Disasters come in many different forms and can happen with varying degrees of warning and notice. The destructive forces of disasters can be experienced by large quantity of a population in an affected area, but often, susceptible populations are more significantly negatively impacted. Infants, with their specific health needs are a vulnerable group that require special consideration regarding their nutritional needs during a catastrophe. Despite well-defined global policy and expert recommendations for infant feeding during a crisis, misinformation and mismanaged assistance can lead to practices that can pose a health threat to babies.
It is estimated that in 2015, globally 200 million people were impacted by disasters and conflicts (OCHA, 2015). Of those with a larger risk for illness and death among the affected population were children under the age of 5 years old (Prudhorn, Benelli, Maclaine, Harrigan, & Frize, 2016). As an example, during the 2014 Kelantan flood in Malaysia, women and infants accounted for a significant proportion of those most heavily impacted during the disaster (Sulaiman, Mohammed, Ismail, Johari, & Hussain, 2016). With Hurricane Katrina, it is estimated that nearly 75,000 infants were directly affected because of the storm (Callaghan, et al., 2007). The effect exerted on infants during catastrophic events exert can be attributed to disruptions to a safe water supply, potential exposure to environmental toxins, interruption of health care, and a change to their primary nutritional sources and dietary patterns, all increasing the vulnerability of this population. Following a disaster when the community is recovering, how is infant nutrition addressed?
Basically, with feeding a child under the age of 1 year of age, the primary nutrient intake options are limited, especially during the first 6 months, to human breast milk and artificial breast milk (ABM). The “gold standard” in infant feeding, according to the World Health Organization (WHO), is that babies breastfeed exclusively within one hour of birth through the first 6 months of life (WHO, 2017). The recommendation to provide human milk to infants, even during disasters, is supported by the International Lactation Consultant Association (Carothers & Gribble, 2014). A few key factors for the recommendation of breastmilk over ABM’s during a disaster include that human milk works actively to provide infants with biologically active immunologic protective factors not found with ABM and breastmilk provides a consistent and easily transportable source of nutrition for infants (WHO, 2017). Even though breastfeeding is the ideal source of nutrition with strong backing from many global experts, there continues to be a trend towards using ABM instead of human milk following a disaster.
While there is a need and a place for ABM to nourish infants after disasters, if breastmilk is not a viable option, it does come with some risks. Following a disaster, the leading causes of illness and death among infants is diarrheal disease and respiratory tract infections (Carothers & Gribble, 2014). Examples of ABM associated with infant diarrhea following a disaster include the 2004 tsunami in Pondicherry, India and the 2006 Yogyakarta and Central Java earthquake. The incidence of diarrhea in Pondicherry following the tsunami of 2004 was three times higher among babies who consumed ABM donated as part of the relief/recovery process than those who did not consume the donated breastmilk substitute (Adhisivam, Srinivasan, Soudarssanane, Deepak Amalnath, & Kumar, 2006). Following the earthquake in Yogyakarta and Central Java, the prevalence of diarrhea was significantly higher post-disaster which researchers attributed to high amounts of donated ABM during the recovery process (Hipgrave, Assefa, Winoto, & Sukotjo, 2011). In both cases above, researchers postulated that ABM use intensified risk for diarrhea among infants. Lastly, because ABM’s require dilution with safe drinking water and/or refrigeration (as with the ready-to-use variety) the desirability of ABM loses some of its practicality following a disaster as both resources may be difficult to secure in comparison to breastfeeding. So why is ABM such a popular option with infant feeding following a disaster?
As seen with recent disasters, in the wake of recovery efforts the global community wants to respond and assist the affected community in any way possible. The coordination of relief and recovery efforts make provisions for infant feeding by providing ABM as a means of nourishing infants (Heinig, 2005). While some events like the 2010 post-earthquake response in Haiti successfully implemented a programmatic distribution point for ready to use infant formula to the affected population, albeit with some challenges, there are more instances where unethical supplementation can adversely affect health (Talley & Boyd, 2013). As such, food companies have used catastrophic events as an opportunity to donate large quantities of ABM as part of recovery efforts and done so without sound ethical tactics (Binns, et al., 2012). A recent disaster that illustrated this example coupled with mixed messages regarding the safety and efficacy of breastmilk was following Cyclone Nargis in Myanmar and the WenChuan Earthquake in China (Gribble, 2013). Some of the messages that were provided included “babies are vulnerable”, “stress prevents successful lactation”, and “infant formula saves” lives while at the same time providing ABM to the affected population (Gribble, 2013). The WHO’s “10 Facts on Breastfeeding” outline recommendations regarding the promotion and provision of ABM which as previously mentioned can be circumvented during a disaster with negative impacts on infant health (WHO, 2017). The primary goal of the United Nations Children’s Fund (UNICEF) and the WHO is first and foremost to protect and promote breastfeeding as a critical factor for survival in humanitarian recovery processes (Branca & Schultink, 2016). So how can we move forward with successful promotion of breastfeeding for vulnerable infant populations that are likely to be affected by disasters?
Promoting breastfeeding as the “gold standard” for infant nutrition under regular/non-emergent conditions, especially in vulnerable populations, but also as a key survival factor during an emergency and as part of the recovery from a disaster is the primary goal. The first step to achieving this goal, is to improve alliances between nutrition and women’s health professionals that work with vulnerable infant populations and to collaboratively provide education and instruction regarding the benefits of breastfeeding (Gribble & McGrath, 2011). Not only is the education important to the immediate family/caregiver of infants but also the education regarding breastfeeding benefits should be promoted on a cultural and social level. Based on lessons learned from recent disasters where opportunities for promoting breastfeeding where mismanaged, like the 2011 Fukushima Health Management Survey, making sure that there are qualified personnel able to provide breastfeeding support and information during the recovery phase is needed to continue beneficial lactation practices (Ishii et al., 2016). Without adequate support, breastfeeding mothers may receive misinformation regarding the safety and efficacy of breastfeeding during a disaster and may be more likely to supplement with ABM (Gribble, McGrath, 2011). Another are where improvement is needed is providing infant nutrition during the disaster planning phase (Morin, 2008). Including infant nutrition as an objective of disaster planning specifically for healthcare workers supporting the recovery efforts of a disaster will increase the opportunity that mothers receive the support and information needed for successful lactation (Morin, 2008). An opportunity exists with the continued development of global polices that continue to build on UNICEF and WHO recommendations that are based on evidenced-based practices regarding infant nutrition and wellness (Sinclair, 2014). Beyond policy development, would be the enforcement with current policies that are designed to protect and promote infant health including the ethical distribution of ABM during a disaster and the information that the media provides to caregivers of infants (Binns, et al., 2012). Lastly, as a global society, we need to continue evolving and assisting operational research on the promotion of peak infant nutritional recommendations that are based on accepted scientific data (Seal, Taylor, Gostelow, & McGrath, 2001).
Author: Victor Rodriguez – University of South Florida