Supporting breastfeeding during humanitarian emergencies

Infants (birth to one year of age) are among the most vulnerable population groups during humanitarian emergencies.1 In these situations, preventable diseases such as malnutrition, diarrheal diseases, and acute respiratory infections are some of the most common contributors to infant death and disease.2 As such, survival strategies targeting infant and child nutrition have been emphasized as emergency response priorities, with much of the discourse on this topic focusing on the merits of breastfeeding (typically in comparison to infant formula). The World Health Organization recommends that all infants are exclusively breastfed (ie given only breast milk unless medically necessary) from birth until 6 months of age, followed by the introduction of complementary foods and continued breastfeeding for up to 2 years.3,4 Decades of research supports this recommendation, providing evidence for the far-reaching benefits of breastfeeding for both mothers and infants.5 Some breastfeeding-related benefits are especially vital during a humanitarian emergency. Breast milk is regarded as the optimal source of nourishment for infants, thus reducing the risk of malnutrition.6,7 Not only is breast milk nutritionally superior to formula in that it provides the appropriate balance of carbohydrates, fatty acids, protein, vitamins, and minerals in highly digestible forms, but breast milk also adapts its composition to meet the nutritional needs of growing infants.7 In addition, breastfeeding protects infants against infection-related morbidity8 and mortality9 due to the antimicrobial, anti-inflammatory, and antioxidant biomolecules found in breast milk.10 Mothers also receive benefits from breastfeeding including a reduced physiological response to stress.11 This may assist in dealing with the taxing circumstances of an emergency, as well as reduce stress-induced immunosuppression and its associated health sequelae.12,13 Further, breastfeeding provides a sustainable infant feeding option in the face of poor sanitation, lack of clean water access, and poverty.14 In accounting for one week’s worth of emergency supplies, an Australian study showed that it costs A$50 to provide necessary supplies for an exclusively breastfed infant, A$250 for an infant fed with powdered formula, and A$550 for an infant fed with ready-to-use liquid formula.15 The authors also noted that while 2 items (diapers and wipes) are needed to support breastfed infants, 12 to 16 items (eg formula, detergent, feeding bottles) are required for formula-fed infants. The amount of time needed to safely and properly prepare formula can also be burdensome. Authors of a study conducted in a rural South African setting where electricity, gas, and tap water were inaccessible found that it took 21 to 25 minutes to prepare one formula feed, for a total of 2.5 hours of daily feeding preparation without accounting for time spent feeding the infant.16 Unfortunately, the health and sustainability advantages of breastfeeding seem to be overlooked during emergencies, with several emergency response reports detailing the uncontrolled distribution of donated formula.17 The detrimental consequences of such widespread formula distribution have been outlined in several epidemiological studies.18–20 In one study recounting the aftermath of an earthquake in Indonesia, the authors found strong and significant positive associations between both mothers receiving donated formula and changes in infant feeding practices (from breastfeeding to formula feeding), and between mothers receiving formula and the onset of infant diarrhea.18 In another study of 4 tsunami-affected villages in India, the authors found that the occurrence of diarrhea was 3 times higher among infants who consumed donated formula compared to those who did not.19 Furthermore, an evaluation of children affected by a flood in Africa showed that a significant risk factor for diarrhea was not breastfeeding (ie receiving breast milk substitutes such as formula or cow’s milk), and that most of the deaths in children under 2 years of age were among those whose HIV-infected mothers received free formula.20


Supporting breastfeeding during humanitarian emergencies
Natalie V Scime Faculty Reviewer: Shauna M Burke, MA, PhD (School of Health Studies) Infants (birth to one year of age) are among the most vulnerable population groups during humanitarian emergencies. 1 In these situations, preventable diseases such as malnutrition, diarrheal diseases, and acute respiratory infections are some of the most common contributors to infant death and disease. 2 As such, survival strategies targeting infant and child nutrition have been emphasized as emergency response priorities, with much of the discourse on this topic focusing on the merits of breastfeeding (typically in comparison to infant formula).
The World Health Organization recommends that all infants are exclusively breastfed (ie given only breast milk unless medically necessary) from birth until 6 months of age, followed by the introduction of complementary foods and continued breastfeeding for up to 2 years. 3,4Decades of research supports this recommendation, providing evidence for the far-reaching benefits of breastfeeding for both mothers and infants. 5Some breastfeeding-related benefits are especially vital during a humanitarian emergency.Breast milk is regarded as the optimal source of nourishment for infants, thus reducing the risk of malnutrition. 6,7Not only is breast milk nutritionally superior to formula in that it provides the appropriate balance of carbohydrates, fatty acids, protein, vitamins, and minerals in highly digestible forms, but breast milk also adapts its composition to meet the nutritional needs of growing infants. 7In addition, breastfeeding protects infants against infection-related morbidity 8 and mortality 9 due to the antimicrobial, anti-inflammatory, and antioxidant biomolecules found in breast milk. 10Mothers also receive benefits from breastfeeding including a reduced physiological response to stress. 11This may assist in dealing with the taxing circumstances of an emergency, as well as reduce stress-induced immunosuppression and its associated health sequelae. 12,13urther, breastfeeding provides a sustainable infant feeding option in the face of poor sanitation, lack of clean water access, and poverty. 14In accounting for one week's worth of emergency supplies, an Australian study showed that it costs A$50 to provide necessary supplies for an exclusively breastfed infant, A$250 for an infant fed with powdered formula, and A$550 for an infant fed with ready-to-use liquid formula. 15The authors also noted that while 2 items (diapers and wipes) are needed to support breastfed infants, 12 to 16 items (eg formula, detergent, feeding bottles) are required for formula-fed infants.The amount of time needed to safely and properly prepare formula can also be burdensome.Authors of a study conducted in a rural South African setting where electricity, gas, and tap water were inaccessible found that it took 21 to 25 minutes to prepare one formula feed, for a total of 2.5 hours of daily feeding preparation without accounting for time spent feeding the infant. 16fortunately, the health and sustainability advantages of breastfeeding seem to be overlooked during emergencies, with several emergency response reports detailing the uncontrolled distribution of donated formula. 179][20] In one study recounting the aftermath of an earthquake in Indonesia, the authors found strong and significant positive associations between both mothers receiving donated formula and changes in infant feeding practices (from breastfeeding to formula feeding), and between mothers receiving formula and the onset of infant diarrhea. 18In another study of 4 tsunami-affected villages in India, the authors found that the occurrence of diarrhea was 3 times higher among infants who consumed donated formula compared to those who did not. 19Furthermore, an evaluation of children affected by a flood in Africa showed that a significant risk factor for diarrhea was not breastfeeding (ie receiving breast milk substitutes such as formula or cow's milk), and that most of the deaths in children under 2 years of age were among those whose HIV-infected mothers received free formula. 20

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Unfortunately, the health and sustainability advantages of breastfeeding seem to be overlooked during emergencies, with several emergency response reports detailing the uncontrolled distribution of donated formula.
In addition to health consequences, there are important ethical considerations regarding the supply of formula during humanitarian emergencies.2][23][24] This code was adopted in 1981 by the World Health Assembly, in part to combat the exploitive and misleading marketing tactics utilized by the formula industry; such tactics include no label warning about the hazards of improper formula preparation, ambiguous claims about nutritional adequacy or similarity to breast milk, and photos idealizing the use of formula. 25In addition, the uncontrolled distribution of formula without offering breastfeeding support, assessing a mother's lactation circumstances, or providing accurate knowledge about the benefits and safety of breastfeeding undermines a woman's funda-commentary mental right to breastfeed. 26,27Given that most emergencies take place in impoverished and developing countries with populations of low health literacy, 28,29 the ethics of formula distribution cannot be ignored.
1][32] In addition to health professionals, evidence points to peer counsellors as an effective strategy for supporting breastfeeding in developing and developed countries. 33Support may include practical (eg assistance with proper technique), informational (eg education about lactation physiology) and emotional (eg encouragement and patience) components.Connections with existing breastfeeding support organizations such as La Leche League, an international organization that promotes mother-to-mother breastfeeding support and information (http://www.llli.org/),can also serve as a valuable resource for emergency responders and mothers.Lastly, formula should remain available to mother-infant dyads that meet needs-based criteria, and should be distributed in plain packaging free of company advertising with the necessary sterile supplies (including clean water). 32s a growing number of researchers and international agencies focus on the impact of infant feeding practices during humanitarian emergencies, there appears to be a need for a more collaborative and informed response approach that supports and prioritizes breastfeeding.Although formula may be viewed as a convenient (and sometimes free by donation) solution to calm a hungry, crying infant and anxious mother, the negative ramifications noted above likely exceed the immediate gains.Taken together, the evidence demonstrates that breastfeeding is medically, economically, and ethically superior to infant formula feeding during humanitarian emergencies, as it represents the best option for protecting infant health and survival.