *TAILOR TO YOUR AUDIENCE*
The OG-IFE is intended for policy-makers, decision-makers and programmers working in emergency preparedness and response, including governments, United Nations (UN) agencies, national and international non-governmental organisations (NGOs), donors, volunteer groups and the private/business sector.
The OG-IFE is relevant across sectors and disciplines, particularly nutrition, but also health (including reproductive health, maternal, newborn and child health (MNCH), curative services, mental health and psychosocial support services (MHPSS); HIV; infectious disease management); adolescent services; water, sanitation and hygiene (WASH); food security and livelihoods (FSL); child protection; early childhood development (ECD); disability; shelter; cash transfer programmes; social protection; agriculture; and logistics.

3. 2001 Version 1.0 2006 Version 2.0 2007 Version 2.1 2010 Addendum 2017
Updated by: The IFE Core Group
Co-led: ENN and UNICEF
Coordinated by: ENN
Funded by: USAID/OFDA (ENN)
2001
Version 1.0
2006
Version 2.0
2007
Version 2.1
2010
Addendum
2017
Version 3.0
The OG-IFE was first developed in 2001 by operational agencies to meet an identified need for a ‘do’s and don’ts’ on infant feeding in emergencies. It is based on existing guidance, expert input and operational experience and has had a number of updates since the first iteration in The OG-IFE was endorsed in a WHA Resolution (23.23) in Version 3 has proved the most significant given the 10 year time lag between 2007 and There has been significant development in guidance, programmatic tools and resources since v2.1 (2007) which was drawn upon for the 2017 version.
Endorsed
WHA resolution 23.23

4. Experiences & resources
V 3.0 Process
March 2016
IFE Core Group Meeting: Interview findings shared, gaps in content and process agreed
Feb 16 – Sept 17
Consultation
Dec 2017
IFE Core Group Meeting: Dissemination & roll out action plan
Experts
Experiences & resources
IFE Core Group
Gaps in content and process agreed at IFE Core Group meeting in Jan 2016.
Regional practitioners had been interviewed beforehand on experiences implementing the OF-IFE, complementary feeding in emergencies (summary report available) and artificial feeding in emergencies. Findings were shared at the meeting.
The development of version 3 was a consultative process, involving IFE Core Group members (working groups) and broader community of practitioners and experts across sectors, disciplines (including WASH, reproductive health, HIV) and regions.
The process has also drawn heavily on agency experiences and considerable tools and resources that have developed in the 10 years since 2007
The IFE Core Group meeting in Dec 2017 will consolidate a rollout action plan and roles and responsibilities in 2018 and beyond
OFDA funding ends in December 2017
The process has been closely connected to the Sphere update process
SPHERE

5. V 3.0 What has stayed the same?
Layout
Headings
Most of existing guidance
Terminology of IFE
Availability in English, French and Arabic
KEY POINTS
PRACTICAL STEPS (1 – 6)
1. Endorse or develop policies
2. Train staff
3. Co-ordinate operations
4. Assess and monitor
5. Protect, promote and support optimal IYCF with integrated multi-sector interventions
6. Minimise the risks of artificial feeding
EMERGENCY PREPAREDNESS ACTIONS  New
KEY CONTACTS
REFERENCES  Expanded
DEFINITIONS  Expanded
ANNEX 1: Multi-sectoral content  New
ACRONYMS  New
There have been no major changes to previous guidance – mostly addition / expansion
The decision was taken to keep IFE (rather than IYCF-E) as an acronym for consistency with previous editions and to avoid implying a change where there is none. Note that IFE and IYCF-E mean the same.
The English version is available as of September Arabic and French versions will be available by December The previous version was available in 12 languages; this will be a key target area to address in 2018.

6. V 3.0 Revisions - Programming
Updated to reflect latest global guidance (published and upcoming)
Greater programmatic detail in all sections
Greater and more balanced content to address needs of non-breastfed infants
More comprehensive content on complementary feeding
Introduction of new concepts e.g. human milk banks
Considers situations where OG-IFE recommendations cannot be immediately met
More content on emergency preparedness
Summary key points updated
Updated to reflect latest guidance, including WHO 2016 guidance on HIV and infant feeding and WHO 2017 Guidance on Ending the Inappropriate Promotion of Foods for Infants and Young Children. Note that it also reflects discussions held on HIV and Infant Feeding in Emergencies.
As part of the update process, a WHO/UNICEF/ENN meeting was convened by WHO in Sept 2016 to examine challenges of putting existing WHO HIV and Infant Feeding guidance into practice in emergencies; proceedings from the meeting informed the content of the Ops G. WHO is finalising operational guidance on infant feeding and HIV in emergencies as a key output of the meeting – coming soon.
Greater programmatic detail in all sections
Greater and more balanced content to address of needs of non-breastfed infants in their own right
More comprehensive content on complementary feeding
Considers situations where OG-IFE recommendations cannot be immediately met and how to handle this
More content on emergency preparedness, including summary table of key actions. KEY POINT: Emergency preparedness is critical to a timely, efficient and appropriate IFE response.
The 14 summary key points have all been revised to reflect the updated content.

7. V 3.0 Revisions – Roles & Responsibilities
Greater emphasis on the lead role of government in preparedness and response
Greater clarity on the respective roles and responsibilities of UN agencies
Greater coverage of sectors beyond nutrition and more explicit actions to take
Incorporated accountability to affected populations
Reflects significantly evolved operational environment
Greater emphasis on the lead role of government in emergency preparedness and response
Greater clarity on the respective roles and responsibilities of UN agencies
Greater coverage of sectors beyond nutrition and more explicit actions to take
Incorporated accountability to affected populations
Reflects significantly evolved operational environment e.g. cluster approach well established, much more attention to IFE

8. V 3.0 Revisions – References, Resources, Terminology
More extensive list of supporting references and resources
Greater referencing of recommendations and definitions
More extensive list of definitions
Changes, and additions, to terminology
Optimal IYCF  Recommended IYCF
HIV Risk Assessment
Donor Human Milk
Human Milk Bank
Cluster Lead Agency
Lipid-based nutrient supplement (LNS)
As reflected in the extensive references / resources section, there has been significant development in guidance, programmatic tools and resources since v2.1 (2007). 200 resources are listed – key references are available in print; the full list is available online. Throughout the Ops Guidance, reference is made to the resources listed at the end.
*CHECK UNDERSTANDING FOR NEW TERMINOLOGY AND EXPLAIN / REFER TO DEFINITIONS IF NECESSARY*

9. 1: Endorse or develop policies
Key provisions regarding IFE should be reflected in government, multi-sector and agency policies and should guide emergency responses.
2: Train staff
Sensitisation and training on IFE is necessary at multiple levels and across sectors.

10. 3: Coordinate operations
Capacity to coordinate IFE should be established in the coordination mechanism for every emergency response. Government is the lead IFE coordination authority. Where this is not possible or support is needed, IFE coordination is the mandated responsibility of UNICEF or UNHCR, depending on context, in close collaboration with government, other UN agencies and operational partners. Where all provisions of OG-IFE cannot be immediately met, context-specific guidance on appropriate actions and acceptable ‘compromises’ should be provided by the IFE coordination authority and mandated UN agencies. Timely, accurate and harmonised communication to the affected population, emergency responders and the media is essential

11. 4: Assess & Monitor
Needs assessment and critical analysis should determine a context specific IFE response
Pre-crisis data
Rapid decision-making and action
Early needs assessment
In depth assessment
Monitoring
It is essential to monitor the impact of humanitarian actions and inaction on IYCF practices, child nutrition and health; to consult with the affected population in planning and implementation; and to document experiences to inform preparedness and future response.

12. 5: Protect, promote and support optimal IYCF with integrated multi-sector interventions
Immediate action to protect recommended infant and young child feeding (IYCF) practices and minimise risks is necessary in the early stages of an emergency, with targeted support to higher risk infants and children
General
Breastfeeding support
Infants who are not breastfed – incl. relactation, wet nursing, donor human milk, BMS
Complementary feeding
Micronutrient supplementation
HIV and infant feeding
Infectious disease outbreaks
Under infants who are not breastfed, we deal with relactation, wet nursing, donor human milk, BMS

13. 5: Protect, promote and support optimal IYCF with integrated multi-sector interventions
In every emergency, it is necessary to assess and act to protect and support the nutrition needs and care of both breastfed and non-breastfed infants and young children. It is important to consider prevalent practices, the infectious disease environment, cultural sensitivities and expressed needs and concerns of mothers/caregivers when determining interventions In every emergency, it is important to ensure access to adequate amounts of appropriate, safe, complementary foods and associated support for children and to guarantee nutritional adequacy for pregnant and lactating women.

14. 5: Protect, promote and support optimal IYCF with integrated multi-sector interventions
Multi-sector collaboration is essential in an emergency to facilitate and complement direct infant and young child feeding (IYCF) interventions. Actions are included for:
Health
Adolescent Services
WASH
FSL
Child Protection
ECD
Disability
Shelter
Cash
Social Protection
Agriculture
Logistics
Key sectors and disciplines to sensitise and work with on IYCF include health (reproductive health; MNCH; MHPSS; HIV; infectious disease management); adolescent services; WASH; FSL; child protection; ECD; disability; shelter; cash transfer programmes; social protection; agriculture; and logistics. Examples of integrated activities are provided.
WASH: Water, Sanitation and Hygiene, FSL: Food Security and Livelihoods, ECD: Early Childhood Development

15. 6: Minimise the risks of artificial feeding
In emergencies, the use of breastmilk substitutes (BMS) requires a context-specific, coordinated package of care and skilled support to ensure the nutritional needs of non- breastfed children are met and to minimise risks to all children through inappropriate use
Donations in emergencies
Artificial feeding management
BMS supplies
BMS specification
Procurement of BMS supplies, feeding equipment and support
Distribution of BMS
Donations of BMS, complementary foods and feeding equipment should not be sought or accepted in emergencies; supplies should be purchased based on assessed need. BMS, other milk products, bottles and teats should never be included in a general distribution.

16. Emergency preparedness
…is critical to a timely, efficient and appropriate IFE response
Examples from Box 1: Emergency Preparedness Actions
POLICY
Develop preparedness plans on IFE
TRAINING
Prepare orientation material for use in early emergency response
COORDINATION
Develop terms of reference for IFE coordination in a response
ASSESS AND MONITOR
Prepare key questions to include in early needs assessment
MULTI-SECTOR INTERVENTIONS
Examine national legislation related to food and drugs, particularly importation
ARTIFICIAL FEEDING
Communicate government position on not seeking or accepting donations
Preparedness has been integrated throughout the OG-IFE.

17. **INSTRUCTION SLIDE**
The following slides cover implications of the revisions in the Operational Guidance on IFE for stakeholders involved with HEALTH in emergencies. Slides on HIV and Mental Health and Psychosocial Support (MHPSS) are available separately. Please delete slides that are not applicable to your audience and cross reference to internal documents and processes where relevant.

18. Implications for…Health
Health is a key sector to sensitise and work with on IYCF.
5.30 Key sectors and disciplines to sensitise and work with on IYCF include health (reproductive health; MNCH; MHPSS; HIV; infectious disease management); adolescent services; WASH; FSL; child protection; ECD; disability; shelter; cash transfer programmes; social protection; agriculture; camp coordination and camp management; and logistics.
5.31 Sector programme entry points for IYCF include: antenatal and postnatal care; immunisation; growth monitoring; prevention of mother-to-child transmission (PMTCT) programmes; HIV prevention and treatment services, acute malnutrition treatment; community health; psychosocial counselling services; hygiene promotion; child protection screening; ECD activities; places of employment; and agriculture extension work.

19. Implications for…Health
5.32 Examples of two-way multi-sector collaboration include:
Enable access of pregnant women to skilled antenatal care and other necessary health services, including MHPSS.
Integrate IYCF support and/or establish referral systems with reproductive, MNCH and adolescent health services; curative health services; acute malnutrition treatment; HIV; and child protection services. Include minimum/initial service packages offered by different sectors.
Work with HIV prevention and treatment services to support access and adherence to ART

20. Implications for…Health
Policy
1.1 Governments and agencies should have up-to-date policies which adequately address all of the following elements in the context of an emergency: protection, promotion and support of breastfeeding; the management of artificial feeding; complementary feeding; the nutrition needs of PLW; compliance with the International Code of Marketing of Breastmilk Substitutes (BMS) and subsequent relevant World Health Assembly (WHA) Resolutions (the Code); prevention and management of donations of BMS; and infant feeding in the context of public health emergencies and infectious disease outbreaks. Additional context-specific provisions may be necessary, such as for refugees or internally displaced persons (IDP). Provisions may exist as a standalone policy and/or may be integrated into other relevant policies. UNICEF and WHO have key responsibilities in supporting national/sub-national policy preparedness.

21. Implications for…Health
Train Staff 2.3 Adapt and prioritise training content to address identified needs, cultural expectations and personal experiences of mothers and staff; capacity gaps; the target audience; and time available. More specialist capacity to counsel mothers and infants with heightened needs, such as stressed or traumatised mothers, malnourished infants and mothers, low birth weight (LBW) infants and disabled infants with feeding difficulties, may be needed. At a minimum, staff in contact with mothers and children aged under two years should be trained to be sensitive to psychosocial issues, on nutrition screening, and on referral pathways to more specialist support.

22. Implications for…Health
Coordinate Operations
3.4 The level of coordination, including whether a dedicated IFE coordinator is necessary, will depend on the context. Wherever possible, support government to fulfil their IFE coordination responsibility and work with existing country-level structures and mechanisms. Identify or locate IFE coordination capacity within the most relevant sector coordination mechanism, such as nutrition, health or food security.
3.6 Coordinate with other sectors to identify opportunities for multi-sector collaboration in needs assessment and programming and to inform sector policies, actions plans and risk management regarding IFE. Actively participate in relevant sector or cluster co-ordination meetings.

23. Implications for…Health
4.2 Explore opportunities to include IYCF questions in other sector needs assessments and draw on relevant multi-sector data.
Pre-crisis data and early needs assessment
4.6.1 Key information to consider includes contextual data:
Health environment, including support offered by providers of antenatal, delivery and postnatal services; age and morbidity profile of admissions to acute malnutrition treatment programmes; infectious disease morbidity rates; crude mortality rate (CMR), infant mortality rate (IMR) and under-five mortality rate (U5MR); coverage of antiretroviral treatment (ART); and support offered by social services and social protection mechanisms.

24. Implications for…Health
Protect, promote and support optimal infant and young child feeding with integrated multi-sector interventions
5.4 Establish accessible IYCF support services to provide for higher risk infants, young children and mothers, such as orphans, unaccompanied children, infants who are not breastfed; children with disabilities that affect feeding or whose caregivers are disabled; mothers in detention; children whose mothers are ill; adolescent mothers; premature infants; LBW infants; and children and/or mothers who are acutely malnourished.

25. Implications for…Health
Breastfeeding support
5.7 Protect, promote and support early initiation of exclusive breastfeeding in all newborn infants. Integrate the Ten Steps to Successful Breastfeeding of the WHO/UNICEF Baby-friendly Hospital Initiative in maternity services. Key newborn health interventions include:
skin-to-skin contact
kangaroo mother care
‘rooming in’ (keeping mothers and infants together)
delayed umbilical cord clamping.
Limit supplementation with BMS to medical needs.

26. Implications for…Health
Breastfeeding support
5.7 Target support to mothers of premature and LBW infants, adolescent mothers and first-time mothers.
Ensure access to HIV services as appropriate, including nutritional support when indicated.
Ensure birth registration of newborns within two weeks of delivery and coordinate with other sectors (such as health, food security and social protection) to facilitate access to support services.
Use and build existing capacity (such as traditional birth attendants, midwives and peers) to provide skilled breastfeeding support.

27. Implications for…Health
Infants who are not breastfed
5.10 In all emergencies, intervene to protect and support infants and children who are not breastfed to meet nutritional needs and minimise risks. The consequences of not breastfeeding are influenced by the age of the child (the youngest are most vulnerable); the infectious disease environment; access to assured supplies of appropriate BMS, fuel and feeding/cooking equipment; and WASH conditions.

28. Implications for…Health
Infants who are not breastfed
5.16 BMS requirement may be temporary or longer term. Temporary BMS indications include: during relactation; transition from mixed feeding to exclusive breastfeeding; short-term separation of infant and mother; short-term waiting period until wet nurse or donor human milk is available. Longer-term BMS indications include: infant not breastfed pre-crisis; mother not wishing or unable to relactate; infant established on replacement feeding in the context of HIV; orphaned infant; infant whose mother is absent long-term; specific infant or maternal medical conditions; very ill mother; infant rejected by mother; a rape survivor not wishing to breastfeed.

29. Implications for…Health
Micronutrient Supplementation
5.29 For children aged 6-59 months, multiple-micronutrient supplements may be necessary to meet nutrition requirements where fortified foods are not being provided, in conjunction with other interventions to improve complementary foods and feeding practices.
In malaria-endemic areas, the provision of iron in any form, including MNPs, should be implemented in conjunction with measures to prevent, diagnose and treat malaria. Provision of iron through these interventions should not be made to children who do not have access to malaria prevention strategies; prompt diagnosis of malaria illness; and treatment with effective antimalarial drug therapy.
Vitamin A supplementation is recommended for children aged 6-59 months.
For PLW, iron and folic acid or multiple-micronutrient supplementation should be provided in accordance with the latest guidance.

30. Implications for…Health
Infectious disease outbreaks
5.40 Anticipate and assess the impact of human and animal infectious disease outbreaks on IYCF, such as interrupted access to health and feeding support services; deterioration in household food security and livelihoods; transmission risks via breastfeeding; and maternal illness and death. Take actions to mitigate risks. Interim guidance may be necessary to address unanticipated IYCF consequences in outbreaks, such as Ebola virus and Zika virus. Consult WHO for up-to-date advice.

31. Implications for…Health
Protect, promote and support optimal infant and young child feeding with integrated multi-sector interventions
For more information on how to work together to jointly achieve shared objectives:
Go to: Operational Guidance on IFE V3.0 Resources – Health
Watch: IYCF Framework

32. **INSTRUCTION SLIDE**
The following slides cover implications of the revisions in the Operational Guidance on IFE for stakeholders involved with Early Childhood Development in emergencies. Please delete slides that are not applicable to your audience and cross reference to internal documents and processes where relevant.

33. Implications for…Early Childhood Development
ECD is a key discipline to sensitise and work with on IYCF.
5.31 Sector programme entry points for IYCF include: antenatal and postnatal care; immunisation; growth monitoring; prevention of mother-to-child transmission (PMTCT) programmes; HIV prevention and treatment services, acute malnutrition treatment; community health; psychosocial counselling services; hygiene promotion; child protection screening; ECD activities; places of employment; and agriculture extension work.

34. Implications for…Early Childhood Development
5.32 Examples of two-way multi-sector collaboration include:
­Integrate ECD into IYCF support at facility and community levels and explore opportunities to incorporate IYCF elements into ECD
See References Section 8.6 Multi-sector Interventions – Early Childhood Development

35. INSTRUCTION SLIDE
You may find it useful to have a discussion on how the revised guidance can be dissemination within your working group / cluster / agency etc.
Suggestions have been made for roll out at:
Individual agency level
National level
Regional level
Select the appropriate slide. Suggested roll out actions will have to be contextualised prior to presenting. Following the discussion, it is recommended to set SMART objectives and work out a timeline to implement the recommended roll-out actions. Consider what resources are required to support the roll-out.

36. Recommendations for dissemination (Agency)
Wide dissemination of Ops Guidance on IFE within <agency>
What does this mean for you and your agency? Roles, responsibilities, agency activities, programming, strategies, position papers etc.
Training for technical staff from health, nutrition and other sectors
Sensitisation for all staff including senior management and communication, logistics, resource mobilization, rapid response and volunteer teams
Inclusion of V 3.0 in induction reading materials, agency resource libraries, training materials etc.
Dissemination and roll out to regional, country and field offices
Update training materials
Training: Target especially nutrition, health, adolescent services, WASH, FSL, CP, ECD, disability, cash transfer, social protection, agriculture and logistics staff.
Sensitisation: relevant personnel across sectors to support IFE, including those dealing directly with affected women and children; those in decision-making positions; those whose operations affect IYCF; those handling any donations; and those mobilising resources for the response. Target groups for sensitisation include sector/cluster leads, donors, rapid-response personnel, government staff, camp managers, communications teams, logisticians and volunteers, among others.
Note that this should not be limited to induction for nutrition staff but also technical staff working in other sectors as well as support services (finance, admin logistics etc.) and senior management.

37. Recommendations for dissemination(National/Cluster)
Wide dissemination to <NiEWG / nutrition cluster members, all other sectors, intercluster, relevant government agencies and authorities, advocacy groups, policymakers>
What does this mean for you? Preparedness and response plans, roles and responsibilities etc.
Dissemination of / sensitisation on update
Translation of Operational Guidance on IFE text into local language
Adaptation of Operational Guidance on IFE to local context
Incorporation of V 3.0 revisions into national guidance & policy
Inclusion into background reading materials
Check at regional / HQ level if translation already exists / is in process

38. Recommendations for dissemination (Regional)
Wide dissemination of Ops Guidance on IFE at <regional level>
What does this mean for you? Preparedness and response plans, roles and responsibilities etc.
Training and sensitisation for regional offices
Translation into regional languages
Dissemination to country offices
Incorporation of V3.0 updates into regional strategies, funding etc.
Arabic, English and French will be available

39. Appropriate and timely support of infant and young child feeding in emergencies (IFE) saves lives, protects child nutrition, health and development and benefits mothers.