Protecting babies in emergencies

Protecting babies in emergencies

Guidance is needed on infant and young child feeding for families in the UK affected by disasters and emergencies.

Heather Trickey and Helen Gray.

Disaster and emergency situations – floods, fires, terrorist attacks and widespread power failures – can affect any country, including the UK. In any disaster or emergency, babies are vulnerable and continued access to adequate and safe nutrition is essential. Families need support to ensure that children continue to be cared for and fed in line with their needs.

 

There is no UK government plan

The World Health Assembly (Resolution 63/2010) has recommended that all countries implement existing global guidelines on infant feeding during emergencies, including specific operational guidance to help relief agencies protect infant nutrition and minimise risk of infection. Although there is national guidance on care of animals during emergencies, a recent World Breastfeeding Trends Initiative (WBTi) report found that there are no UK-wide or national strategies addressing infant and young child feeding during a disaster. Scotland is the only part of the UK that has a named lead on infant feeding in emergencies. Emergency planning and response is devolved to local authorities; because there is no guidance on the protection of families with infants there is no way to ensure that local strategies consider infant nutrition as part of emergency response.

 

Risks for formula fed babies

Babies who are fully or partially formula fed are at risk if their caregivers lose access to clean water, are unable to sterilise feeding equipment or suffer disruption or contamination of their formula milk supplies. A suitable environment for preparation and storage of feeds, sterilising equipment, boiling water and safe storage such as a refrigerator, are all needed to prevent bacterial contamination

Gribble IYCFE liquid photo 13006_2011_Article_127_Fig2_HTML
Emergency supplies required to care for and feed a formula fed baby for one week in a developed country, using read-to-feed milk. From Gribble & Berry 2011 “Emergency Preparedness for those who care for infants in developed country contexts.” International Breastfeeding Journal /2011 6:16

 

Risks for breastfed babies

Breastfeeding protects against infection and can be comforting to infants and mothers during difficult times. Mothers’ supply of breastmilk is resilient, however, chaos, displacement and emotional strain, coupled with commonly held misconceptions about how breastfeeding works, can undermine a mother’s confidence and result in less frequent feeding. Breastfeeding mothers need access to the option of feeding in a private space and reassurance that continuing to breastfeed is the best option for their baby.

Skilled support can help mothers resolve breastfeeding problems and maintain the protective effect of full or partial breastfeeding. If breastfeeding helpers are not pre-authorised as part of planned disaster response the immediate help that families need can be delayed.

 

Risks associated with donated formula milk

The world is a better place than we sometimes think. When a disaster strikes, ordinary people often respond with an outpouring of generosity. We give clothes, equipment and food spontaneously and in response to public calls.

Donations Balham Mosque
Donations of clothing, bedding, toys, food and water, London, June 2017. Photo Credit: @balhammosque

In the absence of guidance, agencies responsible for co-ordinating emergency response and volunteers working on the front line are often not aware that donations of formula milk can put babies at risk. Risks from donated formula milk include inadvertently distributing products that are unsuitable for babies under six months or for babies with special nutritional needs, as well as distributing milk that is contaminated or out-of-date. There is also a risk that donations will be inappropriately provided to parents of breastfed babies, which can undermine the protective effect of breastfeeding and cause parents to become dependent on a continued supply of formula milk.

International guidelines for emergency feeding caution against accepting donations of formula milk. It is recommended that emergency planners and first responders, with expert advice, take responsibility for purchase and distribution of appropriate formula milks in line with the needs of each family.

 

What’s been done so far?

International guidelines for protecting infants in disasters and emergencies are available.  There is a need to adapt these to a UK context, where, beyond the early weeks, many babies are fully or partially formula fed and which includes a rich mix of cultures and nationalities with different feeding practices.

UK-based emergencies have tended to be highly localised and short-term. However, UK guidance will need to ensure preparedness for longer-term support needs, for UK charities and for displaced families and unaccompanied children who have sought refuge from outside of the UK.

Several UK agencies have developed guidance with limited scope. The Food Safety Agency has issued guidance to support safe preparation of formula milk in response to flooding and contamination of local water supplies. A toolkit has also been developed to support food banks, including preventing and managing unsolicited formula milk donations.

 

How to help ensure babies’ nutritional needs are protected

In the absence of national guidance, relief co-ordinators and agencies and members of the public will be concerned to do the right thing in response to a disaster. There is an urgent need to improve planning and raise awareness about the best ways to support infant and child feeding. These key points from have been adapted from UK and international guidance:
1) Members of the public

  • DO donate money to key agencies. This is the best way to support parents who need to buy formula milk. Money will allow parents, caregivers or coordinating aid organisations to buy the most appropriate milk to meet the individual needs of each baby. Donated formula milk can inadvertently put babies at risk.
  • DO offer your time to help agencies co-ordinating relief. Support and encourage mothers who are breastfeeding. Breastfeeding is protective against infection, and provides the baby with the safest possible nutrition.

 

2) Relief workers and aid agencies

  • DO have a local plan to support infant and young child feeding in emergencies in place for local authorities, first responders and aid agencies. All families should be screened to ensure they receive appropriate support or supplies.
  • DO ensure that mothers who are fully or partially breastfeeding have the support they need to continue. Mothers can seek support from their midwife or health visitor. Local emergency planning should have identified appropriate infant feeding support from local health and voluntary services. There are telephone helplines which support caregivers with all aspects of infant feeding:
    • NCT helpline (0300 330 0700)
    • The National Breastfeeding Helpline (0300 100 0212).
  • DO encourage donations of money to recognised agencies so that parents, caregivers and agencies can buy any formula or supplies needed, rather than donations of formula products.
  • Appropriate support or supplies including cash cards specifically for the purchase of infant formula and complementary foods for young children could be considered.
  • DO ensure that formula milk is purchased and distributed only for babies who need formula milk, following basic screening of families (simple triage tools have been recently been developed for use in emergency situations in Greece and Canada).
  • DO NOT distribute formula milk in an untargeted way.
  • DO ensure that parents are aware of guidance on sterilisation of bottles and teats and how to prepare any powdered formula safely and have access to facilities to carry this out, to reduce the risk of contamination. Liquid ready-to-feed formula may be needed if suitable preparation facilities are not available.

 

What is needed now?

There is an urgent need for UK governments to ensure infant and child nutrition is protected as part of the planned new strategy for resilience in major disasters. Local authorities and relief agencies require national guidance to develop local strategies so that we can all be better prepared.

                                                                                         

 

Heather Trickey is a Research Associate based in DECIPHer, Cardiff University. Her research focuses on public health policy and parents, particularly Infant Feeding Policy.

Helen Gray is Joint Coordinator of the World Breastfeeding Trends (WBTi) UK Working Group.

Leadership and collaboration – WBTi actions, Indicator 1

The World Breastfeeding Trends Initiative (WBTi) is a tool to help countries assess their implementation of key policies and programmes. These are drawn from the WHO Global Strategy for Infant and Young Child Feeding, which was adopted by the World Health Assembly, including the UK. The first UK World Breastfeeding Trends Initiative report was published in November 2016 and launched at the Houses of Parliament. Its ten policy and practice indicators address the extent to which there is an infrastructure in a country to support breastfeeding. The process brought together organisations and agencies working in maternal and infant health to monitor progress, identify gaps and generate joint recommendations for action to address those gaps.

What is Indicator 1 about?

Indicator 1 asks if there is a national infant feeding policy, supported by a government programme, with a coordinating mechanism such as a national infant feeding committee and coordinator. The UK assessment found:

key-gaps-and-recommendations

Women have autonomy over their own bodies so decide for themselves how to feed their babies but it can be very hard to carry a specific intention when the environment is unsupportive. It’s similar to the situation faced by someone who wants to avoid becoming overweight in an environment where tempting food is heavily advertised and easily available. A UK mother who wishes to breastfeed is likely to face barriers to achieving her goal throughout her breastfeeding journey.

National leadership

How can the situation be changed? An efficient way that can help to achieve consistency across the country is to have national leadership – a national coordinator with sufficient authority, a representative high level committee and a plan or strategy for change, as described in Indicator 1. Breastfeeding Policy Matters in 2015 highlighted the importance of this and the processes needed [1].

Scotland and Northern Ireland have national leadership in place but England does not. Yet the rhetoric is there. The 2016 government guidance from Public Health England, Health matters: giving every child the best start in life explains why the early years are so crucial [2]. It lists some of the health benefits and states that ‘creating the right environment to promote and support breastfeeding is crucial’. It highlights the importance of good maternal mental health so that the mother can be sensitive to the baby’s emotions and needs, helping the baby to develop secure attachment. Breastfeeding enhances a mother’s mental health while mothers who want to breastfeed but stop before they planned to are at greater risk of postnatal depression [3]. However, instead of increasing the support available to mothers, many support services were cut in 2016 because of reduced funds available. Such preventative services were not seen as a priority.

Freedom to choose how to feed one’s baby is valued in the UK and some people are concerned that mothers might feel pressured to breastfeed if it is encouraged. Ironically, advertising of follow on formula milks that might persuade mothers to switch from breastfeeding seems to cause less concern. Yet thousands of mothers make the often upsetting decision to stop breastfeeding before they wanted to. Where is the focus on these mothers and their suffering? Supporting breastfeeding is not about persuasion but about providing the infrastructure to enable them to continue; since some three quarters of mothers already opt to start breastfeeding, persuasion is irrelevant for them. If more mothers continued as long as they wished to, the proportion starting may well increase as expectant mothers will be less likely to hear negative messages.

Unicef UK’s widely endorsed Call to Action in 2016 included developing a national infant feeding strategy board in each nation [4]. What would a strategic plan encompass? The other WBTi indicators offer key points to include, such as Baby Friendly status being a universal goal, legislation in line with World Health Assembly recommendations, adequate protection for breastfeeding in the workplace, local support that is of high quality and integrated, and health professionals who have adequate training is supporting breastfeeding. If representatives of the four UK nations meet regularly they can also share ideas. Back in 2003 the World Health Organisation produced the Global Strategy for Infant and Young Child Feeding, which includes recommendations for national leadership, and this was followed in 2008 by the European Blueprint document [5,6]. Thus there are plenty of ideas available for developing a plan. The challenge is then implementation.

Alongside national leadership by governments, as described above, the breastfeeding support charities, relevant royal colleges and other similar professional bodies, campaigning organisations and interested individuals can both amplify calls for change and help to bring it about by collaborating. The infant feeding coalition meeting in June 2016, reinvigorating the idea of the former Breastfeeding Manifesto Coalition, demonstrated the keenness there is to work together [7]. Unicef UK’s Baby Friendly consultation on developing an inclusive Foundation provides an urgent opportunity to influence this – urgent because the deadline is 31 January 2017 [8].

Please read the consultation document and respond to the survey, thus helping to influence the future.

Also, check out our campaigning guidance for you to contact your MP and discuss issues highlighted in our report [9].

 

References

  1. McFadden A, Kenney-Muir N, Whitford H, Renfrew M (2015) Breastfeeding: Policy Matters London: Save the Children
    http://www.savethechildren.org.uk/resources/online-library/breastfeeding-policy-matters
  2. https://www.gov.uk/government/publications/health-matters-giving-every-child-the-best-start-in-life
  3. Brown A, Rance, Bennett P (2016) ‘Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties’ J Adv Nurs. 2016 Feb; 72(2): 273–282 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738467/
  4. Unicef UK (2016) Call to action for breastfeeding in the UK.
    https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/advocacy/call-to-action/
  5. WHO (2003) Global Strategy for Infant and Young Child Feeding.
    http://www.who.int/nutrition/topics/global_strategy/en/
  6. European Commission, Directorate Public Health and Risk Assessment (2008) Protection, Promotion and Support of Breastfeeding in Europe: A Blueprint for Action.
    http://www.aeped.es/sites/default/files/6-newblueprintprinter.pdf
  7. Breastfeeding Manifesto The Coalition
    http://www.breastfeedingmanifesto.org.uk/the_coalition.php
  8. Unicef UK Baby Friendly Initiative (2016) Creating a Baby Friendly Foundation: A Consultation Document
    https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/advocacy/foundation-consultation/
  9. Baby Milk Action (2017) Ask your MP to help enable mothers to breastfeed as long as they wish
    http://www.babymilkaction.org/wbtiuk-mps0117

More on Indicator 1 – National Policy, Programme and Coordination

Two weeks ago representatives of the key organisations involved in breastfeeding sat round a table to begin the first UK assessment using the World Breastfeeding Trends initiative tool.

In the first presentation, this graphic popped up, and a collective “ooh” and then an “aah” went round the room. You may be forgiven for wondering why it generated such a response – it doesn’t look particularly inspiring!

 

gear model
Credit: Pérez-Escamilla et al, Advances in Nutrition, Nov 2012

It’s because this picture demonstrates what happens when there is a strong national strategy on breastfeeding – and also what happens when there isn’t.

In the late 1990s, Brazil made a concerted effort to improve infant health through a drive to increase breastfeeding rates in the country. They put in place legislation to protect mothers, training for health professionals, breastfeeding promotion – along with the money to pay for it all. And they had a national coordinated breastfeeding strategy to make it happen.

At the same time, Mexico had no such national strategy. Half-hearted efforts were made in some areas, such as training for health professionals and public promotion of breastfeeding.

As the graphs show, Brazil was able to significantly increase breastfeeding rates over that period while in Mexico they stagnated.

Without a strong, national, coordinated breastfeeding strategy to drive things forward, everything else is just wheels turning in the wind.

That’s the metaphor – what does this all mean in practice for the UK?

Let’s imagine a mother, who has her baby in a Baby Friendly hospital [1] and breastfeeding gets off to a good start. But then she arrives home and starts to experience some problems. Her health visitor suggests she gives the baby some formula [2]. She’s seen some adverts on television and buys a particular brand of formula because it’s “closer to breastmilk” [3]. She lives in a rural area, and the nearest breastfeeding support group is 10 miles away and she doesn’t drive [4]. Her husband has seen the adverts too so he knows that “good dads do the night feeds” [5]. After a couple of weeks the baby is getting more and more formula and is breastfeeding less and less. Her husband suggests she’s given breastfeeding a good go but maybe she should stop now [7]. She had wanted to breastfeed for longer but she gives up [8].

  1. Indicator 2 of the WBTi asks – are babies born in Baby Friendly hospitals?
  2. Indicator 5 asks – do health professionals have adequate breastfeeding training?
  3. Indicator 3 asks – is the International Code of Marketing of Breastmilk Substitutes fully implemented?
  4. Indicator 6 asks– do all mothers have access to breastfeeding support in the community?
  5. (see Indicator 3)
  6. Indicator 7 asks – do parents have access to good information about breastfeeding and the risks of using formula?
  7. Indicator 12 asks – what percentage of babies are exclusively breastfed for the first six months?

Without this central cog (Indicator 1) driving all the other cogs (Indicators 2-10) things cannot move forward. This point is also made clear in a new report from Save the Children, which looked at breastfeeding policies and practices in six countries, including the UK.

The WHO Global Strategy on Infant and Young Child Health (which the UK is signed up to) states that each country should have:

  • a national breastfeeding policy
  • a plan of action based on that policy
  • that plan must be adequately funded
  • there needs to be a National Breastfeeding Committee
  • that committee must meet on a regular basis to review progress
  • that committee needs to link effectively with public health bodies
  • that committee must have a coordinator who communicates national policy at regional and local levels

Indicator 1 of the WBTi assessment asks whether a country has each of the above and gives a total score out of 10. How well do you think the UK as whole will score? How would the countries of the UK score individually? What do we need to do to improve that score? How can policies be turned into actions at a local level?

Post your comments below or on our Facebook page.

In the next blog post we will be talking about Indicator 2 – Baby Friendly care and Baby-Friendly Hospital Initiative and will be asking for your thoughts about how things can be improved.