Activities to Implement Strategy

Many agencies advocate a policy of supporting and protecting breastfeeding in emergency and non-emergency situations. However, some recent emergency experiences have highlighted tensions between policy and practice with regard to infant feeding and have demonstrated how policy makers and planners may occasionally need to be better informed by practical circumstances and problem analysis.

Emergency contexts continuously change, creating new sets of circumstances which can challenge efforts to support and protect breastfeeding. High endemic levels of HIV infection, large numbers of unaccompanied minors and a high prevalence of bottle feeding in some emergency settings can create enormous dilemmas for aid workers about which feeding strategy should be supported. There is a need to clarify best practice for aid workers which is in keeping with policy and strategy statements. There is also a need to develop clear prescriptive guidelines. It was beyond the scope of these meetings to develop such guidelines. However, participants endorsed guidelines produced by Kathy Carter of Oxfam (see abstract below), and also recognised the value of the WHO Guiding Principles for Infant Feeding in Emergencies (see Annex VIII).

There are a number of different activities broadly outlined in the strategy paper which can be undertaken in order to facilitate the implementation of policy. This section of the document presents practical information which will support the implementation of the IFEG strategy. Depending on the type of agency or the position of the individual these activities will differ widely. For example, practice for an advocacy group may be the dissemination of information to the general public or to targeted groups. The activities of NGOs to translate policy into practice are carried out on a number of different levels, such as training for general or technical staff and specific training for staff working in the field. All of these practices or activities should be seen as belonging to a wider group whose emphasis and focus will change depending on profession, position and organisation mandates.

The Infant Feeding in Emergencies Group (IFEG) has produced supporting material intended for practical use for each of the main points outlined in the strategy paper.

IFEG Strategy Paper, p7, point 1 (1) Ensure that any action is based on an adequate understanding of the factors affecting infant feeding practice in that particular situation. This will require thorough assessment and careful analysis of the situation to identify key factors including: pre-emergency infant feeding knowledge and practice; current practice; knowledge and practice on the part of maternity care givers and providers of maternal and child health care; the extent and nature of commercial promotion; access to breastmilk substitutes (pre-emergency and currently).

IFEG activity

a) To support and refer to Feeding in Emergencies for Infants Under Six Months - Practical Guidelines by Kathy Carter (below).

An abstract from:

a) Feeding in Emergencies for Infants Under Six Months - Practical Guidelines

These guidelines will be of use to health and nutrition personnel in agencies both at headquarters and at field level, particularly in situations where there has been a significant percentage of infants dependent on breastmilk substitutes (BMS) prior to the emergency. An initial discussion of the benefits of breastfeeding and factors which may affect breastfeeding is followed by an emphasis on the practicalities of appropriate intervention in order of priority. There is a comprehensive and detailed guide for the assessment of infant feeding practices in emergencies. Next there is a section on appropriate breastfeeding support covering policies, training, camp planning and management, the new-born, relactation, wet-nurses, milkbanks and breastfeeding promotion. Last is a section on appropriate support for carers of infants using BMS, including requirements for safe BMS feeding and distribution of BMS. A list of key texts is included. Requests for copies of the guidelines and/or comments on its use should be made to Judith Appleton, Emergency Department, Oxfam.

IFEG activity

b) To highlight relevant and recent information on HIV and infant feeding and to comment briefly on these.

b) HIV and infant feeding

In an emergency situation the following information must be taken into account before an appropriate infant feeding strategy is determined:

· assessment of the prevalence of HIV in the affected population using secondary sources (including pre-emergency estimates) and relevant information from health information systems;

· assessment of the knowledge of HIV status: were voluntary counselling and testing facilities available pre-emergency? Are there such services available now?

· relevant policies on infant feeding and HIV, from the host and/or home countries.

Breastfeeding is the optimal way to feed an infant in the majority of circumstances. However, studies to date show that breastfeeding can be a route of HIV transmission; 1 in 7 children born to and breastfed by mothers living with HIV become infected by breastfeeding.

Mothers, health workers and policy makers are faced with a dilemma concerning decisions about infant feeding.

There have been many developments recently regarding HIV and infant feeding. Most importantly, WHO, UNICEF and UNAIDS published three documents:

5. HIV and Infant Feeding: Guidelines for Decision Makers (WHO/FRH/NUT 98.1 UNAIDS/98.3)

6. HIV and Infant Feeding: A Guide for Health Care Managers and Supervisors (WHO/FRH/NUT 98.2 UNAIDS/98.4)

7. A Review of HIV Transmission Through Breastfeeding (WHO/FRH/NUT 98.3 UNAIDS/98.5)

The new guidelines are being piloted in eleven countries around the world. At the same time, a number of research projects are underway examining various aspects of mother-to-child transmission of HIV.

IFEG wish to make the following points on the subject:

The guidelines have stimulated a great deal of controversy for a number of reasons, primarily to do with cost, feasibility and appropriateness. They also present a shift in policy by emphasising the use of artificial baby milk for mothers tested and found to be infected with HIV.

Although the guidelines stress the right of mothers to make an informed choice about how to feed their baby (without influence from commercial pressure), there is as yet a great deal about which there is little information. In particular:

· the timing of transmission of the HIV virus through breastmilk;

· the relationship between maternal vitamin A status, HIV viral load in breastmilk, maternal CD4 blood count and risk of transmission;

· the relative risks of artificial feeding and breastfeeding outside a research environment, for infants born to HIV positive mothers in resource-poor contexts;

· the relationship between infant gut development, stomach acidity and virus absorption;

· the relative risk between breastfeeding/wet-nursing and artificial feeding among HIV positive women in emergencies.

Furthermore, the IFEG is concerned that, in resource-poor settings, the preparation of infant formula is not a safe alternative to breastmilk. It is also expensive, even if it is subsidised. UN guidelines emphasise the need to avoid the use of formula milk intended for positive mothers by those who are not infected with HIV or who are of unknown status (referred to as ‘spill over’). This is particularly pertinent to emergency situations where very few women, if any, will be aware of their HIV status.

IFEG would like to reiterate the following points:

· breastfeeding is recommended for infants born to women who are HIV negative or of unknown HIV status;

· breastmilk substitutes may be a preferable option for infants born to women infected with HIV who are aware of their positive status. However, for this to be true, the risks arising from artificial feeding must be less than the risks of HIV transmission through breastfeeding;

· the need to protect mothers from becoming infected with HIV, must remain a priority.

The IFEG is concerned that breastmilk substitutes may be inappropriately targeted to infants for whom breastfeeding is still the optimal feeding option. It is essential that in all circumstances the International Code of Marketing of Breastmilk Substitutes and subsequent resolutions are adhered to.

for further information, including comments on the UN Guidelines, contact: Baby Milk Action, Save the Children or the nutrition sections of WHO and UNICEF.

Strategy Paper, p7, point 2a (2) Protect, support and promote breastfeeding and eliminate practices which undermine breastfeeding, by: f. raising awareness, increasing knowledge and engendering supportive attitudes across all sections of the humanitarian community - donors, governments, UN organisations, NGOs and local groups alike as well as in the emergency affected population;

IFEG activities

IFEG designed two leaflets for specific target groups (see contents page): d. Fact Sheet (for format suitable for duplication contact the ENN) e. Advertorial