One Asia Breastfeeding Partner Forum 6One Asia Breastfeeding Partner Forum 6

Protecting Breastfeeding in Protecting Breastfeeding in EmergenciesEmergencies

Dr. SM Moazzem Hossain

Chief of H&N Section

UNICEF Sri Lanka

18 Nov, 2009

Holiday Inn

ACKNOWLEDGEMENTACKNOWLEDGEMENT

INFANT FEEDING IN EMERGENCIES CORE GROUP INFANT FEEDING IN EMERGENCIES CORE GROUP and and

Partners in the FieldPartners in the Field

BREASTFEEDING OR BREASTFEEDING OR INFANT FEEDING:INFANT FEEDING:

WHY WHY DOES DOES

IT IT MATTER?MATTER?

BECAUSE INFANTS & YOUNG CHILDREN ARE THE

MOST VULNERABLE

Asa

d Za

idi,

UN

ICE

F P

akis

tan

Pakistan, post-earthquake

USA, Hurricane Katrina

Even in healthy populations

child morbidity and crude mortality

can increase by 20% in 2 weeks

In emergencies rates of

child mortality can soar from

2 to 70 times higher than average

YOUNG infants are particularly vulnerable

Mozambique – flooding, 2000

Pakistan – post earthquake 2005

Asad Zaidi, U

nicef,

Timor

Emergencies Emergencies can can happen happen

ANYWHEREANYWHERE

ASIA - TsunamiP

ictu

re c

redi

t: Y

ayas

an ID

EP

Fou

ndat

ion

Picture credit: Real Medicine Foundation: Sri Lanka

Baby in India after Tsunami in camp,

2004

Reu

ters

_Ark

o D

atta

Indonesia – earthquake

Picture credit: M

ary Corbett

Picture credit: Y

ayasan IDE

P foundation &

Ram

a Surya

Pakistan - earthquake

Unicef Pakistan

Bangladesh - cyclone

Picture credit: Top: BBF, Top right & bottom right: Ali Maclaine

USA – Hurricane

Ass

ocia

ted

Pre

ss

CENTRAL AMERICA Colombia - floods

AFRICA Mozambique – flooding

Rositha, born in a tree

EUROPE Balkans – war

Photo credit: MAJKA.JPG

MIDDLE EAST – Lebanon, war

Photos credit: Ali Maclaine, 2006

BREASTFEEDINGBREASTFEEDINGSAVES LIVES SAVES LIVES

IN EMERGENCIES IN EMERGENCIES

Venezualan President Hugo Chavez talking to flooding victim

Lebanon, conflict, 2006

Photo credit: A

li Maclaine 2006

Bangladesh – post cyclone Sidr, 2007

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to c

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t: A

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acla

ine

2007

Artificial feedingArtificial feeding in in emergencies can lead emergencies can lead to to increase in morbidityincrease in morbidity

Lebanon, conflict 2006

Photos: Ali Maclaine, 2006

50 times50 times risk of being hospitalised risk of being hospitalised with diarrhoea if artificially fed than with diarrhoea if artificially fed than

breastfed breastfed (Botswana 2006)(Botswana 2006)

U.S. Army photo by Sgt. Heidi Schaap. Kosovo 2003

AND 10.5 times AND 10.5 times more likely to more likely to

DIE DIE if not breastfedif not breastfed

(multi-centre data)(multi-centre data)

WHY?WHY?Why is there high infant morbidity & mortality

due to artificial feeding in emergencies compared to breastfeeding?

Why?Why? (1) Due to intrinsic (1) Due to intrinsic contamination of infant formula contamination of infant formula

– it is NOT sterile – it is NOT sterile

Photo credit: Ali Maclaine, 2006

Why?Why? (2) Due to (a) lack of water (2) Due to (a) lack of water

Water for sale in Pakistan, post-earthquake

Asa

d Za

idi,

UN

ICE

F P

akis

tan

A 3 month old bottle-fed baby needs 1 litre of water per day to mix with the formula powder. Another 2 litres are needed to sterilize the bottles and teats.

(b) contamination of water (b) contamination of water (poor water & sanitation conditions)(poor water & sanitation conditions)

Bangladesh

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6

Often not helped by overcrowded Often not helped by overcrowded conditions & people on the move…conditions & people on the move…

Aceh post-tsunami

Pic

ture

cre

dit:

yaya

san

IDE

P fo

unda

tion

Why?Why? (3) Due to mode of feeding - bottles & (3) Due to mode of feeding - bottles & teats are hard to sterilise especially with lack teats are hard to sterilise especially with lack

of water, fuel, equipment, etc... of water, fuel, equipment, etc...

Maaike A

rts, UN

ICE

F Pakistan

Pakistan, post-earthquake

Bangladesh, post cyclone Sidr, 2007

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acla

ine

2007

Why?Why? (4) Due to infant formula (4) Due to infant formula being made up incorrectly being made up incorrectly

(over or under-diluted)(over or under-diluted)

Lebanon, conflict 2006 – mother with donated formula – she was worried it

was going to run out…

Mother’s in rural Bangladesh where there is high illiteracy rate

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6

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Why?Why? (5) Due to lack of other (5) Due to lack of other supporting resources supporting resources

e.g. fuel, cleaning equipment, cooking e.g. fuel, cleaning equipment, cooking pots, time constraints, etcpots, time constraints, etc

Bangladesh, 2007. People queuing for relief items after cyclone

People have lost cooking pots, etc after floods

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7

Why?Why? (6) Due to a change in circumstances… (6) Due to a change in circumstances…

Even if artificial feeding before the crisis was Even if artificial feeding before the crisis was ‘safe’.‘safe’. TheThe emergency takes away those emergency takes away those conditions and the mother’s ability to conditions and the mother’s ability to produce formula safely. produce formula safely.

USA – post Hurricane Katrina. Mother’s

trying to formula feed in the Super Dome.

Why? (7) Because, infant formula does Because, infant formula does not have the protective properties of not have the protective properties of

breastmilk or safe feeding mode - breastmilk or safe feeding mode - breastfeedingbreastfeeding

So what happens in So what happens in emergencies?emergencies?

Breastfeeding support? Breastfeeding support?

NO!NO! (rarely) (rarely)

Reality often:Reality often: Large scale donations & distribution of Large scale donations & distribution of - INFANT FORMULA

- BOTTLES/TEATSPhoto credit: Mary Corbett

Donations post-earthquake, Indonesia 2006

- Milk products: powder

Pakistan , post earthquake

Maaike A

rts, UN

ICE

F Pakistan

- Milk Products: Liquid milk

Kurdistan, 1991

DoD

photo by: PH

2 MILTO

N R

. SA

VA

GE

Pakistani soldiers unloading US chinook helicopter.

Pakistan, 2005

BY: THE MILITARY

Asian Tribune 2006

Sri Lanka 2006

Unloading baby milk powder from airforce

plane

BY: INTERNATIONAL NGOsBY: INTERNATIONAL NGOs

Lebanon - 2006

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6

BY: LOCAL NGOs / BY: LOCAL NGOs / ORGANISATIONSORGANISATIONS

Gaza

ALSO BY:ALSO BY:

- INFANT FORMULA COMPANIES- INFANT FORMULA COMPANIES

- ORDINARY PEOPLE WHO SEE - ORDINARY PEOPLE WHO SEE MEDIA STORIES OF NEED & MEDIA STORIES OF NEED &

WANT TO HELPWANT TO HELP

BUT THERE BUT THERE ARE OFTEN ARE OFTEN PROBLEMS PROBLEMS

WITH WITH DONATIONS…DONATIONS…

DONATIONS ARE TOO LARGE DONATIONS ARE TOO LARGE FOR NEEDFOR NEED

Pho

to c

redi

t: M

arie

McG

rath

Leading to problems including: spill-over, storage issues e.g. Balkan Crisis

OFTEN NOT IN LOCAL LANGUAGEOFTEN NOT IN LOCAL LANGUAGE

Donations to Lebanon

in Greek

Photo credit: Ali Maclaine, 2006

- OUT OF DATE / NEAR ‘USE BY’ - OUT OF DATE / NEAR ‘USE BY’ DATEDATE

- SPECIAL ‘MEDICALISED’ - SPECIAL ‘MEDICALISED’ FORMULAS FORMULAS

- WRONG TYPE FOR NEED e.g. - WRONG TYPE FOR NEED e.g. For premature infants, follow-on For premature infants, follow-on formulas.formulas.

Problems with donations of formula continued…

AND, RARELY TARGETED ONLY AND, RARELY TARGETED ONLY TO THOSE WHO NEED IT TO THOSE WHO NEED IT

- EVEN GIVEN TO - EVEN GIVEN TO BREASTFEEDING MOTHERS!BREASTFEEDING MOTHERS!

Sri Lanka post-tsunami.

Distribution of milk powder that the

organisation had been given in ‘big quantities’

REALITYREALITY

BREASTFEEDING IS OFTEN BREASTFEEDING IS OFTEN UNDERMINED IN EMERGENCIES BY UNDERMINED IN EMERGENCIES BY MYTHSMYTHS

THESE ARE THESE ARE NOTNOT TRUE… TRUE…

X MYTH: STRESS ‘DRIES UP’ MYTH: STRESS ‘DRIES UP’ BREASTMILKBREASTMILK

A soldier’s wife feeds her baby at a rest stop in Phnom Penh, Vietnam during the conflict in 1990.

Pho

to c

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t: by

Hel

dur N

etoc

ny/L

inea

ir

X MYTH: MALNOURISHED MYTH: MALNOURISHED MOTHERS CAN’T BREASTFEED MOTHERS CAN’T BREASTFEED

X MYTH: HIV POSITIVE MYTH: HIV POSITIVE MOTHERS SHOULD NOT MOTHERS SHOULD NOT

BREASTFEEDBREASTFEED

X MYTH: TENSION CAN BE MYTH: TENSION CAN BE PASSED ON TO THE BABY PASSED ON TO THE BABY THROUGH BREASTMILKTHROUGH BREASTMILK

Maaike A

rts, UN

ICE

F Pakistan

Jalalabad Park Camp, Muzaffarabad,

Pakistan. The mother of this 4 month old baby was

told she would pass her tension on to the baby

by breastfeeding

X MYTH: ALL MOTHERS HERE MYTH: ALL MOTHERS HERE BREASTFEED & MOTHERS BREASTFEED & MOTHERS

DON’T NEED SUPPORTDON’T NEED SUPPORT

Darfur

Bangladesh

Photo credit: A

li Maclaine

RESULT OF ‘REALITY’ OF RESULT OF ‘REALITY’ OF EMERGENCIES - EMERGENCIES -

Increase in infant and young child morbidity Increase in infant and young child morbidity and mortality and mortality DURING emergency emergency

Reduction in breastfeedingReduction in breastfeeding

Increase in infant and young child morbidity Increase in infant and young child morbidity & mortality & mortality AFTER emergency as optimal emergency as optimal IYCF has been undermined.IYCF has been undermined.

What is needed for infants and What is needed for infants and young children in emergencies?young children in emergencies?

Rita P

lotnikova / ICR

C 2001

Children of Tajikistan -Afghan border camp in Tozalokai

OVERALL:OVERALL: AWARENESS by ALL players in AWARENESS by ALL players in

emergencies of IFE as an issue emergencies of IFE as an issue - GovernmentsGovernments- MilitaryMilitary- DonorsDonors- International NGOsInternational NGOs- Local NGOs Local NGOs - MediaMedia

1 month old child post-

earthquake, Indonesia 2006

RE

UTE

RS

/ Beaw

iharta

PRE-EMERGENCY:PRE-EMERGENCY: Key players to have IFE POLICY & Key players to have IFE POLICY &

ACTION PLAN based on BEST PRACTICE ACTION PLAN based on BEST PRACTICE

Orientation, Capacity Building & Orientation, Capacity Building & Training on IFE & Breastfeeding Training on IFE & Breastfeeding

Care Indonesia B-feeding Counselling course. W.

Timor, 2006

DURING EMERGENCYDURING EMERGENCYHumanitarian Humanitarian

interventions by interventions by ALLALL players, including players, including governments & military governments & military based on ‘best practice’based on ‘best practice’

This should include:This should include:

Care for the breastfed child Active support for exclusive and Active support for exclusive and

continued breastfeeding and continued breastfeeding and supportive counsellingsupportive counselling

An evacuee feeds her baby after fighting

between government forces and rogue Muslim

rebels. Thailand

Appropriate support by all actors in emergencies, including the military, to ensure that breastfeeding is not undermined.

Relactation, Relactation, Wet nurses, Wet nurses, Milk banks Milk banks

are preferred options are preferred options as safer than infant as safer than infant

formulaformulaRelactation using

supplemental-suckling by Grandmother in

Afghanistan - ACF

Care for the non-breastfed infant

Targeted provision of BMS only to Targeted provision of BMS only to those who have been assessed and those who have been assessed and need itneed it

Provision of additional resources, Provision of additional resources, support & monitoringsupport & monitoring

Continuous supplies Continuous supplies of BMS for as long as of BMS for as long as infant concerned infant concerned needs itneeds it

Colombia

Promotion of cup feeding rather Promotion of cup feeding rather than bottles/teatsthan bottles/teats

Felicity Savage

Also MONITORING is IMPORTANT:Also MONITORING is IMPORTANT:

So players can ensure that So players can ensure that their interventions are their interventions are

DOING NO HARMDOING NO HARM

They can change & develop They can change & develop new interventions / new interventions / programmes (if necessary)programmes (if necessary)

AS WELL AS SUPPORTING THEAS WELL AS SUPPORTING THE

BREASTFED CHILDBREASTFED CHILD NON-BREASTFED CHILD NON-BREASTFED CHILD

IN EMERGENCIESIN EMERGENCIES

IFE also covers…IFE also covers…

COMPLEMENTARY FEEDING IN COMPLEMENTARY FEEDING IN EMERGENCIESEMERGENCIES

Zimbabwe, 2005

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Bangladesh – Cyclone Sidr 2007

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7

SUPPORTING HIV POSTIVE SUPPORTING HIV POSTIVE MOTHERS & THEIR INFANTS IN MOTHERS & THEIR INFANTS IN

EMERGENCIESEMERGENCIES

CARE OF THE MALNOURISHED CARE OF THE MALNOURISHED INFANT IN EMERGENCIESINFANT IN EMERGENCIES

Afghanistan

Sta

te D

ept p

hoto

by

Chr

isto

pher

M. W

urst

.

Pakistan – post earthquake 2005

Afghanistan - ACF

SO WHY IS SO WHY IS IFE IFE

IMPORTANT?IMPORTANT?

Because while infants have always Because while infants have always got caught up in emergencies..got caught up in emergencies..

Nagasaki, Japan. World War 2

Ukranian Mother in World War 2

Too many have got Too many have got sick & died due to sick & died due to

poor feeding poor feeding practices in practices in

emergenciesemergencies

IF THE CHILDREN WOULD IF THE CHILDREN WOULD HAVE A VOICE? WHAT HAVE A VOICE? WHAT WOULD THEY TELL USWOULD THEY TELL US

STOPSTOP KILLING US IN THE KILLING US IN THE NAME OF SAVING!!!NAME OF SAVING!!!

THANK YOU!THANK YOU!

Photo credit: Ali Maclaine, 2007