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.

Normalising breastfeeding in the community: peer support and professional training

Normalising breastfeeding in the community: peer support and professional training

 

The inspiring story of breastfeeding support in a London borough

What changed?

I have been reflecting recently on my experiences as a specialist health visitor and infant feeding lead in an outer London borough. The story began twelve years ago, in 2005, when there was a lack of confidence among mothers and staff about the reliability of breastfeeding, which was hidden and rarely seen in public. Over the next eight years, the initiation rate increased from 67% in 2005 to 86% in 2013, and the continuation rate at 6-8 weeks from 50% to 75% (52% breastfeeding exclusively). Breastfeeding became the way most mothers fed their babies. Gradually breastfeeding mothers became visible in cafes, shopping centres, supermarkets, streets, GP surgeries and children’s centres.   The Unicef Baby Friendly Initiative assessors stated in a report that, in this borough, breastfeeding had become ‘the normal way to feed babies’.

How did it happen?

How did this change come about in a relatively short period of time? It began in 2005, as a joint project between the NHS and NCT, which secured local health authority funding to set up a breastfeeding support group in an area of social deprivation with low breastfeeding rates.   This group became very well attended and was facilitated effectively by two NCT breastfeeding counsellors and a health visitor. A similar group was set up in another part of the borough and was run by me, together with other health visitor colleagues. Many of the mothers were very grateful for the support they received in the groups and some of these women expressed the wish to train as volunteer peer supporters, so that they could help other mothers enjoy breastfeeding their babies, as they had. Two training courses were organised and, that year, 20 peer supporters were trained, registered by the voluntary services of the local Primary Care Trust (PCT), and started working in breastfeeding support groups, in the children’s centres and health service clinics. The news of the training spread rapidly and soon there was a waiting list of mothers wishing to train!

Reaching out

The numbers of groups expanded to be easily accessible to mothers across the borough, running every weekday, in children’s centres, cafes, and health premises. The new peer supporters brought fantastic skills with them, one setting up a website, another a mothers’ Facebook page and another designing our leaflets and posters!   One had breastfed twins and set up antenatal sessions for parents expecting multiple births plus a weekly support group for mothers with twins and more. She also visited these mothers at home and lent them cushions, which helped them tandem feed. Soon the exclusive breastfeeding of twins and even triplets became common. A group of Somali mothers was trained and an outreach peer supporter started seeing Somali pregnant women in the hospital.   A teenage ‘buddy’ scheme was also started by some of the younger peer supporters, working with the specialist midwife and running antenatal sessions and postnatal support for young mothers. Two peer support co-ordinators were employed to job-share this important role and to deal with concerns of the peer supporters as well as helping with training and supervision. Over the next ten years, more than 200 voluntary peer supporters were trained in the borough and the training continues until the present day.

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Unicef UK/Mead

Public Health prioritises breastfeeding

In 2006, under the government scheme of “Every Child Matters’, the Director of Public Health made breastfeeding the top priority for all children in the borough with accompanying ‘stretch targets’ and funding.

London services are monitored through the ‘Good Food for London’ report on their Baby Friendly status, with details on how each borough is achieving and sustaining the Baby Friendly standards

Baby Friendly accreditation

In 2012 Unicef UK Baby Friendly Initiative carried out a major review that resulted in new, more holistic, child rights-based standards relating to the care of babies, their mothers and families, with a strong emphasis on building responsive loving relationships. A new award has also been introduced to encourage a focus on sustainability after the accreditation.

In parallel with the rapidly increasing numbers of peer supporters, the journey in the borough to become Unicef Baby Friendly (BFI) accredited started and professional training in the community and local hospital began with the two health trusts starting their journeys jointly. A model of multidisciplinary training of midwives, maternity assistants, neonatal nurses, nursery nurses and health visitors began initially with BFI-facilitated training. This enabled hospital and community staff not only to improve their breastfeeding knowledge and skills, but also each other’s roles, co-operate on work challenges and break down any barriers which may have existed previously. Communication skills and talking about their own life experiences, in order to gain an understanding of their impact, especially with infant feeding, became an important part of the in-service training. Interactive group exercises on different breastfeeding situations became an integral part of the training, emphasising the importance of empathy and seeing the problems through the eyes of the mothers.   A neonatal breastfeeding co-ordinator was appointed and started training all the neonatal staff in the hospital, including the doctors, and by 2014, Unicef had awarded both the community and hospital trusts their Baby Friendly accreditation.

Peer support

Peer supporters were also employed by an adjacent borough to work in the hospital, supporting mothers on the postnatal ward, one even working all night once a week; others taught hand expressing and colostrum harvesting in the antenatal clinic, especially for mothers with diabetes.

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Unicef UK/Mead

Achieving cultural change

Within ten years, breastfeeding became a normal and accepted way to feed babies in the borough. Mothers, fathers, and grandmothers-to-be came in large numbers to the twice monthly breastfeeding workshops, gaining confidence and information, with the expectation of the support that would be available to them to help them achieve their goals. A mother said ‘the session expelled myths and I now know how milk is made and transferred to my baby. I am looking forward to skin-to-skin contact after the birth and will follow my baby’s instincts’. Parents meet peer supporters in the support groups, at toddler groups, in the school grounds, in cafes, at sports events, in churches, temples, synagogues and mosques.   Peer supporters live and work in the community and spread their knowledge through everyone they meet. Even when they move away from peer support, they take their embodied knowledge into the work place and support their colleagues there.   Cultural change can happen through peer support, resulting in breastfeeding becoming embedded in a community. This change is sustainable over time and in future generations, as it spreads through different social groups. Voluntary peer support and informed, professional support is capable of changing attitudes and behaviour within a community to make breastfeeding ‘normal’ in a very cost-effective way. Commissioners need to be aware of how health outcomes can be improved through breastfeeding, for mothers and children, in the immediate and long-term, and it is essential to protect and increase future funding for midwives, health visitors and peer supporters, in order that vital programmes like this can continue.

The World Breastfeeding Trends Initiative UK report in 2016 affirmed the borough’s actions as it recommends in Indicator 6 (Community-based support) that ‘commissioners ensure that there is a range of postnatal services that include both health professional and voluntary-sector breastfeeding support to meet local needs and provide clear access to specialist support’ and that they ‘maintain the full range of health visiting services, and maintain health visiting as a universal service’. Indeed, the borough’s transformation in breastfeeding support is used as a case study in Part 2 of the report.

One mother with an eight-month old baby told me:

‘I so much wanted to breastfeed, but found it incredibly hard at the beginning. I was convinced that it wouldn’t work and it was such a lonely feeling, like I was failing where other mothers were succeeding. Getting support made all the difference- having someone to listen to me and give me confidence to carry on. Suddenly, I didn’t feel alone any more and it changed everything. I know that I would not be breastfeeding now if I hadn’t got help in those crucial first weeks.’

What one London borough has achieved shows what is possible. Unicef UK Baby Friendly Initiative’s Call to Action spells out four key actions to create a supportive, enabling environment for women who want to breastfeed, ranging from national strategy and legal protection from harmful commercial practices to the local implementation of evidence-based practices, as described

 

Photo credits: Unicef UK/Mead

A Spiro photo

 

Dr Alison Spiro

Specialist Health Visitor

Member of the WBTi Steering Group

UN human rights bodies call for global action on breastfeeding

“Breastfeeding is a matter of human rights for both mothers and children,” say United Nations experts in an unprecedented joint statement today. Gaps identified by the UN mirror many of the gaps identified in the recently published World Breastfeeding Trends Initiative (WBTi) report on the state of breastfeeding in the UK, specifically:

  • Gaps in knowledge and skills among healthcare providers (WBTi Indicator 5)
  • Lack of access to accurate information or support (WBTi Indicators 6 and 7)
  • Family, community, and cultural practices and traditions that are not necessarily pro-breastfeeding (WBTi Indicator 7)
  • Limited or non-existent maternity protection in the workplace (WBTi Indicator 4)
  • Misleading marketing of breastmilk substitutes, and the lack of corporate accountability for the adverse consequences of such marketing practices (WBTi Indicator 3)
  • In cases where a woman cannot breastfeed or is not willing to do so, even after having been duly informed about the benefits of breastfeeding, access to good quality breast milk substitutes should be regulated and affordable, without condemnation or judgment (WBTi Indicators 3, 5, 7)
  • Investments to support breastfeeding are often marginal and far from adequate (WBTi Indicator 1)

Previous UN recommendations specific to the UK also included the recommendation to systematically collect data on infant and children’s food and diet (WBTi Indicator 10).

Human rights, and the UK’s obligations under the Convention of the Rights of the Child, underpin the WBTi UK Report, which states: “The mother and the baby are a dyad, and they have rights as a dyad; [neither trumps the other]. Each has explicit rights; both mother and baby require protection and support to make successful breastfeeding a reality.”

UN Special Rapporteurs on the Right to Food, Right to Health, the Working Group on Discrimination against Women in law and in practice, and the Committee on the Rights of the Child issued the statement through the Office of the United Nations High Commissioner for Human Rights today.