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Best Practices in Breast Best Practices in Breast Feeding during Feeding during emergenciesemergencies

Dr Sudarshini Fernandopulle Dr Sudarshini Fernandopulle (MBBS, MSc, MD)(MBBS, MSc, MD)

Consultant Community PhysicianConsultant Community Physician

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Challenges to Breast Feeding in an Challenges to Breast Feeding in an EmergencyEmergency

Priority given to other basic needs such as Priority given to other basic needs such as shelter, clothing, provision of food for adults etc. shelter, clothing, provision of food for adults etc.

Belief that under stressful conditions and/or Belief that under stressful conditions and/or limited access to food mothers are unable to limited access to food mothers are unable to breast feedbreast feed

Disorganized environment Disorganized environment lack of privacy for breast feedinglack of privacy for breast feeding Inadequate support from skilled workersInadequate support from skilled workers

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Un-Controlled DonationsUn-Controlled Donations

Large supply of infant formula at homes,

health centers & distribution points –

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Maliban donates infant milk Maliban donates infant milk food for tsunami victimsfood for tsunami victimsMaliban in collaboration with Maliban in collaboration with the government of Sri Lanka the government of Sri Lanka has once again provided has once again provided assistance to the children of assistance to the children of tsunami survivors, by making tsunami survivors, by making a contribution of infant milk a contribution of infant milk powder to the value of Rs. 20 powder to the value of Rs. 20 million. The donation was million. The donation was handed over… at the handed over… at the President’s House.President’s House.Source: Daily News, Sri Source: Daily News, Sri Lanka. Indian Ocean Lanka. Indian Ocean Tsunami, Sri Lanka, 2004/5 Tsunami, Sri Lanka, 2004/5

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“We distributed children's clothes and about 40 mothers showed up with their babies, we…taught them how to use the milk powder we had received in big quantities.”Source: Real Medicine Foundation News. Sri Lanka, Indian Ocean Tsunami 2004/5

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“A delegation has begun teaching mothers how to properly use infant formula to feed their children. As a result of the Tsunami many women were traumatised and no longer able to properly breastfeed. Over 60 mothers brought their children aged ½ year to 3, to the camp. They wished to learn how to properly maintain hygiene while feeding their children with the infant formula provided by our feeding centre. Word has spread, and every day new parents arrive.”Source: IsraAID Press release. Sri Lanka, Indian Ocean Tsunami, 2004/05.

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Tsunami Victims Relief in Sri Lanka Please donate urgently for the one million+ Tsunami victims who have lost everything and need your help immediately to survive.Critically urgent supplies eg. Infant formula and feeding bottles and medical supplies will be airlifted…The remainder will be shipped in 40 foot container and arrive in Sri Lanka in approximately 21 days.Source: McGill Tribune, Canada. Indian Ocean Tsunami, Sri Lanka, 2004/5

Incorrect Incorrect messages in messages in

mediamedia

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Mechanisms for successful breast Mechanisms for successful breast feedingfeeding

1.1. Breast milk productionBreast milk production

2.2. Suckling the breast (correct attachment and positioning)Suckling the breast (correct attachment and positioning)

Main reasons for breast feeding problems are due to failures Main reasons for breast feeding problems are due to failures in either or both mechanisms.in either or both mechanisms.

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Factors influencing milk Factors influencing milk production:production:

Prolactin

• Secreted during and after feed to produce next feed

Prolactin in blood

Baby suckling

Sensory impulses from nipples

• More prolactin secreted at night

• Suppresses ovulation

3/3

Suckling makes more milk.

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Oxytocin reflexOxytocin reflex

Oxytocin reflex

• Works before or during feed to make milk flow

• Makes uterus contract

Sensory impulses from nipplesOxytocin in blood

Baby suckling

3/4

Good feelings and sensations helps the oxytocin reflex to work and milk to flow

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Dietary recommendations for infants Dietary recommendations for infants and young child feeding during and young child feeding during

emergenciesemergencies

0-6 months:0-6 months:

1.1. All infants including those born to the affected population All infants including those born to the affected population should receive EBF during the first six months. should receive EBF during the first six months.

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Exclusive Breast Feeding forExclusive Breast Feeding for0-6/120-6/12

Babies should start BF within an hour of birthBabies should start BF within an hour of birth EBF and demand feeding until completion of six EBF and demand feeding until completion of six

monthsmonths EBF means giving only BM and no food, no EBF means giving only BM and no food, no

water, no drinks and no teats. Medication on water, no drinks and no teats. Medication on doctor’s recommendation only.doctor’s recommendation only.

Support women and build their confidence for Support women and build their confidence for EBF.EBF.

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……cont 0-6/12cont 0-6/12 If getting both breast milk and formula If getting both breast milk and formula

feeds continue only breast feeding (to feeds continue only breast feeding (to minimise risk of infections)minimise risk of infections)

Every effort should be made to identify Every effort should be made to identify ways to breast feed infants whose ways to breast feed infants whose mothers are absent or incapacitatedmothers are absent or incapacitated

Those already stopped breast feeding re-Those already stopped breast feeding re-lactation should be attempted before lactation should be attempted before considering the use of infant formula.considering the use of infant formula.

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Advantages of breast feeding during Advantages of breast feeding during an emergencyan emergency

Prevents infectionsPrevents infections Provides optimal nutrition to baby Provides optimal nutrition to baby Strengthens bond between mother and child Strengthens bond between mother and child

providing crucial physical and emotional support for providing crucial physical and emotional support for the child.the child.

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Reasons for Higher risk of Reasons for Higher risk of infections in an emergencyinfections in an emergency

Lack of safe water and sanitationLack of safe water and sanitation Poor personal hygiene Poor personal hygiene Unhealthy/unclean environmentUnhealthy/unclean environment No access to health servicesNo access to health services Psychological traumaPsychological trauma

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6-24 months:6-24 months:

Start CF on completing six months while Start CF on completing six months while continuing to BF for two years or longercontinuing to BF for two years or longer

Support women to BF for two years or longer.Support women to BF for two years or longer.BM produces half baby’s nutrition requirement -6 to 12 monthsBM produces half baby’s nutrition requirement -6 to 12 months1/31/3rdrd during second year during second year10% during third year10% during third year

Encourage children to eat CFEncourage children to eat CF6 – 9 m – 2 to 3 times a day6 – 9 m – 2 to 3 times a day9-23 m9-23 m 3-4 times a day with 1-2 snacks3-4 times a day with 1-2 snacks Non breast fed – 4-5 mealsNon breast fed – 4-5 meals

Support families to prepare and feed CFSupport families to prepare and feed CF

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Supportive care for womenSupportive care for women

Should be provided to all those breast feedingShould be provided to all those breast feeding Create an enabling environment for BFCreate an enabling environment for BF

BF cornersBF corners One to one counselingOne to one counseling Mother to mother support groupsMother to mother support groups Mental and emotional support especially for the Mental and emotional support especially for the

traumatised womentraumatised women Support those on mixed feeding to increase BF Support those on mixed feeding to increase BF Skilled helpSkilled help

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Skilled support for BF mothersSkilled support for BF mothers

Assess need of individual mothersAssess need of individual mothers Help to BFHelp to BF

Ensure effective suckling by correcting positioning Ensure effective suckling by correcting positioning and attachmentand attachment

Build mother’s confidence and help milk flowBuild mother’s confidence and help milk flow Increase milk production by:Increase milk production by:

encouraging frequent and longer feedsencouraging frequent and longer feeds Ensure mother gets enough to drinkEnsure mother gets enough to drink Remove interferenceRemove interference Keep mother and baby togetherKeep mother and baby together

Mobilize family supportMobilize family support Encourage age appropriate feedingEncourage age appropriate feeding

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Additional support neededAdditional support needed

Expressing BMExpressing BM Cup feedingCup feeding Kangaroo careKangaroo care Help traumatized mothersHelp traumatized mothers Support to LBW babiesSupport to LBW babies Support to malnourished babiesSupport to malnourished babies Support to malnourished mothers BF babiesSupport to malnourished mothers BF babies Re-lactationRe-lactation Breast conditionsBreast conditions

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Correct positioningCorrect positioning

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Good and poor attachmentGood and poor attachment

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Supportive care for womenSupportive care for women

Extra foodExtra food Food supplementationFood supplementation Micronutrient supplementationMicronutrient supplementation Family supportFamily support Family PlanningFamily Planning Priority in receiving foodPriority in receiving food Priority and adequate waterPriority and adequate water Priority to use toilets and bathingPriority to use toilets and bathing

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Other measures to support BF Other measures to support BF during emergenciesduring emergencies

Developed a circular on Protecting, Developed a circular on Protecting, promoting and supporting Breast feeding promoting and supporting Breast feeding during Emergenciesduring Emergencies

Developed IYCF guidelines during Developed IYCF guidelines during emergenciesemergencies

Trained health staff on IYCF during Trained health staff on IYCF during emergenciesemergencies

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Indications for formula feeds:Indications for formula feeds:

If mother is not availableIf mother is not available If child was on formula prior to emergency and If child was on formula prior to emergency and

re-lactation failedre-lactation failed Scientific evidence for inadequate breast milk in Scientific evidence for inadequate breast milk in

an infant less than six months on EBFan infant less than six months on EBF Urine output less than six monthsUrine output less than six months Inadequate weight gain (average of 125 grams per Inadequate weight gain (average of 125 grams per

week during first six months while on EBF)week during first six months while on EBF)

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Formula feedsFormula feeds

The quantity, distribution and use The quantity, distribution and use of breast milk substitutes at emergency of breast milk substitutes at emergency sites should be strictly controlledsites should be strictly controlled

Those responsible for feeding infant Those responsible for feeding infant formula should be adequately trained formula should be adequately trained and equipped to ensure safe preparation and equipped to ensure safe preparation and useand use

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…….cont.cont

Feeding infant formula to a minority of Feeding infant formula to a minority of children should in no way interfere with children should in no way interfere with protecting and promoting breastfeeding protecting and promoting breastfeeding for the majority.for the majority.

The use of infant feeding bottles and The use of infant feeding bottles and artificial teats in emergency settings artificial teats in emergency settings should be actively discouraged and cup should be actively discouraged and cup feeding promoted instead as cups are feeding promoted instead as cups are easier to keep clean.easier to keep clean.

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Risk of formula feedsRisk of formula feeds

Higher risk of diarrhoeaHigher risk of diarrhoea Aggravates malnutritionAggravates malnutrition Higher risk of deathHigher risk of death No guarantee of continued suppliesNo guarantee of continued supplies

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If on formula feedsIf on formula feeds

Use cup instead of bottleUse cup instead of bottle First six months – formula oneFirst six months – formula one 6-12 months – formula 11/6-12 months – formula 11/ After one year - full cream/goat or cow’s After one year - full cream/goat or cow’s

milk recommendedmilk recommended

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Breast feeding sick infants Breast feeding sick infants

Continue BFContinue BF Keep mother and baby togetherKeep mother and baby together If baby can suckle encourage the mother to do If baby can suckle encourage the mother to do

soso If cannot suckle feed with expressed BMIf cannot suckle feed with expressed BM If unable to feed expressed BM teach mother to If unable to feed expressed BM teach mother to

express BM to maintain BM productionexpress BM to maintain BM production Teach mother to cup feed when dischargingTeach mother to cup feed when discharging Give ORS through cupGive ORS through cup

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Illness of motherIllness of mother

Do not stop Breast feedingDo not stop Breast feeding Treat motherTreat mother Keep mother and infant together and encourage Keep mother and infant together and encourage

BFBF Mobilize family support to help with BFMobilize family support to help with BF If mother cannot breast feed help to express breast If mother cannot breast feed help to express breast

milk milk Help mother to increase production as she Help mother to increase production as she

recoversrecovers Monitor weight gain and urine outputMonitor weight gain and urine output

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Maternity careMaternity care

Identify pregnant women near term earlyIdentify pregnant women near term early Early initiation and EBFEarly initiation and EBF Strengthen BFHIStrengthen BFHI

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