Summary of presentation1
The Core Group2, composed of UNICEF, UNHCR, WFP, WHO, ENN and GIFA/IBFAN have developed and disseminated module 13 on Infant Feeding in Emergencies. Module 2 is nearing completion, and has a greater technical component to support health and nutrition staff operating in emergency situations to assist mothers with infant feeding in emergency settings.
Between 16 and 17 April, 2003 a meeting was held by the Core Group4, hosted by UNHCR, Geneva, to identify the key steps necessary to finalise the training modules. Presentations were made by ENN, on a recent collaborative project with GIFA to support the development of the modules, and by Professor Mike Golden, on the use of diluted F100 in infants under six months.
Key steps necessary to complete the modules were identified. The management of malnutrition in infants less than six months emerged as an outstanding issue which requires a wider consultation outside the Core Group.
In order to strengthen the development of the training modules, a project was developed between the Geneva Infant Feeding Association (GIFA) and the Emergency Nutrition Network (ENN) to evaluate the application of Module 1 to date, and to collate field experiences (in the form of case studies) of agencies involved in infant and young child feeding in emergencies to support module 2. Key findings were reported to the Core Group at a two day meeting (15-17 April, 2003) in Geneva, and key issues to emerge are summarised here.
Evaluation of Module 1
Information was collected through email and phone interview on the use of the module, its value and if there was a need to update/revise it. Four key user groups were targeted - the Core Group involved in the development of the training module, individuals who downloaded the material from the website, institutions involved in humanitarian training courses and key organizations involved in emergency nutrition interventions.
Since April 2001, over 1000 sets of module 1 training material have been disseminated to agencies and institutions. The material had been used in both formal and informal training by agencies, institutions and individuals. The ENN site has proved a significant distribution mechanism. Overall, 158 individuals from 20 different countries, representing at least 12 different international organisations, have downloaded material from the site.
All sections and training modules were used to varying degrees. However there was a call for more detail on supporting appropriate feeding practices, more focus on complementary feeding issues and more guidance on the challenges of infant feeding and HIV/AIDS. More case studies were also requested, with more updated information on recent or current emergencies and situations, e.g. displacement of large numbers of unaccompanied children.
Although module 1 was devised for nontechnical staff, technical staff, e.g. health and nutrition workers, largely used the material. Those contacted felt the material could be marketed and targeted better. Some were not aware that the material was still available, while others felt it would be worthwhile investing in training of trainers to realise the full potential of the module.
The majority felt that translation would be premature until the modules had been finalised, however material had already been locally translated into Arabic, Spanish and Portuguese.
Based on this evaluation, it was recommended that the necessary steps to finalise module 2 should be taken. Both modules need to be appropriately marketed and targeted to emergency staff.
A variety of experiences and case studies were constructed. Experiences were gathered from staff currently working in a variety of countries, including Burundi, Liberia, Afghanistan, Sudan and Sierra Leone.
During the course of gathering field material, a number of issues emerged which were highlighted at the meeting.
First, a number of experiences touched on topics that were not extensively dealt with within the current draft of the training material. These particularly related to small scale (e.g. orphanage feeding) and large-scale (e.g. Iraq situation) interventions, where artificial feeding was a significant part of the emergency response.
Secondly, a critical issue emerged regarding the most appropriate management of malnourished infants less than six months - an area already identified by the Core Group as lacking in evidence. A number of field practices were identified, with individual experiences and effectiveness of interventions varying between countries and programmes. A comparative review was made of recommendations/field practice, to identify common ground, gaps, and conflicts, review the supporting evidence and determine the implications for the development of technical guidance within module 2. Protocols and practices from MSF (Afghanistan and Burundi), ACF (Afghanistan, Liberia, Burundi), Merlin (Sierra Leone), Concern (Bangladesh), and recommendations from MSF, ACF, WHO and the Ethiopian Framework for severe malnutrition were included.
Examples of specific differences between protocols and practice regarding infants less than six months included:
- Different supplementary milks used in addition to breastmilk, including F75 and F100, diluted F100, and infant formula.
- Various admission criteria, with permutations on weight and height criteria as well as reported age, medical and clinical criteria.
- Differences in discharge criteria, most significantly whether anthropometric targets were included or not.
The majority of guidelines (i.e. MSF, ACF) aimed to re-establish breastfeeding in the severely malnourished young infant, if necessary using supplementary suckling, and relied on breastmilk to achieve subsequent catch-up growth. In contrast, draft WHO recommendations for severely malnourished infants less than six months advise that breastfeeding cannot be relied upon for treatment. Supplementary milk (F75 during stabilisation, F100 during rehabilitation) is recommended by WHO before each breastfeed, which they feel is necessary to ensure the survival of the severely malnourished infant.
Varying sources and levels of evidence supported current recommendations and practice. Most of the field activities and agency protocols that were reviewed have been guided by the ACF guidelines5, developed on the basis of documented interventions in Liberia6 and operationalised in many programmes since. In many cases, however, reported evidence based on programme experiences has not been fully documented, or has not been widely disseminated. Also, the context of emergency programmes has a significant influence on outcomes and is critical in interpreting effectiveness of interventions.
Evidence behind technical sources of guidance is also variable. The lack of substantial research in this area means that limited data may be given a higher credence than they merit. As it stands, there is scope for considerable confusion as to appropriate practice in the field. Conflicting recommendations may undermine the perceived value of guidance, and have a detrimental effect on the management of malnourished infants.
On the basis of this study it was recommended that artificial feeding of infants is addressed in greater depth within the technical guidance of module 2. It was suggested that resolution of issues regarding the management of malnutrition in young infants is critical, but requires involvement of a wider network of technical experts and practitioners outside the Core Group. An urgent consultation involving agencies active in the field and technical individuals/bodies is required to achieve consensus.
1Presentation, ENN/GIFA project, Marie McGrath, Core Group meeting, Geneva, 16-17 April, 2003
2A group of agency personnel committed to taking forward the process of improving practice in infant feeding in emergencies through the development and dissemination of appropriate training materials
3Infant Feeding in Emergencies, Module 1 for emergency relief staff. Draft material developed through collaboration of: WHO, UNICEF, LINKAGES, IBFAN, ENN and additional contributors. March 2001
4In addition to the Core Group members, also attending were Professor Mike Golden, Dr Andy Seal (Institute of Child Health, London), Rebecca Norton (Terre des Hommes) & Felicity Savage.
5Assessment and Treatment of Malnutrition in Emergency Situations, Manual of Therapeutic Care and Planning for a Nutritional programme. Written by Claudine Prudhon*, published by Action contre la Faim (2002)
6Field Exchange, Issue 9, Infant feeding in a TFP, MSc thesis, Mary Corbett, p7
Taken from Field Exchange Issue 19, July 2003