Spotlight on Infant and Young Child Feeding in Emergencies during National Breastfeeding Month

It’s Week Three (August 16-24) of National Breastfeeding Month, recognized as Spotlight on Infant and Young Child Feeding in Emergencies by the United States Breastfeeding Committee (USBC). 

Among the many effects of the novel coronavirus, the pandemic has truly exposed our nation’s deficiencies; one of them being emergency unpreparedness. 

Years ago, Federal Emergency Management Agency (FEMA) called Hurricane Katrina “the single most catastrophic natural disaster in US history.”

In preparation for the storm, the government organized an alternate site for the Super Bowl but failed to employ an infant feeding in emergencies (IFE) plan, Healthy Children Project Executive Director Karin Cadwell reports. In the aftermath of the catastrophe, pets and exotic animals were accounted for, but mothers and infants were separated from one another as hospitals were evacuated.

In 2016, Healthy Children Project, Inc. (HCP)  convened an Expert Panel to complete the World Breastfeeding Trends Initiative (WBTi), an international tracking, assessment and monitoring system for national implementation of the Global Strategy on Infant and Young Child Feeding, as originally reported in Underdeveloped plans for infant and young child feeding during emergencies

WBTi Panel Members

The USA scored 0 out of 10 points on WBTi Indicator 9, which measures implementation of actions to protect infant and young child feeding (IYCF) during emergencies.

WBTi originator Dr. Arun Gupta challenged HCP to conduct a state-by-state review of WBTi indicators that can be measured on a state level. 

The US Expert Panel reconvened in 2017 to complete the United States of America and U.S. Territories 2017 Assessment Report. Results further show the absence of state policies ensuring babies and young children are safely fed during emergencies.

HCP’s Cindy Turner-Maffei says that the lack of well-developed plans for protecting IYCF during emergencies was one of the most worrisome findings of the U.S. WBTi Assessment.

She explains: “Scores above two points were rare, and most of the points scored regarded funding allocation for emergencies, not for specific inclusion of the needs of infants and young children in emergency plans.”

Puerto Rico and Texas scored 0 out of 10. New Jersey and Mississippi scored 2 out of 10. Oklahoma 3 out of 10. Connecticut took the lead at 6 out of 10.

“Panel members were struck by the fact that few of the states and territories that had recently experienced significant disasters were among those with significant scores for Indicator 9,” Turner-Maffei continues. “Ironically, some states and territories have well-elaborated plans for the care and feeding of household pets in shelters, but none for infants and young children.”

Photo by Luiza Braun on Unsplash

Although there are always crises occurring, since being thrust into a global pandemic, our nation has had to reevaluate how we care for families with babies and young children. Especially in marginalized populations, poverty, health inequities, and other burdens are amplified during an outbreak or other emergency. 

Carolina Global Breastfeeding Institute states,  “Any crisis presents an opportunity for positive, sustainable change and coordinated involvement of all. #COVID19 taught us that we are all affected and an immediate societal response is required.” 

In an effort to increase awareness and preparation, 1,000 Days— a non-profit working to improve nutrition and ensure women and children have the healthiest first 1,000 days–compiled a list of five things we need to know about breastfeeding in emergencies in a 2018 blog post:

1. Breastfeeding is the safest, most nutritious and reliable food source for infants under the age of six months.

2. Breastfeeding decreases the risk of infection and disease, which is vital to survival in emergency settings.

3. Breastfeeding mothers need (even more!) support during emergencies.

4. When breastfeeding is not possible, immediate support is necessary to explore feeding options and protect the health of vulnerable infants.

5. Preparedness is key to ensure babies everywhere have the best opportunity to survive and thrive. 

Parents and care providers can consult Global Health Media’s video How to Express Breastmilk in situations where hand expression is warranted. 

More recently, USBC has compiled a comprehensive resource page for Infant and Young Child Feeding in Emergencies, including COVID-19.

USBC calls on us to take action by urging policymakers to take three actions to integrate infant and young child feeding into emergency preparedness and response efforts:

  • Expand the Federal Interagency Breastfeeding Task Force to include emergency and infectious disease experts
  • Direct the Federal Emergency Management Agency to ensure breast/chestfeeding people have appropriate services and supplies during a disaster or pandemic
  • Enact World Health Assembly Resolution 12.6 related to infant and young child feeding in emergencies

The CDC offers their guide to disaster planning here

CGBI’s Dr. Aunchalee Palmquist leads Lactation and Infant Feeding in Emergencies (L.I.F.E.) Amid the Pandemic Initiative, an active hub of research, policy advocacy, and technical support with recommendations relating to current emergency situations.

The World Alliance for Breastfeeding Action (WABA) has made available an interview between Dr. Felicity Savage and Dr. Amal Omer Salim which touches on proper breastfeeding support during normal and crisis situations. 

Dr. Savage points out that one of the biggest concerns about breastfeeding counseling during emergent situations is actually getting the counseling to parents. Specifically during the Covid-19 pandemic, Drs. Savage and Salim emphasize that separating mother and baby is not necessary to prevent the spread of the infection from mother to child, and make clear that care providers should follow WHO and UNICEF guidelines

#NBM20 

#IYCFE 

#ManyVoicesUnited

Breastfeeding in shelters

Among the many effects of the novel coronavirus, the pandemic has exposed our nation’s deficiencies: emergency unpreparedness, racial health disparities, our “highly polarized, fragmented, and individualistic society…” (I would add arrogant), and the failure of capitalism.  In marginalized populations, poverty, health inequities, and other burdens are amplified during an outbreak or other emergency. 

Long before the pandemic hit, individuals and advocacy organizations have been ringing the alarm, calling for better access to education, better healthcare, and equity and justice for all.

Of these trailblazers is Powerhouse Nikki Lee RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, CKC, RYT whose recent endeavor includes creating and implementing the 10 Steps to a Breastfeeding Friendly Shelter

In her role at the City of Philadelphia Department of Public Health, Lee noticed the challenges breastfeeding people face in shelters. 

The barriers are a result of our cultural attitude toward lactating people and misunderstandings about their bodies and needs. 

Lee talks about issues of privacy and ‘fairness’ in a shelter. Organizational dress codes often require residents to dress modestly, so when a person exposes their breasts to feed a baby, other residents can wonder why they’re not allowed to wear short shorts. Parents can express concern about the teenage boys in their families seeing breasts while a baby is being fed.

There’s the concern over safe milk storage and the mythology around reimbursement through the Child and Adult Care Food Program. Shelter staff may believe that if a mother breastfeeds, the facility will lose money to buy food because the allotted amount for infant formula isn’t getting used. Lee clarifies that if a mother breastfeeds, the institution will have more money to spend on food.  

Just like in the rest of the US, there tends to be a push for formula feeding because the baby’s intake is easily measured, and staff are more comfortable with what is familiar, i.e. bottle-feeding

Lee continues, “There is a genuine honesty from people who don’t understand anything about breastfeeding, ‘Why are we breastfeeding?’ ‘Why are we bothering?’”  Staff in hospitals have been educated about breastfeeding over the past few decades; staff in shelters have not.

So when she conducts trainings, she starts at the rudimentary level of ‘what are mammals?’ 

“All the worst mythology that you can imagine is in the shelter,” Lee says. “All the worst in how society treats mothers and babies gets magnified in shelters.” 

With the problem identified, Lee says she started “from scratch in a way,” looking for a written policy to support breastfeeding people.  Early on in her search, she followed up on a news story featuring a homeless mother in Hawaii. She posted inquiries on Lactnet, CDC listserv, international online forums, Facebook groups, and reached out to shelters at random wondering if they had breastfeeding policies . 

“Nothing,” Lee reports. “There is probably a shelter somewhere that has a policy, but after two years of a global search, I wasn’t able to find it.” 

In all her search,  Lee found one published document— a Canadian study looking at the factors that influence breastfeeding practices of mothers living in a maternity shelter– that could be helpful. 

Lee wrote the first draft of the 10 Steps to a Breastfeeding Friendly Shelter with policies like the Ten Steps to Successful Breastfeeding and Ten Steps to Breastfeeding-Friendly Child Care in mind. 

She sent it out to colleagues at CHOP’s Homeless Health Initiative for feedback, and for quite a while, there was none. Lee’s colleague Melissa Berrios Johnson, MSW,  a social work trainer with HHI, and the convenor of its breastfeeding workgroup subcommittee, helped to make the policy reality. 

Partner agency Philadelphia Health Management Corporation (PHMC) received a grant that funded research which took the policy to four different shelters for staff and resident feedback. 

“Everyone, residents and staff alike, felt this policy was important and feasible,” Lee says. 

PHMC’s next step was to identify a shelter staff member to become a breastfeeding champion. This champion would be provided with free breastfeeding training, and receive an honorarium.

As program oversight changed though, “breastfeeding champion” became a job, with a list of responsibilities. So far, Lee says they’ve only found four people out of 10 shelters who are willing to take on the task.

“There are some folks in shelters working hard to make things better,” Lee says. “They are those champions, most of whom have breastfed themselves.”

Currently, Lee and colleagues are in the process of developing training for staff members and ironing out how to help staff implement the policy.  

Lee’s and co-authors Alexandra Ernst MPH, and Vanesa Karamanian MD, MPH landmark paper about the 10 Steps to a Breastfeeding Friendly Shelter has been submitted to the  Journal of Human Lactation (JHL)

At present, COVID has put all of this work on hold.