Breastfeeding in Emergencies

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The purpose of this document is to provide guidance to World Vision field staff on how to support infant and young-child feeding (IYCF) in emergencies through the implementation of baby-friendly tents. This document provides a description of baby-friendly tents and provides an overview of their general set-up and operation. This is not a technical guide on the management of IYCF issues in emergencies. A World Vision nutrition/health technical adviser should be consulted to support the implementation of baby-friendly tents. 

Supporting Breastfeeding in Emergencies

BACKGROUND

The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) recommend that infants should initiate exclusive breastfeeding within one hour of birth and continue exclusively breastfeeding for the first six months of life. After this time, infants should continue breastfeeding to two years of age or beyond while also receiving age-appropriate, nutritious and hygienic complementary foods.

WHY ARE BABY-FRIENDLY TENTS NEEDED?

Emergency situations can seriously threaten breastfeeding practices and consequently child nutrition, health and survival. Misconceptions of mothers, community members and those involved in the relief effort about the effects of trauma, stress and maternal malnutrition on breast milk may reduce a mother’s confidence in her ability to breastfeed. Though a woman’s ability to produce breast milk is not affected by a stressful situation, her body’s capacity to ‘let down’ milk can be impaired by stress. The inability of the mother to let down can interfere with effective suckling and further reduce her confidence. A lack of privacy in shelters or camp settings may restrict a mother's ability to comfortably breastfeed and heighten her stress level. As well, post-traumatic stress, illness, sexual violence and severe depression – all potentially elevated during emergency settings – may cause mothers, to reject their infants or the act of breastfeeding.

Time constraints may also be heightened during emergency settings and undermine breastfeeding. Women who must travel long distances, queue in long lines for food, water and fuel rations, and carry rations back to communities may be unable to travel with their infants. This interferes with on-demand and frequent feeding necessary to maintain breast milk supply. These activities also restrict the time the mothers can dedicate to appropriate breastfeeding and care of their children. Lastly, the unregulated distribution of breast milk substitutes (BMS), which includes powdered milk provided in food rations, may also undermine women’s efforts to breastfeed. (Note: BMS are any food being marketed or otherwise represented as a partial or total replacement for breast milk, whether or not it is suitable for that purpose. This includes infant formula, other milk products, therapeutic milk and bottle-fed complementary foods marketed for children up to two years of age, and complementary foods, juices and teas marketed for infants less than six months.)
   
Mothers have the right to specialist support to reinforce and restore their confidence and capacity to breastfeed their children. Given the unique challenges and heightened risks in emergency situations, specific and extra efforts must be taken to ensure that breastfeeding is protected and promoted. Protection and support of non-breastfed infants and young children must also be provided. Baby-friendly tents are one strategy for addressing many of these challenges. 

WHAT ARE BABY-FRIENDLY TENTS?

Baby-friendly tents, also called baby-friendly corners, are safe, low-stress spaces where mothers can breastfeed, rest, eat and receive skilled counselling and targeted advice about breastfeeding and nutrition. It should be noted the term ‘tents’ is used for convenience, as they may be stand-alone units, spaces within other existing structures or simply specified areas in the camp setting where women can come and breastfeed safely and comfortably. In cases where it is culturally necessary, the spaces may also provide private areas for individual breastfeeding. Mothers may attend the tents during the day and return to their homes or shelters at night.

The purpose of baby-friendly tents is not restricted solely to breastfeeding. The spaces may also jointly serve to provide information and training on appropriate complementary feeding and infant and newborn care, or to provide therapeutic and/or supplementary feeding of malnourished children. Baby-friendly tents have also been used as a regulated space to provide BMS to orphaned children and those identified as needing artificial feeding. Skilled assessment of the potential to breastfeed and available alternative sources to breast milk are important criteria in determining whether artificial feeding is indicated in individual infants (see Artificial Feeding of Infants section below for further guidance on use of BMS in baby-friendly tents).

ESTABLISHING BABY-FRIENDLY TENTS

Because the interruption of breastfeeding can lead to the rapid deterioration of an infant’s health, adequate and professional support to overcome feeding challenges should be provided in the immediate aftermath of an emergency. Interventions to protect and promote optimal IYCF, including the use of baby-friendly spaces where appropriate, should be a standard activity and form part of World Vision’s early emergency response. The following guidance notes for establishing and operating baby-friendly tents are based on the Infant Feeding in Emergencies (IFE) Core Group modules, the Inter-Agency Standing Committee (IASC) Nutrition Cluster Harmonised Training Package and the UNICEF Emergency Field Handbook. These guidance notes aim to help meet the IYCF Sphere Standards (2011).

Objectives of Baby-Friendly Tents

The overall objective of a baby-friendly tent is to prevent morbidity and mortality of infants associated with poor IYCF practices.

Additional objectives include:

1. To prevent a rise of inappropriate IYCF practices in emergency settings.
2. To improve IYCF practices in the affected population.
3. To provide professional support for breastfeeding women to address breastfeeding problems.
4. To prevent or reduce the inappropriate use of BMS.

1. Identify a space where mothers can gather to rest and recuperate. This may be a stand-alone structure (such as a tent) or a space within another site (such as a corner). In planning a ‘safe space’, investigate whether other sectors have similar initiatives that could be complemented by integrating an infant and young-child feeding component. For example, a nutrition component could be added to the protection and psychosocial support offered in child-centred spaces that provide safe, physical spaces for children affected by emergencies.
2. Determine an appropriate size for the space, based on the estimated number of mothers in the area. If the area affected by the emergency is large, estimate the total number of sites needed so that women need to walk only a minimum distance to reach a site.
3. Make sure the location of the space is safe and in a quiet area away from excess outside noise and smells, such as those found near markets, garbage dumps and main roads.
4. Based on context and available resources, decide whether the construction of a physical structure, with walls and/or roof for example, is necessary, appropriate and feasible. In areas where it is culturally necessary, individual private spaces, whether as partitioned spaces within a tent or individual small tents, may be needed.
5. Ensure the space is comfortable for breastfeeding. Provide mats or chairs. If women are sitting on floor mats, then it may be necessary to provide them with a pillow or other item so they can rest their backs to make breastfeeding more comfortable. A pillow or rolled-up cloth is also useful to help the mother hold the baby at a comfortable level while breastfeeding.
6. Make sure the mothers have easy access to water and food while at the space. In settings where maternal malnutrition and dehydration are high, supplemental feeding of breastfeeding women at the space may be indicated as an additional integrated service (see Supporting the Nutrition of Breastfeeding Mothers, below). Ideally, latrines and handwashing stations would be easily accessible from the tents or part of the tents themselves.
7. Inform mothers and caregivers that the space is available for them.
8. Arrange for health workers, members of the community or others trained in breastfeeding counselling to support mothers within the space. Given that mothers will likely be accompanied by older children, it may be useful to have toys and other interactive items available for their use. Health workers may be also trained to support women in appropriate interaction and play with children to promote proper development and help children cope with the trauma associated with emergencies.
9. Screen new arrivals to identify and refer any mothers or infants with severe malnutrition and/or feeding problems for immediate assistance.
10. Establish and foster mother-to-mother support, if culturally appropriate.
11. When artificial feeding is occurring at a baby-friendly site, ensure that support for artificial feeding is provided in an area of the tent that is separate and disctinct from the area where support for breastfeeding is provided, to reduce the risk of spillover of BMS to breastfeeding women. If there are a significant number of cases requiring artificial feeding support, World Vision should consider providing in-kind support to breastfeeding mothers, to ensure there is no perceived advantage to artificial feeding. This could include additional food rations or vouchers.
12. Special attention should be given to newly responsible caregivers (of orphaned children, for example), and special arrangements with supervision made for women who might be building up their breast milk supply using both artificial feeding and breastfeeding during the relactation process.

Baby-Friendly Tents in Emergencies

Bosnia: In Albanian refugee camps in the 1990s, baby-washing tents established by Action Against Hunger became ad hoc breastfeeding centres. The tents were staffed with health-care workers. Women would come not only to bathe their infants, but also to breastfeed, and seek advice and assistance with breastfeeding.

Tanzania: In 1998, breastfeeding corners were established near maternal centres in Hutu refugee camps. The tents provided lactation support to all women soon after birth. The spaces, built of poles and plastic sheeting, had straw mats on the ground for sitting; necessary equipment, including cups, basins for bathing and weighing scales; and specially trained breastfeeding corner assistants who provided support and collaborated closely with community workers and the feeding programme staff to support breastfeeding.

Haiti: After the earthquake in 2010, UNICEF assisted in establishing 107 baby tents that provided services to more than 23,000 mothers and their infants. In addition to receiving breastfeeding support, women received information on complementary feeding, hygiene and nutrition. The tents also provided care for almost 3,000 infants who required artificial feeding with BMS.

In many instances, other services may be offered through the baby-friendly tents, including nutritional support of breastfeeding women, support for relactation, and care and feeding of orphaned children or those for whom artificial feeding is indicated. Below are some general recommendations for these situations – seek the advice of a World Vision nutrition adviser for such situations. The tents can be used as sites to screen for acute malnutrition. Refer to the World Vision Measuring and Promoting Child Growth tool.

“Breastfeeding corners or tents are set up in order to provide adequate support to breastfeeding mothers. In emergency settings, women would arrive at camps exhausted, not having eaten properly for many days as they trekked through difficult terrain. Often they are very traumatised and may exhibit a ‘no breast milk’ syndrome....Providing them some secluded space where breastfeeding support is provided offers that edge of comfort, and usually relactation rates are very high.” – UNICEF representative, Kenya

It is important that breastfeeding women receive an adequate diet – both in terms of the quantity and quality of the food. Additional food rations and micronutrient supplements are recommended for pregnant and lactating women in emergency situations. Furthermore, fluid intake is a particular concern with populations on the move, in severe drought conditions and during natural disasters that contaminate water. Dehydration may interfere with breast milk production.

The following actions can be carried out at baby-friendly tents to ensure that breastfeeding women have safe access to sufficient food and water:

1. Support the nutrition and hydration of breastfeeding women by ensuring that drinking water and food rations are available in the baby-friendly space and provide drinking water wherever women must wait in line a long time or in the sun.
2. Ensure that drinking water is freely available to breastfeeding mothers and help provide an extra litre of water a day in situations where drinking water supplies are severely restricted.
3. Baby-friendly tents can assist with registration of newborns (in a camp situation) so that the family receives an additional ration that the breastfeeding mother should use.
4. If the baby-friendly tent is providing rations for home preparation, ensure the rations provide a sufficient amount to support the household and the breastfeeding women. A lactating woman may require 1,000 to 1,200kcal per day in addition to the standard household ration.

Many lives are saved when conditions are created that protect breastfeeding, especially exclusive breastfeeding, by avoiding interruption due to personal stress or use of BMS, and by providing safe areas for stress reduction and personal assistance to mothers who need it. This means that it is necessary to create a safe haven, or protected area, and to provide support for mothers to ensure that they receive required additional rations for themselves. It is essential to help mothers to continue to provide exclusive breastfeeding for the first six months...and to continue breastfeeding supported by high-quality complementary foods until the child is two years and beyond. Given the stress of emergencies and its potential to temporarily disrupt milk flow, breastfeeding support and counselling is necessary from the earliest days of an emergency.

UNICEF, Emergency Field Handbook: A Guide for Field Staff, www.unicef.org/lac/emergency_handbook.pdf

Women who have breastfed in the past or whose breast milk production has diminished can breastfeed again. It can be easier for a mother to relactate when an infant is less than six months old, but previously breastfed infants as old as 12 months can also begin breastfeeding again. The most important conditions for relactation are the mother’s motivation, stimulation of the breasts from frequent suckling of the infant and support for the mother.

1. Identify women who need to or would like to relactate. A seriously ill or severely undernourished woman should get appropriate treatment first; relactation can be started once her condition improves.
2. Designate an area where women can receive assistance in relactation and provide a lower-stress area that will be beneficial to breastfeeding in general (such as a baby-friendly tent).
3. Provide a safe and comfortable environment, including adequate nutrition and sufficient fluids.
4. Make sure that women have access to skilled assistance and equipment.

Artificial Feeding of Infants

In certain situations, some infants will require BMS either temporarily or for a long-term period. Special care must be taken in the acquisition, distribution and use of BMS so that breastfeeding practices in the general population are protected, promoted and supported. Regular monitoring must be undertaken to ensure that support for artificial feeding does not undermine breastfeeding.

Conditions for temporary or long-term use of BMS include a mother who is absent or deceased, very ill, relactating, HIV-positive and has chosen not to breastfeed, is unable or unwilling to relactate, is a rape victim and does not wish to breastfeed, has rejected her infant or has been artificially feeding her infant  prior to the emergency.

Assessment as to whether a woman qualifies for BMS feeding should be carried out by qualified health and/or nutrition personnel who have training in IYCF. Care should be taken that no stigma is attached to these women choosing to use substitutes. Distribution of infant formula to an individual caregiver should always be linked to education, one-on-one demonstrations and practical training about safe preparation, and to follow-up at the distribution site and at home by skilled health workers. Distribution of essential needs to support safe artificial feeding may also be necessary; for example, safe water, fuel and cooking equipment. Follow-ups should include regular monitoring of infant weight at the time of distribution (no less than twice a month). It is recommended that support for artificial feeding occurs in an area that is distinct from where breastfeeding support is being provided to safeguard against the risk of spillover. 

Nutrition Education

It may be appropriate to use the baby-friendly tent to provide nutritional education to address common misconceptions and poor practices that exist regarding IYCF in a population. It is important to identify the key decision-makers and those who have influence regarding infant feeding decisions (for example, grandmothers and fathers) and include these individuals in educational sessions.

Breastfeeding Counselling in the Context of HIV

Mothers of unknown or negative HIV status should be supported to breastfeed as per general IYCF recommendations for the population. HIV-infected mothers need extra support regarding infant feeding. Normally, this support should be provided through government health systems and by staff specifically trained in HIV counselling. However, in the event that these systems are not functioning in an emergency, there may be a need to support HIV-infected mothers in baby-friendly tents. For HIV-infected mothers, combining antiretroviral (ARV) interventions with breastfeeding can significantly reduce postnatal HIV transmission. Given the heightened risks of artificial feeding in an emergency, breastfeeding offers the greatest likelihood of survival for infants born to HIV-infected mothers in an emergency and for survival of HIV-infected infants, including where ARV interventions are not yet available. Infant-feeding counselling for HIV-infected mothers should be done in close collaboration with HIV services. It is essential that staff have knowledge of and are able to refer women to appropriate HIV services if needed. Urgent assistance is needed for infants already established on replacement feeding.

Infant Feeding in Emergencies Orientation Package, 2010. IFE Core Group. Available at http://www.ennonline.net/ife/orientation

Technical Guidance on IYCF-E

Infant Feeding in Emergencies E-Lessons available at http://www.ennonline.net/ourwork/capacitydevelopment/iycfeelearning

Infant Feeding in Emergencies for Emergency Relief Staff (for orientation, reading and reference). Module 1 November 2001. Available at http://www.ennonline.net/resources/1

Infant Feeding in Emergencies for Health and Nutrition Workers in Emergency Situations (for training, practice and reference). Module 2, v1.1, December 2007. Available at http://www.who.int/nutrition/publications/emergencies/ife_module2/en/index.html

The Harmonised Training Package (HTP): Resource Material for Training on Nutrition in Emergencies, Module 17: Infant and Young Child Feeding in Emergency Situations. Version 2, 2011, NutritionWorks, IASC Global Nutrition Cluster. Available at http://www.ennonline.net/resources/888

UNICEF Emergency Field Handbook: A guide for UNICEF Staff. July 2005. Available at www.unicef.org/lac/emergency_handbook.pdf

Policy Guidance

Sphere Handbook 2011. The Sphere Project, 2011. Available at http://www.sphereproject.org/handbook/

Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Program Managers, version 2.1, February 2007 and the Addendum to Operational Guidance on IFE, version 2.1, 2007. IFE Core Group. Available at http://www.ennonline.net/pool/files/ife/ops-guidance-2-1-english-010307-with-addendum.pdf

World Vision International Policy Governing the Procurement and Use of Milk Products in Field Programmes, revised 2011. Download here

World Vision International Measuring and Promoting Child Growth tool, 2011. Download here

Infant Feeding in HIV Context

World Vision International Nutrition Guidelines in the Context of HIV, 2011. Download here

Guidelines on HIV and Infant Feeding 2012. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. WHO, 2010. Available at http://whqlibdoc.who.int/publications/2010/9789241599535_eng.pdf

Micronutrient Supplementation in Emergencies

Preventing and controlling micronutrient deficiencies in populations affected by an emergency: Multiple vitamin and mineral supplementation for pregnant and lactating women, and for children aged 6–59 months. WHO, WFP and UNICEF, 2007. Available at http://www.who.int/nutrition/publications/WHO_WFP_UNICEFstatement.pdf