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Call for support for appropriate infant and young child feeding in Haiti

UNICEF, WHO and WFP call for support for appropriate infant and young child feeding in the current emergency, and caution about unnecessary and potentially harmful donations and use of breast-milk substitutes

During emergency situations, disease and death rates among under-five children are higher than for any other age group; the younger the infant the higher the risk. Mortality risk is particularly high because of the combined impact of a greatly increased prevalence of communicable diseases and diarrhoea and soaring rates of under-nutrition. Appropriate feeding and care of infants and young children is essential to preventing malnutrition, morbidity and mortality.

Major health problems among Haitian children, which have been exacerbated by this crisis, are acute and chronic malnutrition and communicable diseases. Given the structural damage caused by the earthquake to water supply systems, there is an additional risk of water borne diseases affecting large numbers of the urban, rural and displaced populations. Many infants and young children have been orphaned or separated from their mothers. Risks to children in Haiti are exacerbated by pre-earthquake poor infant and young child feeding practices and malnutrition. In this emergency situation, the lifeline offered by exclusive breastfeeding to children for the first six months of life and continued breastfeeding with complementary feeding for two years or more is of utmost importance and must be protected, promoted and supported as much as possible.

Most mothers initiate breastfeeding in Haiti, and the majority of infants less than six months of age were at least partially breastfed prior to the earthquake. At this stage it is critical to encourage and support mothers to initiate breastfeeding immediately after the delivery, exclusively breastfeed up to six months and for those with infants below six months who ‘mix feed’ to revert to exclusive breastfeeding. Nonbreastfed infants are at especially high risk and need early identification and targeted skilled support, including re-establishing breastfeeding (relactation).

Protection and support for breastfeeding women
No food or liquid other than breast milk, not even water, is needed to meet an infant’s nutritional and fluid requirements during the first six months of life. The valuable protection from infection that breastfeeding confers is all the more important in environments without safe water supply and sanitation.

Therefore, creation of a protective environment and provision of skilled support to breastfeeding women are essential interventions. There is a common misconception that in emergencies, many mothers can no longer breastfeed adequately because of stress or inadequate nutrition. Concern for these mothers and their infants can fuel donations of breastmilk substitutes (BMS) such as infant formula. Although stress can temporarily interfere with the flow of breastmilk, it is not likely to inhibit breastmilk production, provided mothers and infants remain together and are supported to initiate and continue breastfeeding.

Mothers who lack food or who are malnourished can still breastfeed. Provision of adequate fluids and food for mothers must be a priority as it will help to protect their health and well-being as well as that of their young children.

Basic interventions to facilitate breastfeeding include prioritising mothers with young children for shelter, food, security, and water and sanitation, enabling mother-to-mother support, providing specific space for skilled breastfeeding counselling and support to maintain or re-establish lactation. Traumatised and depressed mothers may have difficulty responding to their infants and require particular mental and emotional support. UNICEF, WHO and other organizations involved in infant feeding in emergencies will support training of staff on individual assessment of the best options for feeding infants, as well as education and support of caregivers on optimal infant feeding in these  emergency circumstances.

Feeding of the non-breastfed child less than six months of age
Infants less than six months of age who are not breastfed need urgent identification and targeted skilled support. The priority to feed these infants should be relactation. If this is not possible or when artificial feeding is indicated by skilled staff such as health providers or infant feeding counsellors, breast-milk substitutes are necessary and must be accompanied by training on hygiene, preparation and use to minimise their associated risks. Artificial feeding in an emergency carries high risks of malnutrition, illness and death and is a last resort only when other safer options have first been fully explored.

Any needed breast-milk substitutes should adhere to Codex Alimentarius Standards and should be procured in an efficient and rapid manner, in coordination with UNICEF, the nutrition coordinating agency in Haiti. The preferred type of breast-milk substitute is ready-to-use formula. Any distribution and use of breast-milk substitutes should be carefully monitored to ensure that only the designated infants receive the product. For further information UNICEF should be contacted (see contact below).

When breast-milk substitutes are used caregivers should be encouraged and taught to feed with a cup and spoon. Bottles and teats should not be provided as they are more difficult to clean. Skilled support by appropriately trained staff should be provided to caregivers on how to use the breast-milk substitute safely. Because infants’ receiving breast-milk substitutes are at increased risk for illness, a mechanism to monitor their health should be established.

Donations and procurement of breast-milk substitutes and other milk products
In accordance with internationally accepted guidelines, donations of infant formula, bottles and teats and other powdered or liquid milk and milk products should not be made. Experience with past emergencies has shown an excessive quantity of products, which are poorly targeted, endangering infants’ lives. Any procurement of breast milk substitutes should be based on careful needs assessment and in coordination with UNICEF. Human milk donations while safe when processed and pasteurized in a human milk bank also require fully functioning cold chains. Such conditions are not currently met in Haiti and human milk donations cannot be used at present. All queries and any donations that do appear should be directed to UNICEF, the designated nutrition coordinating agency in Haiti.

Complementary feeding of children above six months of age
Children from the age of six months require nutrient-rich, age-appropriate and safe complementary foods in addition to breast milk. Priority should be placed on locally available, culturally acceptable, nutritionally adequate and age-appropriate foods. When cooking facilities are non existent or severely limited, ready-to-use fortified foods are an option. Micronutrient powders that can be added to local foods, emergency rations or blended foods will also improve dietary quality. In addition, once cooking facilities have been set up, provision of fortified blended food is recommended. A monitoring system to ensure the appropriate targeting, distribution and use of food and food products for infants and young children should be established.

Feeding infants and young children in the context of HIV
Mothers known to be HIV-infected should be supported to exclusively breastfeed their infants for the first six months of life, to introduce appropriate complementary foods thereafter, and to continue breastfeeding for the first 12 months, along with provision of ARVs, as per current WHO recommendations on HIV and infant feeding (see references below). If an HIV-positive mother was already giving her child commercial infant formula, she should receive an adequate supply of ready-touse formula and support. A separate guidance is being prepared for the situation in Haiti.

Treatment of severe acute malnutrition
Treatment of severely malnourished children, whether facility or community based, should be implemented in accordance with international standards and best practice and closely monitored.

Specially formulated therapeutic milks F75 and F100 and ready to use therapeutic food are required.

Conclusion
UNICEF, WHO and WFP strongly urge all who are involved in funding, planning and implementing the emergency response in Haiti to avoid unnecessary illness and death by promoting, protecting and supporting breastfeeding and appropriate complementary feeding and by preventing uncontrolled distribution and use of breast-milk substitutes. Public and private sector entities and individuals who wish to support infants and young children and their mothers and caregivers in this emergency should donate funds rather than send goods. We further urge governments and partners to include capacity building for breastfeeding and infant and young child feeding as part of emergency preparedness and planning, and to commit financial and human resources for appropriate and timely protection, promotion and support of optimal infant and young child feeding in this and other emergencies.

For more information please contact:
UNICEF Nutrition Section, New York:
Ilka Esquivel, iesquivel@unicef.org, tel: + 1 212 326 7756,
Nune Mangasaryan, nmangasaryan@unicef.org, tel: +1 212 326 7159

UNICEF office in Port-au-Prince:
Mija-Tesse Ververs, Nutrition Cluster Coordinator in Haiti, mijaververs@hotmail.com
Marie-Claude Désilets, desilets26@hotmail.com and mdesilets@unicef.org, tel: (509 ) 2245 3525

WFP office in Rome:
Tina van den Briel, Tina.VanDenBriel@wfp.org, tel. +39 06 6513 2171
WHO offices in Geneva and Washington DC (PAHO):
Zita Weise Prinzo, weiseprinzoz@who.int, tel: + 41 22 791 4440
Chessa Lutter, lutterch@paho.org, tel: + 1 202 974-3871

WHO office Port-au-Prince:
Montserrat Escruela, Mescruela@yahoo.com and montserrates@hai.ops-oms.org, tel: +501 244 7675

References1
Operational Guidance on Infant and Young Child Feeding in Emergencies, v2.1, Feb 2007
http://www.ennonline.net/ife/view.aspx?resid=6

Messages for the media in Haiti: http://www.ennonline.net/resources/735  
 
Guide for the media on infant and young child feeding in emergencies:
http://www.ennonline.net/pool/files/ife/ife-media-guide-french(1).pdf

Module 2 on Infant Feeding in Emergencies, v1.1, Dec 2007, for health and nutrition workers in emergency situations. http://www.ennonline.net/ife/view.aspx?resid=4

HIV and Infant Feeding: Revised Principles and Recommendations. Rapid Advice. WHO. 2009.
http://www.who.int/child_adolescent_health/documents/9789241598873/en/index.html

International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly

Resolutions. WHO (1981): http://www.unicef.org/nutrition/files/nutrition_code_english.pdf
and: http://www.ibfan.org/site2005/Pages/list2.php?iui=1&cat_id=46

Global Nutrition Cluster Toolkit on Nutrition in Emergencies :
http://www.humanitarianreform.org/humanitarianreform/Portals/1/cluster%20approach%20page/clusters%20pages/Nutrition/Global_Nutrition_Cluster_Nutrition_Emergencies_Toolkit_June_2008.pdf 
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1 Contributions to this joint statement were made by the ENN/IFE Core Group

 

 
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