Infant and Young Child Feeding in Emergencies IFE

1. Infant and Young Child Feeding in Emergencies (IFE) Essential Orientation Work with the charity, the Emergency Nutrition Network, or ENN, and I ’m going to describe a positive experience of working together on infant and young child feeding in emergencies (IFE). This relates to an interagency collaboration that has become known as the IFE Core Group., a group concerned with developing policy guidance and capacity building in IFE. This collaboration developed in response to a need identified at an IBFAN-hosted International Meeting on Infant Feeding in Emergency Situations in Croatia in 1998. Which ofr the last 7 yearsor so has been working on policy guidance and capac buiindg onit Work with the charity, the Emergency Nutrition Network, or ENN, and I ’m going to describe a positive experience of working together on infant and young child feeding in emergencies (IFE). This relates to an interagency collaboration that has become known as the IFE Core Group., a group concerned with developing policy guidance and capacity building in IFE. This collaboration developed in response to a need identified at an IBFAN-hosted International Meeting on Infant Feeding in Emergency Situations in Croatia in 1998. Which ofr the last 7 yearsor so has been working on policy guidance and capac buiindg onit

2. Origins of Ops Guidance Concept ‘do’s and don’ts’ emerged 2000 IFE Interagency Group, Version 1.0, 2001 Version 2.0, May 2006 Version 2.1, February, 2007 English, French, Spanish, Portuguese, Arabic, Russian, Chinese, Japanese, Kiswahili, Bahasa (Indonesia), Farsi

3. Do’s and don’ts Need for clear, concise, practical guidance on IFE Pull various components of a response together Non-technical Not just nutrition and health staff, but including logistics, watsan, military,……… 1-2 pager………………………26 booklet What was clear from the Macedonia and Kosovo experience, was the need for concise…….. That pull the various relevant components of a humanitarian response that touched directly or indirectly on IFE together in one place. As a result, this guidance was not just for……. And it was for all players including national governments, etc We oringially envisaged a one or two pager, which escalated into the bookelt in front of you now. It is a compromise between a list of what to do and what not to do, and the need to include a degree of evidence, reference and detail. What was clear from the Macedonia and Kosovo experience, was the need for concise…….. That pull the various relevant components of a humanitarian response that touched directly or indirectly on IFE together in one place. As a result, this guidance was not just for……. And it was for all players including national governments, etc We oringially envisaged a one or two pager, which escalated into the bookelt in front of you now. It is a compromise between a list of what to do and what not to do, and the need to include a degree of evidence, reference and detail.

4. Operational Guidance Key audience: Emergency relief staff incl national governments, UN agencies, national and INGOs, donors International Code for Marketing of Breastmilk Substitutes embedded All emergencies in all countries and to non-emergency contexts (preparedness). Target group: infants and young children 0-2 years of age and their caregivers. The Core Group have been working in two areas – policy guidance that is embodied in the Operational Guidance on IFE and capacity building in the form of two training modules. The first version was produced in an interagency collaboration in 2001. An updated version 2.1 was produced in May 2006 by the Core Group, and tweaked to produce V2.1, Feb 2007 The Core Group have been working in two areas – policy guidance that is embodied in the Operational Guidance on IFE and capacity building in the form of two training modules. The first version was produced in an interagency collaboration in 2001. An updated version 2.1 was produced in May 2006 by the Core Group, and tweaked to produce V2.1, Feb 2007

5. Structure of the Ops Guidance Key Points Sections 1-6 1. Endorse or develop policies 2. Train staff 3. Coordinate operations 4. Assess and Monitor 5. Protect, promote and support IFE interventions 6. Minimise the risks of Artificial Feeding Section 7 - Key Contacts Section 8 – References Section 9 - Definitions On that note, I am now going to take you on a whistle stop tour of the Ops Guidance. I’m going to approach it from the original notion of dos and don’t’s with some of the thinking and explanations around them. What I really want out of this session is for you to get handle on the Ops Guidance, what it is saying and why it says it, to give you the confidence to apply it and use it in your own line of work. Beginning with a quick outline on the structure. It begins on page 5 with 11 Key Points that homes in on the key elements of the Ops Guidance. You can really consider this the 1 or 2 pager that we originally were dreaming of. Sections 1-6 that follow add the detail to these key points and how to achieve them, but if you are stuck for time or want to circulate something on the Ops Guidance, to include in briefing packs for new staff or training manuals for agency staff, then use the Key Points. It is a good starting point, and if anyone has questions or issues with any of them, then the full Ops Guidance can be the key reference. Sections 1-6 are organised into the following practical steps and Sections 7-9 are the support sections to these. Section 7 was a new addition in the latest version. We included this really to encourage accountabilty and feedback from you working in the field. Secction 8 includes key references to support the content of the On that note, I am now going to take you on a whistle stop tour of the Ops Guidance. I’m going to approach it from the original notion of dos and don’t’s with some of the thinking and explanations around them. What I really want out of this session is for you to get handle on the Ops Guidance, what it is saying and why it says it, to give you the confidence to apply it and use it in your own line of work. Beginning with a quick outline on the structure. It begins on page 5 with 11 Key Points that homes in on the key elements of the Ops Guidance. You can really consider this the 1 or 2 pager that we originally were dreaming of. Sections 1-6 that follow add the detail to these key points and how to achieve them, but if you are stuck for time or want to circulate something on the Ops Guidance, to include in briefing packs for new staff or training manuals for agency staff, then use the Key Points. It is a good starting point, and if anyone has questions or issues with any of them, then the full Ops Guidance can be the key reference. Sections 1-6 are organised into the following practical steps and Sections 7-9 are the support sections to these. Section 7 was a new addition in the latest version. We included this really to encourage accountabilty and feedback from you working in the field. Secction 8 includes key references to support the content of the

6. Section 9 Definitions Standard, internationally recognised Infant, Exclusive breastfeeding Infant Formula, Breastmilk substitute (BMS) Optimal infant and young child feeding (IYCF) AFASS criteria – acceptable, feasible, affordable, sustainable, safe Standard definitions built upon ‘Infant’ complementary food Home modified milk I’m going to start with Section 9 on definitions as these are fundamental to understanding and implementing the Ops Guidance. There are three types of definition here: First, we have got the standard ones – those that are internationally recognised, so that we are consistent. The second group are standard indicators that we have built upon, where we have felt there was a need for clarification, for further detail, in a definition for an emergency context. One example is the term ‘infant complementary food’. The defintion is based on the standard one for a complementary food. Can anyone tell me what the definition is here? where complemetnary food which is defined as any food used as a complement to breastmilk or BMS and that should be used after six months of age. However the term complementary food is also used in the context of Food Aid to describe foods beyond the basic food aid commodities given to a population ot complement and diversify the food ration. So to be clear, we use the term infant complementary food in the Ops Guidance and this is an important point to remember if you are talking about CFs in the field, especially with those involved in food aid rather than infant feeding, and if you are designing monitoring forms for CF commodities. Other defintions we have added detail to, including the practical implications. We define it, give examples, give their limitations and advise they should be used as a last resort.I’m going to start with Section 9 on definitions as these are fundamental to understanding and implementing the Ops Guidance. There are three types of definition here: First, we have got the standard ones – those that are internationally recognised, so that we are consistent. The second group are standard indicators that we have built upon, where we have felt there was a need for clarification, for further detail, in a definition for an emergency context. One example is the term ‘infant complementary food’. The defintion is based on the standard one for a complementary food. Can anyone tell me what the definition is here? where complemetnary food which is defined as any food used as a complement to breastmilk or BMS and that should be used after six months of age. However the term complementary food is also used in the context of Food Aid to describe foods beyond the basic food aid commodities given to a population ot complement and diversify the food ration. So to be clear, we use the term infant complementary food in the Ops Guidance and this is an important point to remember if you are talking about CFs in the field, especially with those involved in food aid rather than infant feeding, and if you are designing monitoring forms for CF commodities. Other defintions we have added detail to, including the practical implications. We define it, give examples, give their limitations and advise they should be used as a last resort.

7. Section 9 – Definitions, contd Created definitions Nutrition and health emergency response: For an agency to be part of the nutrition and health response, they must have staff actively involved in the healthcare system who are responsible for targeting the BMS, monitoring the infants, and ensuring the supply of BMS is continued for as long as the infants concerned need it. The third group are definitions that we have created where we felt a clarification was needed support the implementation of the Ops Guidance. The most significant one is ………………………. . This is defined as The definition of healthcare system is the one used from the International Code. This definition emerged from the experiences of Lebanon and Indonesia in implementing the Ops Guidance and the International Code. You will see more clearly the implications of this definition as we work through the sections of the Ops Guidance.The third group are definitions that we have created where we felt a clarification was needed support the implementation of the Ops Guidance. The most significant one is ………………………. . This is defined as The definition of healthcare system is the one used from the International Code. This definition emerged from the experiences of Lebanon and Indonesia in implementing the Ops Guidance and the International Code. You will see more clearly the implications of this definition as we work through the sections of the Ops Guidance.

8. 1 Endorse or Develop Policies 1.1 Agency central level endorse/develop policy addresses protection and support of IFE Makes specific reference to what should be included. 1.2 Disseminate it, integrate it, reflect it in procedures Working examples – DFID, World Vision Country Level – National policy on IYCF in which IFE is specifically addressed The first key action step of the Ops Guidance – every agency…………….. It is not enough to say we like the Ops Guidance this will do the job nicely, we’ll call this our Agency policy. You need to look and address how the Ops Guidance is reflected in the current policy and thinking within your agency and deal with any issues that emerge around that. It needs to be integrated into the agency policy. It is not enough to just have a nice policy, you then need to disseminate it, and reflect it in procedures. This isn’t easy, but we have found that it is key step to translating the Operational Guidance into practice. And following the Oxford meeting, a number of agencies have really worked to take in on board, with individuals within those agencies taken the responsibility to push on it. One sample is DFID. Another is World Vision. What are the challenges? Where supporting the Ops Guidance and reflecting it in your agency policy is going to mean the need to change practice. May be especially difficult if this is seen to impact on revenue. For example, an agency may accept donations of infant formula to distribute. Seen as a money saving exercise. Need to ‘sell’ the cost of this versus the cost of inappropriate distribution, morbidity, cost of staff sorting it out in the fiel – there is a hidden cost to bad practice that is currently poorly measured. The first key action step of the Ops Guidance – every agency…………….. It is not enough to say we like the Ops Guidance this will do the job nicely, we’ll call this our Agency policy. You need to look and address how the Ops Guidance is reflected in the current policy and thinking within your agency and deal with any issues that emerge around that. It needs to be integrated into the agency policy. It is not enough to just have a nice policy, you then need to disseminate it, and reflect it in procedures. This isn’t easy, but we have found that it is key step to translating the Operational Guidance into practice. And following the Oxford meeting, a number of agencies have really worked to take in on board, with individuals within those agencies taken the responsibility to push on it. One sample is DFID. Another is World Vision. What are the challenges? Where supporting the Ops Guidance and reflecting it in your agency policy is going to mean the need to change practice. May be especially difficult if this is seen to impact on revenue. For example, an agency may accept donations of infant formula to distribute. Seen as a money saving exercise. Need to ‘sell’ the cost of this versus the cost of inappropriate distribution, morbidity, cost of staff sorting it out in the fiel – there is a hidden cost to bad practice that is currently poorly measured.

9. 2 Train Staff 2.1 Basic orientation for all national and international staff on IFE 2.2 Technical training for health and nutrition staff 2.3 Seek specific expertise national and international level on breastfeeding/infant feeding counselling and support The second practical step is on orientation and training. Every agency should ensure basic orientation on IFE for national and international staff on IFE. You need to set the ground rules. How might you do that in practice? (Regular meetings at an INGO hQ, every six months have an IFe slot for orientation/update. Have a few powerpoints slides, printouts that staff going to the field can use – key points of the Ops Guidance. Do’s and don’ts, where to go for further info (Ops Guidance), where to go for assistance (Key contacts plus agency contacts). Every agency should include technical training for health and nutrition staff on IFE. How many of you here are involved with or in an agency that has nutrition or health related training for your staff? How many include a component on IFE? There are two modules on IFE that can be drawn upon. But this will only really work if IFE is integrated into training and briefing. ‘Here is your three day training, and when it comes to IFE, read module 1 and 2 will not work). We highlight that specific expertise on breastfeeding support and counselling should be sought at national level. Eg MOH, IBFAN) and international level, ILCA, IBFAN-GIFA, WHO, UNICEF. Sitting in this room here are a group or people who are just the sort of expertise you want to tap in on at a country level. How might you do this? Get some of the bF course to suggest ways of contacting them. What are the challenges to orientation and training? No time High staff turnover IFE not a priority within an organisation Last minute recruitment for a sudden onset emergency Emergency preparedness – have briefing notes ready, online. The second practical step is on orientation and training. Every agency should ensure basic orientation on IFE for national and international staff on IFE. You need to set the ground rules. How might you do that in practice? (Regular meetings at an INGO hQ, every six months have an IFe slot for orientation/update. Have a few powerpoints slides, printouts that staff going to the field can use – key points of the Ops Guidance. Do’s and don’ts, where to go for further info (Ops Guidance), where to go for assistance (Key contacts plus agency contacts). Every agency should include technical training for health and nutrition staff on IFE. How many of you here are involved with or in an agency that has nutrition or health related training for your staff? How many include a component on IFE? There are two modules on IFE that can be drawn upon. But this will only really work if IFE is integrated into training and briefing. ‘Here is your three day training, and when it comes to IFE, read module 1 and 2 will not work). We highlight that specific expertise on breastfeeding support and counselling should be sought at national level. Eg MOH, IBFAN) and international level, ILCA, IBFAN-GIFA, WHO, UNICEF. Sitting in this room here are a group or people who are just the sort of expertise you want to tap in on at a country level. How might you do this? Get some of the bF course to suggest ways of contacting them. What are the challenges to orientation and training? No time High staff turnover IFE not a priority within an organisation Last minute recruitment for a sudden onset emergency Emergency preparedness – have briefing notes ready, online.

10. 3 Co-ordinate Operations 3.1 UNICEF co-ordinating agency (cluster approach) or designated agency with the necessary expertise Policy coordination – specific policy for emergency operation based on national and agency policies Intersectoral coordination – food aid, watsan, reproductive health Action plan – identifies responsible agencies and mechanisms for accountability Dissemination of policy and action plan , including operational agencies, donors, media Evaluation of emergency response once an operation is over In an emergency, strong, technically driven and responsive coordination is critical. UNICEF….. The Operational G details the level of coordination needed, that includes policy coordination, interesctoral cordination to make sure that water and santitaiton, and reproducitnve health, and food security, and shelter and are all on board, not just health and nutrition. You need an action plan, that defines who does what, where and when and monitors this, ………………. You may be that designated coordinating agency. Or you may be part of this process in an emergency. By being aware of what is expected of the coordinating agency, you can help push issues. For example, under dissemination, has a brief on IFE been circulated to the media to advise against appeals for infant formula? Andy what do you need in the field – do you need support? We feel that part of the coordianitng role is address capacity building and technical support requirements amongst operational agencies. What are the challenges in the field to implementing this? No designated coordinating agency, or weak coordination. How to monitor, inform and hold to account agencies and activities that do not fall under the nutrition sector but impact on IFE. For example, a shelter organisation distributing infant formula. How do you find out about it? Not good enough to rely on incidental? How can you make a difference in the field in an emergency?In an emergency, strong, technically driven and responsive coordination is critical. UNICEF….. The Operational G details the level of coordination needed, that includes policy coordination, interesctoral cordination to make sure that water and santitaiton, and reproducitnve health, and food security, and shelter and are all on board, not just health and nutrition. You need an action plan, that defines who does what, where and when and monitors this, ………………. You may be that designated coordinating agency. Or you may be part of this process in an emergency. By being aware of what is expected of the coordinating agency, you can help push issues. For example, under dissemination, has a brief on IFE been circulated to the media to advise against appeals for infant formula? Andy what do you need in the field – do you need support? We feel that part of the coordianitng role is address capacity building and technical support requirements amongst operational agencies. What are the challenges in the field to implementing this? No designated coordinating agency, or weak coordination. How to monitor, inform and hold to account agencies and activities that do not fall under the nutrition sector but impact on IFE. For example, a shelter organisation distributing infant formula. How do you find out about it? Not good enough to rely on incidental? How can you make a difference in the field in an emergency?

11. 4 Assess and Monitor 4.1 Key information on IYCF always be collected in initial rapid assessment (4.2 – details) -Conspicuous infant formula, infants not breastfed pre-crisis 4.3 Additional key qualitative and quantitative information - Water availability and quality, fuel, potential support givers - Nutritional adequacy of food ration, infant feeding practices 4.3.3 Maintain records and share experiences The fourth practical step is on assessment and monitoring. Andy Seal is going to do an hour long session on assessment later this morning so I am not going to go into huge detail here but flag the key points. Why this section is particularly important is that over the last 7 years or so, our experience is that infants are poorly assessed and monitored in emergencies. You need decent assessments to get decent interventions. And you need to monitor to see whether you are effective, achieving what you set out to do, and are doing no harm. Andy will go into the key info to gather in an early or initial rapid assessment using a tool dev by the nutrition cluster. The Ops Guidance states that key info on IFe should always be included, not just when you think there is a problem or you are considering an intervention. This key information helps to raise warning signs early and help identify the need for a more comprehensive or detailed assessment. 4.3 of the Ops Guidance goes into some detail of the types of quantitative and qualitative information who should gather in a more detailed assessment. For example, you may assess the antenatal care and support to newborn infants if mothers are newborns are asking for infant formula t health facilities, or gather more quantitative information on the nutritional adequacy of the food ration if complemetnary feeding of young children is a problem area identified by carers. And it is important to keep records – considering the turnover of staff in emergencies, so much goes home with the field worker.The fourth practical step is on assessment and monitoring. Andy Seal is going to do an hour long session on assessment later this morning so I am not going to go into huge detail here but flag the key points. Why this section is particularly important is that over the last 7 years or so, our experience is that infants are poorly assessed and monitored in emergencies. You need decent assessments to get decent interventions. And you need to monitor to see whether you are effective, achieving what you set out to do, and are doing no harm. Andy will go into the key info to gather in an early or initial rapid assessment using a tool dev by the nutrition cluster. The Ops Guidance states that key info on IFe should always be included, not just when you think there is a problem or you are considering an intervention. This key information helps to raise warning signs early and help identify the need for a more comprehensive or detailed assessment. 4.3 of the Ops Guidance goes into some detail of the types of quantitative and qualitative information who should gather in a more detailed assessment. For example, you may assess the antenatal care and support to newborn infants if mothers are newborns are asking for infant formula t health facilities, or gather more quantitative information on the nutritional adequacy of the food ration if complemetnary feeding of young children is a problem area identified by carers. And it is important to keep records – considering the turnover of staff in emergencies, so much goes home with the field worker.

12. 5 Protect, promote and support IFE Integrated Multi-Sectoral Interventions Integrated multi-sectoral Many direct and indirect supports of IFE, eg reproductive health, shelter, water and sanitation, food aid delivery IFE not just a standalone intervention The 5th practical step relates to….. Integrated, multi-sectoral element is key here. There are many direct and direct influences and ways of supporting IYCF, and none of these are going to have a standalone IFE intervention. So integrating key elements is essential, and that should be one of the key areas that you should work on within your agency and within the field. I think this is also one of the key challenges – how do you ‘sell’ IFE to the shelter crowd, to water and sanitation? Integrated responses also relates to the types of infant feeding support. For example, if you have an intervention to support artificial feeding In the Ops Guidance, we consider interventions as two types – basic interventions that reflect a minimum level of intervention to protect and support IFE that should always happen, and technical interventions, where you have specific interventions to address defined needs carreid out by experienced agencies.The 5th practical step relates to….. Integrated, multi-sectoral element is key here. There are many direct and direct influences and ways of supporting IYCF, and none of these are going to have a standalone IFE intervention. So integrating key elements is essential, and that should be one of the key areas that you should work on within your agency and within the field. I think this is also one of the key challenges – how do you ‘sell’ IFE to the shelter crowd, to water and sanitation? Integrated responses also relates to the types of infant feeding support. For example, if you have an intervention to support artificial feeding In the Ops Guidance, we consider interventions as two types – basic interventions that reflect a minimum level of intervention to protect and support IFE that should always happen, and technical interventions, where you have specific interventions to address defined needs carreid out by experienced agencies.

13. 5.1 Basic interventions Meet nutritional needs of the general population. Prioritise pregnant and lactating women with supplementary foods (5.1.1). If foods are lacking, then multiple micronutrients should be given to pregnant and lactating women and children 6-59 months (NB Refer to guidance for malaria endemic areas) (5.1.2) Address infant complementary feeding from the outset Supplement food ration with local foods, micronutrient fortified blended foods, e.g. CSB, WSB (5.1.3) Commercial baby foods – consider cost and nutritional value and risk of undermining infant feeding practice (5.1.6) First and foremost, you should aim for nutritional adequacy for the general population – if you do this, then you are nourishing caregivers as well as infants and children. If the ration is lacking, advocate for improvement and if suppl…… If the quality of food is limiting, then unitl it is sorted, multiple micronuts should be used in p and l and children 6-59 m. Make sure to consult with the latest guidance on us of micronut suppls where malaria is endemic. Second, address complementary feeding of infants from the beginning. This may be through support of the food ration with local foods or fortified blended foods. Commercial baby foods, eg jars or packets, have little place in emergency interventions. Before using them, consider………Also if they are targeted at infants under six months, then they will fall under the remit of the Int Code. First and foremost, you should aim for nutritional adequacy for the general population – if you do this, then you are nourishing caregivers as well as infants and children. If the ration is lacking, advocate for improvement and if suppl…… If the quality of food is limiting, then unitl it is sorted, multiple micronuts should be used in p and l and children 6-59 m. Make sure to consult with the latest guidance on us of micronut suppls where malaria is endemic. Second, address complementary feeding of infants from the beginning. This may be through support of the food ration with local foods or fortified blended foods. Commercial baby foods, eg jars or packets, have little place in emergency interventions. Before using them, consider………Also if they are targeted at infants under six months, then they will fall under the remit of the Int Code.

14. 5.1 Basic interventions, contd Establish the population you are dealing with: Demographic breakdown at registration of U2s (0-<6m, 6-<12m, 12-<24m) Registration of newborns within 2 weeks of delivery Refugees and displaced populations Rest areas, secluded areas for breastfeeding Screen new arrivals to identify any IYCF problems and refer

15. 5.2 Technical Interventions Training of health/nutrition/community health staff knowledge and skills to support mothers and caregivers Integrate breastfeeding and IYCF into all levels of healthcare, e.g. maternity services, growth monitoring, selective feeding programmes More targeted detailed support Services to support orphans and unaccompanied children Correct preparation of unfamiliar infant complementary foods The technical interventions are the agencies or programmes that mothers or carergivers and their infants and young children are referred to or supported by when issues or problems are identified through basic level screening or through the course of programming or through general awareness or stumbling across problems. So having skilled staff on the ground is critical, and training of these staff fundamental. I’ve already mentioned integration, and here the Ops Guidance gives a bit more detail on where to work on integrating IYCF – for example, …….. So if you are an agency working in reproductive health, you should look at how you can work in or strengthen the support to breastfeeding here. If you re working in a community based programme for managing severe malnutrition, where and how does breastfeeding support feature? More targeted specifc support may be needed based on needs assessment, for example……..The technical interventions are the agencies or programmes that mothers or carergivers and their infants and young children are referred to or supported by when issues or problems are identified through basic level screening or through the course of programming or through general awareness or stumbling across problems. So having skilled staff on the ground is critical, and training of these staff fundamental. I’ve already mentioned integration, and here the Ops Guidance gives a bit more detail on where to work on integrating IYCF – for example, …….. So if you are an agency working in reproductive health, you should look at how you can work in or strengthen the support to breastfeeding here. If you re working in a community based programme for managing severe malnutrition, where and how does breastfeeding support feature? More targeted specifc support may be needed based on needs assessment, for example……..

16. 5.2 Technical Interventions, contd Address HIV/AIDS Primary prevention, e.g. through condom provision (5.2.6) Individual HIV status unknown, support optimal IYCF (5.2.7) Testing and counselling in place: Individual HIV negative, support optimal IYCF (5.2.7) HIV positive women support informed decision about infant feeding choice applying AFASS criteria and supported to see this through (5.2.8) When it comes to emergency responses, there are few places where HIV/AIDS does not come up and it needs to addressed. The Ops Guidance also touches on infant feeding and HIV/AIDS. I say touches on, as dealing with this area in great detail was beyond the scope of the Ops Guidance but it is a key issue. What are the current recommendations on infant feeding and HIV/AIDS? The Ops Guidance emphasizes the importance of primary prevention of HIV transmission, which is easy to forget when you start getting tied up in breastmilk transmission rates. Decisions on infant feeding and HIV/AIDS are made at an individual level, not a community or population level. To make decisions on an individual level, you need counselling and testing in place. So if an indivddual mothers HIV status is unknown, whether the HIV prevalence in country is 5% or 50%, you support optimal IYCF as for the general population. If testing and counselling is in place (most likely out of acute phase/protracted emergency situation), and a mother tests HIV negative, then again ………… If a mother tests HIV positive, then she needs to be supported to make an infomred decision and supoprted to see this decision through. What are the AFASS criteria? We are going to go into these in much more detail this afternoon because they apply not just in the context of replacement feeding and HIV/AIDS, but to artifiicial feeding in emergencies in general. The Ops Guidance has taken quite a strong position on infant feeding in the cntext of HIV/AIDS, which has increasingly been bourne out in the experiences from Botswana, etc. When it comes to emergency responses, there are few places where HIV/AIDS does not come up and it needs to addressed. The Ops Guidance also touches on infant feeding and HIV/AIDS. I say touches on, as dealing with this area in great detail was beyond the scope of the Ops Guidance but it is a key issue. What are the current recommendations on infant feeding and HIV/AIDS? The Ops Guidance emphasizes the importance of primary prevention of HIV transmission, which is easy to forget when you start getting tied up in breastmilk transmission rates. Decisions on infant feeding and HIV/AIDS are made at an individual level, not a community or population level. To make decisions on an individual level, you need counselling and testing in place. So if an indivddual mothers HIV status is unknown, whether the HIV prevalence in country is 5% or 50%, you support optimal IYCF as for the general population. If testing and counselling is in place (most likely out of acute phase/protracted emergency situation), and a mother tests HIV negative, then again ………… If a mother tests HIV positive, then she needs to be supported to make an infomred decision and supoprted to see this decision through. What are the AFASS criteria? We are going to go into these in much more detail this afternoon because they apply not just in the context of replacement feeding and HIV/AIDS, but to artifiicial feeding in emergencies in general. The Ops Guidance has taken quite a strong position on infant feeding in the cntext of HIV/AIDS, which has increasingly been bourne out in the experiences from Botswana, etc.

17. Infant feeding and HIV/AIDS in emergencies 5.2.8 Risk of infection or malnutrition from using BMS likely to be greater than risk of HIV transmission through breastfeeding. EBF for first six months of life, with continued breastfeeding will give best chance of SURVIVAL Decision based on individual circumstances but should take greater consideration of the health services available and the counselling and support she is likely to receive (WHO, 2006) Mixed feeding is the worst option as gives highest transmission rate.

18. 6 Minimise the risks of any artificial feeding 6.1 BMS donations and supplies BMS donations are not needed Avoid soliciting or accepting donations of BMS Any unavoided donations: collected by designated agency dealt with under guidance of UNICEF/coordinating agency and the government This section applies to all artificial feeding, whether in the context of HIV/AIDS or not. Within this section in particular, the International Code is embedded and has been built upon based on field experiences and challenges. Rebecca and Ali are going to go into more detail on the Code and field experiences in the session after coffee. Section 6.1 deals with how to handle BMS donations and supplies Sections 6.2-6.4 deals with how to handle supplies of BMS being used in an emergency We have many reasons for this position: In version 2.1 we have also added a new point This section applies to all artificial feeding, whether in the context of HIV/AIDS or not. Within this section in particular, the International Code is embedded and has been built upon based on field experiences and challenges. Rebecca and Ali are going to go into more detail on the Code and field experiences in the session after coffee. Section 6.1 deals with how to handle BMS donations and supplies Sections 6.2-6.4 deals with how to handle supplies of BMS being used in an emergency We have many reasons for this position: In version 2.1 we have also added a new point

19. 6.1.4 One agency supply BMS to another, only if both working as part of the nutrition and health emergency response and the provisions of the Code and the Ops Guidance are met. Both the donor and recipient agency are responsible to ensure provisions are met and continue to be met.

20. 6.2 Establish and implement criteria for targeting and use 6.2.1 Infant formula Targeted to infants requiring it (criteria, 6.2.2) Assessed health/nutrition worker trained in BF and IF issues Individual training on safe preparation Follow-up at distribution site and at home (not less than twice a month)

21. 6.2.4 UNICEF or designated nutrition coordinating agency responsibility to train and support agencies in training staff and mothers on safe preparation of infant formula in given context 6.2.5 Assess whether AFASS prior to establishing a household based programme. Where safe preparation cannot be assured,, on-site preparation and consumption should be initiated. Ongoing assessment is critical to ensure conditions continue to be met.

22. 6.3 Control of procurement 6.3.1 Donor agencies considering funding: Ensure that the provisions of the Ops Guidance and the Code are met Cost implications to meet associated needs Interventions to support non-breastfed infants should always include a component to support breastfed infants Equal consideration should be given to skills based as to commodity based interventions - considering funidng supply of BMS or milk products shoud esnre ….. By the implementing agency. Last point – this point comes out of the dominance of commodity based responses to emergencies, and agency experiences in recent emergencies where breastfeeding was not considered an emergency intervention, and they were having to hide breastfeeding support in their proposals to donors to try and get it in. So these points aer both to inform donors of what the should be considering funding, the type of interventons and integrated approaches that agencies should be considering, but also and to for agencies to use and highlight to donors when they get short shrift from them. Both DFID and USAID have signed up to support the Operational Guidance so this is now a powerful tool. - considering funidng supply of BMS or milk products shoud esnre ….. By the implementing agency. Last point – this point comes out of the dominance of commodity based responses to emergencies, and agency experiences in recent emergencies where breastfeeding was not considered an emergency intervention, and they were having to hide breastfeeding support in their proposals to donors to try and get it in. So these points aer both to inform donors of what the should be considering funding, the type of interventons and integrated approaches that agencies should be considering, but also and to for agencies to use and highlight to donors when they get short shrift from them. Both DFID and USAID have signed up to support the Operational Guidance so this is now a powerful tool.

23. 6.3.2 Type and source of BMS Generic (unbranded), locally purchased. Manufactured and packaged in accordance with Codex Alimentarius standards. At least six months shelf life on receipt of supply. Type of infant formula appropriate for the infant, including age. Follow on milks, growing up milks, not necessary. UNICEF does not supply infant formula. 6.3.2 of the Ops Guidance details the type and source of BMS to purchase,6.3.2 of the Ops Guidance details the type and source of BMS to purchase,

24. 6.3.3 Labels – detailed requirements laid down by the Code 6.3.4 Infant formula supply is continued for as long as the infants need it: Breastfeeding is re-established, or At least six months of age and some source of milk/animal source food available (6-24 months of age). 6.3.5 Use of bottles and teats is discouraged. Use of cups promoted. . There are detaield requirements laid down by the Code on labelling, and Ali and Rebecca will go into this more. 6.3.4 Procurement should be managed so that … 6.3.6 This amy seem obvious but F100 a therapeutic milk, was distributed in Korea as a BMSThere are detaield requirements laid down by the Code on labelling, and Ali and Rebecca will go into this more. 6.3.4 Procurement should be managed so that … 6.3.6 This amy seem obvious but F100 a therapeutic milk, was distributed in Korea as a BMS

25. 6.4 Control of Management and Distribution 6.4.1 Infant formula purchased by agencies working as part of the nutrition and health emergency response may be used or distributed by the healthcare system. Distribution should be discrete and not part of food aid distribution. WHA 47.5: No donations of free or subsidised BMS in any part of the healthcare system. Ali and Rebecca again will go more into detail of the provisions of the Code. Avoiding donations in emergencies solves this issue. (2) to ensure that there are no donations of free or subsidized supplies of breast-milk substitutes and other products covered by the International Code of Marketing of Breast-milk Substitutes in any part of the health care system; Ali and Rebecca again will go more into detail of the provisions of the Code. Avoiding donations in emergencies solves this issue. (2) to ensure that there are no donations of free or subsidized supplies of breast-milk substitutes and other products covered by the International Code of Marketing of Breast-milk Substitutes in any part of the health care system;

26. 6.4.2 BMS, milk products, bottles and teats should never be part of a general or blanket distribution. Dried milk products should not be distributed as single commodity, only distributed if pre-mixed with milled staple food. Single tins of infant formula should not be given to mothers unless part of an assured continuous supply. No promotion at point of distribution – displays, leaflets with brands, etc.

27. 7 Key Contacts 7.1 Violations of the Code – report to WHO and International Code Documentation Centre (ICDC) 7.2 IYCF and/or coordination of IFE, contact UNICEF 7.3 UNHCR milk policy, contact UNHCR 7.4 Feedback on Ops Guidance and share field experiences, contact IFE Core Group via ENN

28. In conclusion….. Field driven policy guidance Challenge is implementation Responsive and timely updates Feedback on use ife@ennonline.net