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Infant feeding post-tsunami
Infant feeding in the post Indian Ocean tsunami context: reports, theory and action
Karleen D Gribble BRurSc PhD
Telephone: 02 43284340
Fax: 02 96859343
Email: [email protected]
School of Nursing, Family and Community Health
University of Western Sydney
Locked Bag 1797
Penrith South DC NSW 1797
Infant feeding post-tsunami
Infant feeding in the post Indian Ocean tsunami context: reports, theory and action
The recent Indian Ocean tsunami resulted in a large-scale disaster in which millions of
people required emergency assistance. Reports that some of the assistance provided
included the disorganised or liberal distribution of breastmilk substitutes in relief aid are
concerning. The reason for this concern is that in emergency situations children who are
not breastfed are at a much greater risk of illness and death. Thus, the supply of
breastmilk substitutes in such circumstances should be tightly controlled and provided
only when absolutely necessary in order to prevent unnecessary weaning. Close
supervision of the use of breastmilk substitutes should also be provided so as to minimise
risk. In addition, breastfeeding should be protected promoted and supported with
exploration of the options of relactation and wet nursing when an infant is not being
breastfed. Each infant feeding situation is different and the appropriate solution to any
challenge must be individually determined as seen in the examples presented. Those who
have knowledge of the risk of breastmilk substitutes in emergency situations can assist by
making aid agencies aware of the issues surrounding infant feeding in emergencies,
reporting the inappropriate use of breastmilk substitutes and educating others on the value
of protecting and supporting breastfeeding, regardless of the context.
Key words: breastfeeding, emergency, infant formula, relactation
Infant feeding post-tsunami
The tsunami that devastated communities in or bordering the Indian Ocean on December
26th, 2004 was arguably the most destructive natural disaster of modern times. The
resultant death toll exceeded 200 000, more than 5 million people were left without basic
services and 1.5 million children were orphaned or separated from their families.1
Extensive media attention brought the reality of the tragedy to the notice of the global
population and an unprecedented response in giving to aid appeals resulted.2 Staff and
volunteers from a multitude of major and minor non-governmental aid agencies as well
as many unaffiliated volunteers quickly mobilised to provide emergency relief3 with their
efforts widely reported in the media. Those with expertise in the wellbeing of young
children examined such media reports carefully because of concern that there could be
well-meaning but dangerous distribution of breastmilk substitutes occurring as a part of
aid efforts.
Unfortunately, there were several worrisome accounts regarding the supply of breastmilk
substitutes in tsunami-affected areas. In early January 2005, the website of the aid agency
IsrAID included a photo of a Western aid worker in a refugee camp demonstrating how
to use breastmilk substitutes. In this photo, mothers sit with their babies and toddlers on
their laps. One child is clearly breastfed.4 The text of an associated press release reads,
“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
Infant feeding post-tsunami
children with the infant formula provided by our feeding centre. Word has spread, and
every day new parents arrive.”5
Somewhat less obvious, but nonetheless disturbing, an article in the Sydney Morning
Herald describes how an unaffiliated Australian volunteer in a refugee camp
“...gets details of the numbers of families at each camp so she can supply….infant
formula to babies.” The volunteer states, “At the moment some babies are being given
the wrong formula and the mothers don’t know how to use it. It’s a little bit
The problem of breastmilk substitutes in emergency situations
Concerns associated with the inappropriate distribution of breastmilk substitutes are well
founded. According to the World Health Organisation, in the disrupted circumstances
that accompany emergencies artificially fed babies have a 1300% increased risk of death
from diarrhoeal disease and a 200% increased risk of death from respiratory disease as
compared to babies who are breastfed.7 The reasons for this high risk are that the clean
water and fuel required for safe artificial feeding are usually scarce in emergency
situations while unsanitary and crowded conditions allow diarrhoeal diseases (the most
common cause of death in emergency situations)8,9 to flourish.7 In addition, babies that
are artificially fed are inherently more vulnerable to disease since they do not receive the
anti-infective antibodies that are in breastmilk.7 Experience from past emergencies has
been that the risk of death for young children in emergency situations is very high with
reported crude mortality rates ranging from 12 to 75%.9,10,11 As one health worker
Infant feeding post-tsunami
reported, “Younger children require exclusive breastfeeding if they are to have any
chance of survival.”12
The poorly controlled distribution of breastmilk substitutes is dangerous because it
undermines breastfeeding. Thus, while some babies may have been artificially fed prior
to an emergency, easy access to breastmilk substitutes has a direct impact in promoting
weaning from the breast and increasing infant mortality.13,14,15 As described by one health
care professional in reference to a past emergency, “(this disaster took) infant formula off
the shelves where it was too expensive to buy and put it into the clinics and food
distributions centres where it is free.”14 Unfortunately, the inappropriate distribution of
breastmilk substitutes has had an impact in the current disaster and, for example, in the
Indonesian city of Banda Aceh “relief supplies of infant formula has (sic) discouraged
breastfeeding and is causing problems, e.g., difficulty finding drinking water to mix with
the formula, additional serious health risks for all formula fed babies.”16 The supply of
any type of powdered milk is an issue because of the danger of it being used as a
breastmilk substitute.17 Thus, in any emergency relief work powdered milk should not be
distributed on its own but may be mixed with a milled fortified staple.17,18
A problem in past emergencies that has re-emerged in the post-Tsunami relief work is the
unsolicited donation of breastmilk substitutes. From breastmilk substitute manufacturers
to individual families who were a part of ad hoc collections, large quantities of breastmilk
substitutes were transported into tsunami-affected areas, with the general approval of the
public. Thus, one breastmilk substitute manufacturer proudly proclaimed via a news
Infant feeding post-tsunami
distribution service that they were “donating infant formula and pediatric nutritional
drinks to the victims of the Indian Ocean Tsunami disaster…..Many babies and children
in the areas affected by the Tsunami will benefit from this type of donation”19 and schools,
clubs and individuals made “tsunami” appeals requesting donations of breastmilk
substitutes and feeding bottles.20,21,22
Such unsolicited donations are problematic for a number of reasons. Firstly, controlling
their distribution can be very difficult and donated breastmilk substitutes may be sent to
areas where they are not needed but are nonetheless distributed by those ignorant of the
risk.14 Secondly, the products themselves may be unsuitable because they have passed
their use-by date, are not labelled with instructions in the language required or are simply
nutritionally inappropriate.14 Thirdly, disposal of unusable donations can be difficult and
expensive (e.g., during the 1999 Balkan crisis, the destruction of one unusable donation
of milk was estimated to have cost US$500 000).14
Despite the problems associated with donated breastmilk substitutes, soon after the Indian
Ocean tsunami some aid agencies were also actively requesting donations of milk powder
and distributing them.16 The situation was so serious and widespread that it was necessary
for Unicef’s Nutrition Section Chief to circulate a letter warning non-governmental aid
agencies of the danger milk powder and breastmilk substitutes could pose.23 While most
major aid agencies have policies that specify how infant feeding in emergency situations
should be handled, it is clear that many smaller agencies do not. In addition, even where
there are policies in place, ensuring all staff are adequately trained in this area is difficult.
This is particularly the case in large emergencies where coordination challenges can
Infant feeding post-tsunami
exacerbate the difficulties of making all staff in all agencies aware of procedures.14
Without specific education on the subject, individuals involved in aid work may
unwittingly cause harm. Thus, Western staff may extrapolate the experience in their
home country of breastmilk substitutes as “just fine” to the emergency situation. This is
easy to understand because the infant mortality rate in most Western countries is low and
the increased risk of death in non-breastfed babies relatively small. There is little research
in this area but a recent study found a 27% increase.24 Local aid workers may believe that
the wide distribution of breastmilk substitutes is desirable because of the large quantity of
donations arriving in relief aid and the economic value of breastmilk substitutes may
make it difficult for aid workers to reject. Mothers may also actively seek breastmilk
substitutes believing that such expensive milks are better for their babies than anything
they can produce.25 Unfortunately, once breastmilk substitutes have been inappropriately
distributed it can be difficult to ameliorate the situation.14
Addressing infant feeding in emergency situations
There is consensus amongst the major health and aid agencies on how to manage infant
feeding issues in emergency situations17 as outlined below.
1) Women breastfeeding their children are to be supported. This involves giving
them given appropriate information, practical assistance and encouragement to
continue breastfeeding, especially if they are experiencing difficulties.17 The
general recommendation that mothers should be supported to exclusively
breastfeed their babies for 6 months and then continue to breastfeed for up to 2
years or beyond also applies in emergency situations.7,11,18
Infant feeding post-tsunami
2) Mothers who have weaned their babies should be encouraged, and provided with
assistance to relactate as a first choice intervention.17 Relactation being the
process by which weaning is reversed.26,27
3) In cases where there are babies whose mothers have died or cannot be located,
the option of wet nursing should be explored. In such situations babies may be
breastfed by a woman who is already lactating or a friend or relative may relactate
or induce lactation.7,15 In locations where there is a high prevalence of HIV
infection, care needs to be taken with wet nursing but it is still an option to be
4) Only in instances where mothers have weaned and for some reason relactation is
not possible or a baby has lost his/her mother and wet nursing is not an acceptable
solution should artificial feeding be supported and assistance needs to be provided
to minimise risk.15 Such assistance should include ensuring the mother has access
to a constant supply of breastmilk substitutes and the necessary resources for
preparation. It should also include education on preparation and close monitoring
of the use of the breastmilk substitute and health of the baby.15 Where artificial
feeding is necessary infants should be fed using cup or spoon. Feeding bottles or
teats should never be used due to the risk of bacterial contamination.11,17 It should
also be noted that women who are relactating or inducing lactation may need
some breastmilk substitute supplements for their babies until their milk supply is
Infant feeding post-tsunami
Thus, it is clear that distribution of breastmilk substitutes should be tightly controlled,
carefully monitored and only provided as a last resort to babies with a clear need.13 The
number of infants requiring breastmilk substitutes in most situations is likely to be
small15,17 however, when breastmilk substitutes are used appropriately lives can be saved.
Supporting Mothers
In emergency situations, providing support for mothers to continue to breastfeeding their
children is vital. In some circumstances women or aid workers may believe that trauma
or stress can prevent mothers from producing sufficient milk for their babies14 (as was
described in the previously quoted IsrAID press release).15 However, psychological stress
does not impede milk production and the inhibitory effect of stress on the milk ejection
reflex will be overcome if the baby continues suckling.14,31 It should be noted that
breastfeeding may assist mothers to cope better with their difficult circumstances as
breastfeeding decreases mothers’ response to both physical and psychological stress.32 In
addition, since breastfeeding involves close physical contact and the release of the
hormones oxytocin and prolactin promoting mothering behaviour 33 it may also assist
traumatised mothers to be more responsive in their care giving and thus maximise child
survival and limit the emotional damage of trauma.7,34,35
Another circumstance in which mothers or aid workers may believe women will be
unable to breastfeed is if the mother is malnourished. However, women who are
malnourished will continue to make milk in all but the most extreme of cases and in such
situations feeding the mother will enable her to feed her child.15,36
Infant feeding post-tsunami
Nevertheless, when circumstances are difficult, mothers and caregivers may need special
attention and support in order to breastfeed.15 The experience of workers in the field is
that it is helpful to provide physical and emotional nourishment via “safe spaces” where
stress is reduced and women can find appropriate rations and knowledgeable
breastfeeding support.13,18,37 Placing mothers in contact with other mothers who will
provide mother-to-mother support is desirable.15
Clearly each infant feeding situation presents differently and resourcefulness on behalf of
the carers of infants and aid workers is required in order to minimise the use of
breastmilk substitutes and maximise infant survival. Some extracts of published examples
of how breastfeeding has been supported in emergency situations follow.
A newspaper article describes how a community found care solutions for one family of
motherless children after the Indian Ocean tsunami.
Her mother and brother are dead, her father is in hospital and her home, by the
beach, has been washed away. Two sisters and a brother survive, and like her,
are being watched over by former neighbours.…In her makeshift cradle- a sari
wrapped around a beam- six month old Senaka knows nothing of these things. She
is being breastfed by a family friend Ranaseelan Jeweta, who is also nursing her
own baby. “There’s nobody else to do it. The mother is gone. I have to look after
her. I have enough milk,” she said.38
Infant feeding post-tsunami
And from a previous emergency, an aid worker describes how a number of people
worked together to ensure that a baby was given the care she needed.
An infant was brought to us whose mother had died, it was already wasted but
thirsty and eager to drink…I asked a lactating woman to feed this child in
addition to her own since she had enough milk for two. Initially it was quite
difficult to get her agreement. I was told that it was culturally unacceptable as the
child was no relative. The priest had to help me to persuade her to at least
breastfeed the infant until it would recover and reach normal weight. We also
promised her extra food for herself. The next day a young woman was brought to
the hospital and introduced as the younger sister of the dead mother. She agreed
without any resistance to breastfeed her related child. As far as I remember, this
young woman had never given birth to a child before herself. These two women
saved the infant’s life. The orphan had to be fed frequently. With every feed it
attached first to the aunt’s breast to suck. As soon as the sucking became slightly
weaker, the baby was attached to the breast of the other lactating woman to
satisfy the baby before exhaustion and frustration… It took at least 2-3 weeks
until the young woman was able to fully breastfeed the infant. The two women
became quite close to each other... The baby developed well. This young woman
managed in spite of the difficult circumstances with the help of her family.39
From a specialist in infant and young child feeding in emergency situations, a report of
the systematic support of breastfeeding of severely malnourished babies in a refugee
Infant feeding post-tsunami
Aid workers were faced with infants of less than 6 months at high risk of death….
Although formula feeding was likely to prevent death and ensure recovery it
meant, almost always, the end of breastfeeding. In the prevailing circumstances,
the then formula fed infant would then be at high risk of relapse due to infection
and underfeeding40... We have repeatedly tried “trials” of exclusive breastfeeding
in these wasted infants: they are almost always insufficiently strong to stimulate
increased breast milk output41…(We employed a) “supplemental suckling”
technique. One hour after each 3 hourly breastfeed, that is at 3 hourly intervals,
each infant was breastfed again but at this time one end of a size 8 nasogastric
tube was placed alongside the mother’s nipple in the infant’s mouth while the
other end was below the surface of a rehabilitation infant formula. As the infant
suckled, it also sucked on the tube and obtained the formula40…The infants
rapidly gained weight AND stimulated the breast more and more as they regained
their strength - so that after about 10 days the supplemented `suckling could be
stopped and they continued to gain weight at an accelerated rate on breastmilk
And finally, from an aid worker, how “safe spaces” for breastfeeding support developed
in a refugee camp
A tent set up for washing babies and staffed by relief workers became an ad hoc
meeting place for breastfeeding support. Women with infants found that they
could take care of their older children while also consulting with advisors, nurses
and midwives about their breastfeeding concerns. Soon each of the 6 (refugee)
Infant feeding post-tsunami
camps (in that area) had a space set aside where mothers could breastfeed and
bathe their children. This enhanced support for breastfeeding….raised awareness
of the indiscriminate use of infant formula in the camps and led to its regulation.
A relactation programme was started to help mothers who had used donated
formula to resume breastfeeding.42
Encouraging the appropriate provision of aid
Those who have knowledge of the issues surrounding infant feeding in emergencies have
a role to play in encouraging the support of breastfeeding and discouraging the
inappropriate use of breastmilk substitutes in such situations.
Firstly, individuals can make the aid agency recipients of their monetary contributions
aware of the need to adequately train staff to protect and support breastfeeding. They can
ensure that the agency has an appropriate policy on infant feeding in emergencies before
donating43 (suitable training and information packages are available for free download
online).15 In cases where aid agencies are working with overseas partner organisations
they should be alerted to the fact that they are also responsible for ensuring that their
partner has a suitable infant feeding policy and the ability to implement it.14
Secondly, individuals can be alert to reports of the inappropriate use of breastmilk
substitutes in media or aid agency bulletins and inform the relevant authorities (which
may mean bringing the issue to the attention of the aid agency or Unicef). If individuals
become aware of relief drives requesting donations of breastmilk substitutes or feeding
Infant feeding post-tsunami
bottles, making them aware of the damage that such donations can cause may prevent
inappropriate in-kind donations.
Finally, individuals can educate others in the context in which they live and work on the
value of protecting and supporting breastfeeding in all environments. The higher the level
of knowledge about breastfeeding in the general population the greater chance there is
that aid and health care workers might understand the importance of breastfeeding and
have the knowledge to support mothers to breastfeed in emergency situations.
Reports of the liberal or disorganised distribution of breastmilk substitutes by aid workers
post the Indian Ocean Tsunami are concerning because of the risk that breastmilk
substitutes pose to babies. Supporting and protecting breastfeeding in emergency
situations remains the best way in which to maximise the survival of vulnerable infants.
Aid agencies and individuals who donate to them are responsible for ensuring that
appropriate infant feeding policies are in place and are being followed in emergency
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