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Breastfeeding in emergencies: a question of survival

Dr Francesco Branca, WHO Director of Nutrition for Health and Development, and
Mr Werner Schultink, Chief of Nutrition, UNICEF

Commentary
20 May 2016

Kitham is a Syrian refugee who shares a shelter with her husband, children, mother and 2 sisters in an informal tented settlement in Jib Janine, in Lebanon’s Bekaa Valley.

When she gave birth last May to her sixth child, her baby had some health complications and the doctors didn’t let her feed him for several days. “I lost my milk,” Khitam said, “so I fed him formula but he was getting thinner.” Weeks later, as her baby’s health deteriorated, Kitham carried him many kilometres on foot to seek help at the nearest health centre. “When we first saw baby Manhal, we thought he may not make it,” says Fatima Al Hayek, lactation consultant with International Orthodox Christian Charities.

Dr Francesco Branca, WHO Director of Nutrition for Health and Development
Dr Francesco Branca, WHO Director of Nutrition for Health and Development
WHO

Baby Manhal was immediately hospitalized and remained in hospital for 3 weeks, during which time his mother was helped to restart her milk supply, and Manhal gradually gained weight and strength. “I feel like my son was born again,” says Khitam, “and I am still breastfeeding him”.

Manhal was one of the luckier ones, but an estimated 820 000 children die every year because they were not breastfed in line with WHO recommendations – that is, fed nothing but breast milk for 6 months, after which they should continue breastfeeding as well as eating other foods until 2 years of age. A child who is not breastfed for his or her first 6 months of life is more than 14 times more likely to die compared to a baby who gets breast milk only. Breastfeeding has major benefits for mothers’ health too, by reducing rates of breast cancer, ovarian cancer, and type 2 diabetes.

Breastfeeding becomes even more critical for survival in humanitarian emergencies. Whether caused by conflict or natural disasters, emergencies jeopardize the health of populations, and young children are among the most vulnerable. They face risks from diarrhoeal diseases, pneumonia and undernutrition. Overcrowding, food insecurity, unsafe water, poor sanitation, and overburdened health systems all contribute to a more dangerous situation for infants and children. Failure to fully protect breastfeeding in these circumstances dramatically worsens the situation.

Challenges in breastfeeding

Humanitarian emergencies pose special challenges for protecting, promoting and supporting breastfeeding. First, uncontrolled distribution of breast-milk substitutes (including infant formula) is often a problem. Well-meaning donors may send supplies of breast-milk substitutes to feed starving children, not realizing that infants and children who are not breastfed are vulnerable to infection and to developing diarrhoea. They can then easily become malnourished and dehydrated and so are at real risk of death. Even in countries with appropriate implementation of the International Code that governs the marketing of breast-milk substitutes, enforcement may break down in emergencies. Feeding with a breast-milk substitute always carries risks, and these are heightened in emergencies since there may be no clean water with which to make up infant formula or to clean bottles and teats. Breast-milk substitutes should only be used as a last resort.

Mr Werner Schultink, Chief of Nutrition, UNICEF
Mr Werner Schultink, Chief of Nutrition, UNICEF
UNICEF

Second, the usual networks of family and friends that help mothers who have difficulties breastfeeding are often not accessible in emergencies. Health workers who are trained in breastfeeding counselling and lactation management are often redeployed to direct emergency response activities, leaving mothers with nobody to turn to for help. Stress and disruption of daily routines pose new challenges for breastfeeding women, increasing the need for assistance.

Third, emergencies often lead to displacement. It may be difficult for mothers to find comfortable, private places to breastfeed. How critical this issue is depends greatly on the cultural context where the emergency occurs.

Humanitarian organizations must protect, promote, and support breastfeeding in emergencies. Policies need to be in place that prohibit the donation of breast-milk substitutes and control their procurement and distribution in emergencies, based on appropriate needs assessments. Skilled breastfeeding assistance needs to be part of health services and private places need to be made accessible for mothers to feel safe breastfeeding. Special attention needs to be paid to the care and nutrition of women who are pregnant or breastfeeding. In emergencies where not enough nutrient-rich food is available, these women should be given vitamin and mineral supplements. Finally, multiple communication channels are needed to reach mothers and their family members with messages on the importance of continued breastfeeding and the dangers of using breast-milk substitutes.

There are examples of emergencies where this has worked well. For instance, the infant and young child feeding programme in Syrian refugee camps in Jordan. Save the Children Jordan established mother-baby friendly spaces in caravans and promoted them as safe havens for breastfeeding, where privacy and support were provided for all pregnant women and mothers with children under the age of 5. Daily education sessions were held in the caravans on the importance of breastfeeding, which foods to give to children aged 6 months to 2 years, and how to feed a young child who is ill. More than 15 000 mothers in Za’atari camp benefited from caravan and tent counselling sessions between December 2012 and May 2014. Similar examples exist in Croatia, Serbia, and the former Yugoslav Republic of Macedonia where UNICEF and its partners established specialized mother-and-baby spaces.

Following the devastating earthquakes of 25 April and 12 May 2015 in Nepal, the government provided a comprehensive response to ensure the protection, promotion and support of breastfeeding. Immediately after the first earthquake, a statement was issued emphasizing the importance of breastfeeding and banning the general distribution of breast-milk substitutes. Within 6 months, more than 20 mother-baby sites were established in community camps to provide suitable space for breastfeeding mothers and almost 160 000 mothers of children under the age of 2 received breastfeeding counselling. Radio Nepal and community and private radio stations reached 380 000 families with information on the benefits of breastfeeding, the risks of breast-milk substitutes and other key nutrition messages.

A key lifesaving intervention

All too often, breastfeeding is overlooked as a key lifesaving intervention, especially in emergencies. At the first-ever World Humanitarian Summit in Istanbul, we must make sure that breastfeeding is top of mind among all those involved in funding, planning and implementing an emergency response.

We must increase awareness among the humanitarian community that, however well-intentioned, unsolicited donations of infant formula, bottles and artificial teats in emergency settings put babies’ lives at risk and that these donations should be refused. We must quash the common misconception that mothers cannot breastfeed adequately in stressful settings or if they have poor nutrition.

Governments must ensure that financial and human resources dedicated to supporting breastfeeding are part of their emergency preparedness plans.

One of the key issues up for discussion at the Summit is how to reduce reliance on international assistance and build community resilience. Promoting and supporting breastfeeding is a perfect example of something that countries can do, not only to save lives in emergencies, but to give children who are having such a difficult start in life a much better chance for a brighter future.