Annex 6. Guiding principles for feeding infants and young children in emergencies

Increased mortality and morbidity in emergencies are most serious and most frequent in children under 5 years of age; the increased rates may be as much as 20 times higher than the usual level. This is partly the result of increased exposure to infections, but also due in large measure to inadequate feeding of infants and young children. In recent years awareness of this problem has grown enormously, both as a critical issue for survival of young children and as an aspect of management of nutrition in emergencies. The 10 guiding principles outlined in this annex have been elaborated by WHO to help promote more effective action. More details will be available in:

· Guiding principles for feeding infants and young children during emergencies. Geneva, World Health Organization (document in preparation; will be available from Programme of Nutrition, World Health Organization, 1211 Geneva 27, Switzerland).

Full and exclusive breast-feeding of infants until 4-6 months of age is a critical element of optimal feeding, and breast-feeding should continue, with adequate complementary feeding, through to age 2 years if possible. High priority in emergency situations should therefore be given to the following:

· protecting and promoting breast-feeding;

· ensuring provision to, and consumption by, the infant and the lactating mother of adequate energy and nutrient supplies;

· promoting the physical, mental, and social well-being of care-givers;

· ensuring that breast-milk substitutes are used only where they are critically needed, and that safety precautions are observed;

· identifying and eliminating the underlying causes of suboptimal feeding practices.

Breast-feeding

Even in communities where breast-feeding is almost universal, breast-feeding patterns are often undermined in emergencies by the breakdown of traditional care networks. However, shortage of resources and difficulties in safe food preparation for infants make the protection of breast-feeding even more important.

Principle 1. Infants born into populations affected by emergencies should normally be breast-fed.

Breast milk is vital to the growth and development of children during the first months of life. It provides valuable protection against many infections. The first months of breast-feeding favour contraception.

Principle 2. Every effort should be made to create and sustain an environment that encourages frequent breast-feeding of all children under 2 years of age.

Where breast-feeding has been interrupted or mothers are missing or totally unable to breast-feed, strenuous efforts should be made to promote relactation or wet nursing. An appropriate individual should be given full-time responsibility for this. Success hinges on positive development of a woman's attitude, knowledge, and self-confidence, and on frequent suckling. Breast-feeding is the most crucial life-saving activity and should be vigorously supported by health workers and community networks.

Breast-milk substitutes

Principle 3. The quantity, distribution, and use of breast-milk substitutes at emergency sites should be strictly controlled.

Emergency situations tend to aggravate health risks associated with artificial feeding. It should be avoided by raising public awareness through:

· mass media information in donor countries;

· appropriate training of relief programme planners and field staff;

· ensuring that governments and agencies involved in donor and recipient countries are properly informed;

· refusing well-meant but ill-advised donations of "baby foods".

Breast-milk substitutes, fed by cup, should be available only for infants under 6 months of age for whom breast-feeding is not possible and breast milk is not available. For populations that lack a breast-feeding tradition, wider distribution of breast-milk substitutes may be required initially but should be phased out within 6 months by vigorous promotion of breast-feeding among all women who give birth subsequently.

Individuals using breast-milk substitutes should be adequately informed and equipped to ensure their safe and appropriate preparation and use.

Use of breast-milk substitutes in a minority of cases should in no way interfere with protecting and promoting breast-feeding among the majority.

The use of infant-feeding bottles and artificial teats should be actively discouraged.

Complementary feeding

Principle 4. To sustain growth, development and good health, older infants and young children need hygienically prepared foods that are both easy to eat and digest and that nutritionally complement breast milk.

Complementary foods are usually introduced at 4-6 months of age. In emergencies complementary foods are often coarse, difficult to prepare in soft form, of low nutrient density, and liable to contamination. Their introduction should be delayed until absolutely essential.

The first food is usually a porridge made from a cereal provided in the basic food ration, often together with a pulse, vegetable oil, and vegetables or sugar as available. Suitable locally adapted and feasible recipes and preparation techniques should be worked out and promoted, with special attention to newly responsible caregivers.

Frequent feeding (4-6 times daily) should be encouraged by the provision of fuel and appropriate cooking pots, by using snacks and jointly or collectively prepared meals, and by income-generating activities that allow the purchase of additional foods. Special care is needed to promote appetite, eliminate inhibiting factors, and encourage interaction between child and care-giver.

The complementary foods used should be concentrated sources of dietary energy; special attention should be given to the content of protein, iron, and vitamins A and C. A common problem is that foods provided are too dilute or too bulky

Principle 5. Caregivers need uninterrupted access to appropriate ingredients with which to prepare nutrient-dense foods for feeding to older infants and young children.

Care-givers' access to essential ingredients can be ensured if:

· food aid and its distribution are well planned;

· local markets are within reach, functioning, and adequately supplied;

· good relations are maintained with local food suppliers;

· income-generating activities and/or household gardening and small-scale animal husbandry are undertaken.

Adequate feeding of infants and young children can be assured only if basic household needs are met. This calls for continuous monitoring of food distribution, household food reserves, and preparation, to identify "food insecure" households.

The contents of the food basket (supplemented from any available resources) should be adequate in amount, taking into account supplies to which people already have access. The commodities should be nutritionally balanced, regularly available, safe for consumption, easy to cook, digestible, and culturally appropriate. They should be equitably distributed among families within the community and in accordance with family size. Families should also know how to distribute equitably according to individual needs - remembering that young children need about 2.5 times as much for size (i.e. per kg of body weight) as adults, and bearing in mind the extra requirements of pregnancy and lactation.

For infants and young children there are special concerns for energy density and micronutrients. Up to now, deficiencies of the latter have been relatively common.

Rations are generally based on cereals, usually with added pulses and oil, and sometimes with sugar and blended foods (cereal-pulse mixes). These foods are commonly rather low in absorbable iron and in vitamins A and C.

Blended foods, especially if fortified, are useful particularly for vulnerable groups. However, provision of blended foods should not be allowed to reduce efforts to promote full use of local products for preparing complementary foods for older infants and young children.

Special commodities sometimes include fresh fruits, vegetables, meat, and fish. Where there is evidence of inadequate intake of essential nutrients, such foods can prevent micronutrient deficiencies.

Selective food distribution for vulnerable groups such as young children may be needed as a temporary measure but the aim is to establish quickly a basic ration adequate to cover the needs of everyone.

Foods available from other sources include the following:

· household food production (e.g. in home or collective gardens) - land must be available, and it may be necessary to supply planting materials, tools, fertilizers, and pesticides;

· foods purchased or bartered, in the market or with neighbours - the relative costs of nutrients obtained in this way should be analysed and explained; various options for increasing income should be explored;

· natural foods that may be available (wild) in the environment - these are usually very nutritious.

Complementary foods should be prepared frequently, safely, and in a clean environment. The basic principles of safe food preparation are detailed in Annex 5.

Caring for care-givers

Principle 6. Because the number of care-givers is reduced during emergencies and their ability to cope is diminished by physical and mental stress, strengthening care-giving capacity is an essential part of promoting good feeding practices for infants and young children.

The physical care of care-givers should include safety, health care, and adequate nutrition. Attention should be paid to the additional food needs of pregnant and lactating women, including wet nurses. In the context of emotional and social security, victims of trauma or rape and the bereaved will have special needs.

Households with only one adult need special attention because of limitations in their mobility, income, self-supporting status, and ability to provide shelter and physical and material security. Opportunities for cooperative child care, income-generation, skills training, etc. should be provided.

Protecting children

Principle 7. To encourage adequate food intake, the health and vigour of children, especially newborns, should be actively protected. Children need to suckle frequently and well, and, as appropriate, to maintain their appetite for complementary foods.

Prenatal care for mothers should include energy and iron supplements, plus iodine and vitamin A in areas where deficiencies of these micronutrients are prevalent.

Appropriate measures to provide protection from illness include promotion of breast-feeding, immunization, environmental health and vector control, and rapid and adequate curative care. Protection from the effects of exposure requires adequate shelter and clothing, especially for newborns.

Infants who are not breast-fed need special care in all these areas because they are highly vulnerable.

Malnutrition

Principle 8. There should be a continual search for malnourished children so that their condition can be identified and treated before it becomes severe. The underlying causes of malnutrition should be investigated and corrected.

Care-givers and community workers should be able to recognize faulty feeding practices, and early symptoms, signs, and probable main causes of malnutrition, and to refer and follow-up recognized cases.

Therapeutic feeding is essential for severely malnourished children, either in hospitals or nutrition rehabilitation centres (which are usually needed if the prevalence of malnutrition exceeds about 10%). Essential elements of management include maintenance of breast-feeding, frequent feeding (initially with a specially formulated liquid diet), and control of infections and fever.

Acute phases of emergencies

Principle 9. To minimize the negative impact of emergencies on feeding practices, interventions should begin immediately, during the acute phase. The focus should be on alleviating pressures on care-givers and channelling scarce resources to meet the nutritional needs of infants and young children.

Appropriate interventions in the acute phase of an emergency would include the following:

· identification of households with infants, young children, and pregnant women, and of the most vulnerable households in this group (e.g. single-parent households, households headed by the elderly, disabled members, etc.);

· priority allocation of resources to these households;

· support for breast-feeding women;

· emergency nourishment for infants whose mothers are absent;

· immediate provision of appropriate emergency foods for feeding young children;

· drawing up locally adapted guidelines for feeding infants and young children;

· developing information/education/communication and feedback systems for young child feeding.

Assessment, intervention and monitoring

Principle 10. Emergencies, by definition, are marked by frequent and rapid change. Promoting optimal feeding for infants and young children in such circumstances requires a flexible approach based on careful continual monitoring.

Assessment priorities for monitoring child-feeding practices include the following:

· dialogue with care-givers to identify current (and desired) feeding practices;
· identification of less appropriate practices and the groups in which they occur;
· identification of decision-makers concerned with infant and young child feeding;
· identification of imperative "quick-fix" measures;
· initial and periodical subsequent gathering of information on

- general health and nutritional status
- food availability, costs, preparation methods
- community attitudes to breast-feeding, relactation, wet nursing, breast-milk substitutes
- availability of human resources
- income-generating opportunities,
- services and resources suitable for implementing needed measures.

Essential interventions include the following:

· education and information;
· provision of necessary material resources;
· establishment of communications and support networks;
· coordination with related services;
· development of special programmes for breast-feeding, rehabilitation, orphans.

Effective action depends on setting priorities, searching for solutions, and sustaining the selected action:

· expand and promote existing good practices, curb harmful ones;

· emphasize immediately feasible and sustainable actions that give maximum and lasting results;

· build the capacities of households and communities;

· avoid dependence on single products, e.g. blended foods;

· define objectives and develop a "miniplan" of action for each intervention;

· monitor, using well-defined methods and criteria:

- nutritional status of children under 3 years of age and pregnant/lactating women

- prevalence of low birth weight

- feeding practices (prevalence of exclusive and non-exclusive breast-feeding; adequacy, energy density, frequency, micronutrient content, safety of complementary feeding)

- household food security

- mortality rates (infants, young children, maternal);

· review activities and refine, enhance, reduce, or replace them as necessary;

· modify action plan accordingly.

Ten steps to successful breast-feeding¹

¹ From: Protecting, promoting and supporting breast-feeding: the special role of maternity services. A joint WHO/UNICEF statement. Geneva, World Health Organization, 1989.

Every facility providing maternity services and care for newborn infants should:

1. Have a written breast-feeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breast-feeding.

4. Help mothers initiate breast-feeding within a half-hour of birth.

5. Show mothers how to breast-feed, and how to maintain lactation even if they should be separated from their infants.

6. Give newborn infants no food or drink other than breast milk, unless medically indicated.

7. Practise rooming-in - allow mothers and infants to remain together - 24 hours a day.

8. Encourage breast-feeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to breast-feeding infants.

10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.

Acceptable medical reasons for using breast-milk substitutes¹

¹ Reproduced from WHO/UNICEF Guidelines for the Baby-friendly Hospital Initiative, Part II: Hospital-level implementation. Geneva, World Health Organization/United Nations Children's Fund, 1992. For a fuller discussion of these and related issues see: Akré J. ed., Infant feeding: the physiological basis, Bulletin of the World Health Organization, 1990, 67 (Suppl.).

A few medical indications in a maternity facility may require that individual infants be given fluids or food in addition to, or in place of, breast milk.

It is assumed that severely ill babies, babies in need of surgery, and very low-birth-weight babies (less than 1500 g) will be in a special-care unit. Their feeding will be individually decided, given their particular nutritional requirements and functional capabilities, though breast milk is recommended whenever possible. These infants in special care are likely to include:

· infants with very low birth weight or who are born pre-term, at less than 1500 g or 32 weeks gestational age;

· severely premature infants with potentially severe hypoglycaemia, or who require therapy for hypoglycaemia, and who do not improve through increased breast-feeding or by being given breast milk.

For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements. In order to assess whether a facility is inappropriately using fluids or breast-milk substitutes, any infants receiving additional supplements must have been diagnosed as:

· infants whose mothers have severe maternal illness (e.g. psychosis, eclampsia, or shock);

· infants with inborn errors of metabolism (e.g. galactosaemia, maple syrup urine disease);

· infants with acute water loss, for example during phototherapy for jaundice, whenever increased breast-feeding cannot provide adequate hydration;

· infants whose mothers are taking medication which is contraindicated when breast-feeding (e.g. cytotoxic drugs, radioactive drugs, and anti-thyroid drugs other than propylthiouracil).

When breast-feeding has to be temporarily delayed or interrupted, mothers should be helped to establish or maintain lactation, for example through manual or hand-pump expression of milk, in preparation for the moment when breast-feeding may be begun or resumed.

HIV and infant feeding: WHO/UNAIDS/UNICEF guidelines

Introduction

The number of infants born with HIV infection is growing every day. The AIDS pandemic represents a tragic setback in the progress made on child welfare and survival.

Given the vital importance of breast milk and breast-feeding for child health, the increasing prevalence of HIV infection around the world, and the evidence of a risk of HIV transmission through breast-feeding, it is now crucial that policies be developed on HIV infection and infant feeding.

In 1997, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and two of the six co-sponsoring agencies - WHO and UNICEF - issued a joint policy statement on HIV and infant feeding,¹ and initiated the development of guidelines to help national authorities to implement the policy. Other documents on related topics have since been prepared.² At the Technical Consultation on HIV and Infant Feeding held in Geneva on 20-22 April 1998, implementation of the guidelines contained in these documents was discussed, and a broad consensus on a public health approach, based on universally recognized human rights standards, has been reached.

¹ HIV and infant feeding: a policy statement developed collaboratively by UNAIDS, WHO and UNICEF. Geneva, Joint United Nations Programme on HIV/AIDS, 1997; available from Joint United Nations Programme on HIV/AIDS, 1211 Geneva 27, Switzerland.

² HIV and infant feeding: a review of transmission through breast feeding. Geneva, Joint United Nations Programme on HIV/AIDS, 1998 (unpublished document UNAIDS/98.5). HIV and infant feeding: guidelines for decision makers. Geneva. Joint United Nations Programme on HIV/AIDS, 1998 (unpublished document UNAIDS/98.1). HIV and infant feeding: a guide for health-care managers and supervisors. Geneva, Joint United Nations Programme on HIV/AIDS, 1998 (unpublished document UNAIDS/98.4). (All available from Joint United Nations Programme on HIV/AIDS, 1211 Geneva 27, Switzerland.)

The guidelines recognize that:

· HIV infection can be transmitted through breast-feeding. Appropriate alternative to breast-feeding should be available and affordable in adequate amounts for women who have been tested and found to be HIV-positive.

· Breast-feeding is the ideal way to feed the majority of infants. Efforts to protect, promote, and support breast-feeding by women who are HIV-negative or of unknown HIV status need to be strengthened.

· HIV-positive mothers should be enabled to make fully informed decisions about the best way to feed their infants in their particular circumstances. Whatever they decide, they should receive educational, psychosocial, and material support to carry out their decision as safely as possible, including access to adequate alternatives to breast-feeding if they so choose.

· To make fully informed decisions about infant feeding, as well as about other aspects of HIV, mother-to-child transmission, and reproductive life, women need to know and accept their HIV status. There is thus an urgent need to increase access to voluntary and confidential counselling and HIV testing, and to promote its use by women and, when possible, their partners, before alternatives to breast-feeding are made available.

· An essential priority is primary prevention of HIV infection. Education for all adults of reproductive age, particularly for pregnant and lactating women and their sexual partners, and for young people, needs to be strengthened.

Alternative to breast-feeding for HIV-infected mothers

The guidelines describe a number of infant feeding options that women who are HIV-positive may consider, including replacement feeding, modified breast-feeding, and use of breast milk from other sources.

Replacement feeding means providing a child who receives no breast milk with a diet that contains all the nutrients needed throughout the period for which breast milk is recommended, that is for at least the first 2 years of life.

From birth to 6 months of age, milk is essential and can be given in the form of commercially produced infant formula, or as home-made formula made by modifying fresh or processed animal milk, accompanied by micronutrient supplements (especially iron, zinc, folic acid, and vitamins A and C).

From 6 months to 2 years, replacement feeds should consist of appropriately prepared nutrient-enriched family foods given three times a day if commercial or home-prepared formula continues to be available, or five times a day if neither formula is available. If possible, some form of milk product (such as dried skim milk or yoghurt) should be added to the food as a source of protein and calcium; meat or fish as a source of iron and zinc; and vegetables to provide vitamins A and C, folic acid, and other vitamins. Micronutrient supplements should be given if available.

Families need careful instruction about the preparation of adequate and safe replacement feeds, including accurate mixing, cleaning and sterilizing of utensils, and the use of cups to feed infants instead of bottles. They need resources such as fuel, clean water, and time to enable them to prepare foods safely. The risk of illness and death from replacement feeding must be less than the risk of transmission of HIV through breast-feeding or there will be no advantage in choosing this alternative.

Other options that may be appropriate are modified breast-feeding (early cessation of breast-feeding, or expression and heat treatment of the mother's breast milk), or use of other breast milk (from a breast-milk bank or from an HIV-negative wet-nurse within the family).

Nasogastric tube feeding instructions

Feeding by nasogastric tube is a last-resort emergency procedure that should be carried out only by nurses or other medically trained staff. The procedure is as follows:

· Introduce a moistened tube (internal diameter 2 mm, length 50 cm) into the nose, passing it down the throat and into the stomach. The passage of the tube into the oesophagus is easier if the patient swallows.

· It is essential to check that the tube is in the stomach and not in the lungs. This can be done by using a syringe to remove a small amount of clear fluid from the tube. Alternatively, inject a few ml of air into the tube; if the tube is in the stomach, a loud bubbling noise will be heard in the child's abdomen.

· Secure the tube to the child's temple or cheek with sticking plaster. Carefully check again that the tube is in the stomach. Use a large syringe (50 ml) to feed the normal volume of liquid food slowly down the tube.

· After the feeding, rinse the tube through with a few ml of clean water. It can then be left in place or removed and reinserted at the next feeding.

Nasogastric tubes can also be used to administer oral medicines that cannot be given in any other way.