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Outline
• Overview of the camp situation
• Infant feeding in the camps
• Case #1
• Case #2
• Wet nursing advantages and disadvantages
-1- Cultural background
-2- HIV considerations
• Conclusion
Overview of the camp situation
• A general food ration is distributed to 22,000 registered refugees in the official camps but omits 5,000 unregistered refugees
• Refugees have no access to land for cultivation and are officially not allowed to work; household income is minimal
Overview of the camps situation
• UNHCR survey in 2007(implemented by HKI) global acute malnutrition prevalence in 6 to 59 months = 12.1% and 64% of 6 to 59 months are anemic (Hb< 11g/dl)
• General lack of food diversity especially animal protein is reported
Infant feeding practices in the camps versus rural Bangladesh
56.5
27.2
93.2
54.7
76.9
24
43.9
99.293.6 97.1
0
20
40
60
80
100
Initi
atio
n to
brea
stm
ilk
Exc
lusi
vebr
east
feed
ing
Con
tinue
dbr
east
feed
ing
1 ye
ar
Con
tinue
dbr
east
feed
ing
2 ye
ars
Bre
astfe
edin
gdu
ring
diah
rrea
In the camps
In rural Bangladesh
Case #1 in the feeding center• Nutritionist: Hello, good morning, how are you
today? • Refugee with baby: Good Thank you!• N: How is your child doing today?• R: This is not my child, it is an orphan. His mother
died while giving birth to him 25 days ago.• N: Oh, I see, and you are taking care of him• R: yes• N: Are you a relative?• R: Not really, his mother was a friend.• N: I am so sorry for her death. Are you finding
trouble feeding him?• R: I put water with some white powder
Comments on the discussion
• “White powder” could be inappropriate
• Please share your thoughts:_______
Case #1 in the feeding center• N: White powder?• R: yes, the same they use in the inpatient center • N: Did they provide you with that powder or did
you purchase it• R: no I bought it• N: Ok, so how can you make sure that it is the
same powder, did anything or anyone indicate it to you?
• R: No, I cannot read but the powder was white and it looked the same
• N:I understand. What about the dosage, how many teaspoons do you use?
• R: Oh just a little bit, I don’t have enough and cannot afford to buy more
Comments on the discussion
• Inpatient center provides F100
• Caretaker cannot read
• Preparation is not appropriate
• Caretaker cannot afford the powder
• Please share your thoughts:_____
Comments on the discussion
Item Cost in Taka
Daily labor 70 -80 /day
Cheapest rice 27 /kg
Lentils 30 /kg
Vegetables 70 /kg
Fish and shrimps 60 /kg
Meat and Dairy Products
170 /kg
Infant formula tin 300 / tin
Case #1 in the feeding center• N: I see! And do you boil the water you use?• R: No, the water is clean, I prefer to save cooking
fuel• N: I see! Do you feed the child anything else?• R: Yes, often I give him some rice• N: Would you please provide us with the packet of
powder you purchased?• R: sure, {5 minutes later comes back with a full
cream powder packet with a large inscription saying ; “is not appropriate for infant below 1 year”}
Comments on the discussion
• Water is not boiled
• Caretaker cannot afford fuel
• Not exclusive artificial feeding/mixed feedings
• Full cream powder not appropriate for infants
• Please share your thoughts:________
Imagining that this is not a refugee camp, what conditions would lead
to the same answers?• Illiteracy
• Poverty
• Lack of community awareness
• Presence of misconceptions
• Healthcare: the “money making machine”
Case # 2 Summary
• Mother died shortly after delivery and an aunt naturally became the wet nurse. “it is highly viewed in the Muslim community, you know, since Mohammed the prophet had a wet nurse”. The caretaker wet-nurses the child and attends to all his needs
Comments on the case
• Culturally appropriate practice naturally undertaken in the community
• Supported by religious beliefs
Wet-nursing Disadvantages
• Breastfeeding is a risk for HIV transmission and wet nurses should undergo Voluntary Counseling and Testing (VCT)
• Night feeds are problematic if the wet nurse lives far away from the orphan and caretaker
• Wet-nurses day to day duties that interfere with attending to the orphan
Wet-nursing Advantages • Infant formula is not AFASS in this context• Wet-nursing is done naturally and is
culturally accepted• Wet nurses (as are all lactating women)
are provided with a package services/interventions to promote optimal health and nutrition status
• Some of this also aims to decrease the risk of HIV transmission (malaria prevention and treatment, breast care and nipple care, detection and treatment of oral candidiasis in the infant)
HIV Situation
• Bangladesh is experiencing a low level HIV epidemic
• Level of HIV infection in southern Bangladesh where the refugees are located is extremely low (no HIV detected in sex workers or injecting drug users in nearest sites in 2006 surveillance)
• However, wet nursing need to ensure that the “donor” is HIV negative
• But many challenges in this regard…
Challenges: wet nursing and HIV
• National HIV capacity, including in HIV VCT, is very weak
• Availability of quality HIV VCT is very limited and closest sites outside of the camp are targeting most- at-risk populations
• Level of knowledge relating to HIV is poor and stigma is prevalent
• A minimum care and support package needs to be put in place before undergoing VCT
Conclusion HIV and Wet nursing
• Despite the operational and contextual constraints UNHCR will work with its implementing and operational partners to ensure that before potential wet nurses begin to breastfeed infants, they are HIV negative
• This will require the provision of VCT