PLANNING AND MANAGING ARTIFICIALFEEDING INTERVENTIONSDURING EMERGENCIES

A guide for decision makers and programmers working in emergency preparedness and response
During emergencies, ensuring that infants and young children are fed as recommended is crucial to safeguarding their health, development
and survival. For infants who cannot be breastfed, it is important to provide a timely and well designed artificial feeding programme.
Poorly managed distributions of breastmilk substitutes (BMS) increase the risk of malnutrition, illness and death for all children.

1

Assess the need for artificial feeding support and critically analyse the context!

Artificial feeding is a last resort for non-breastfed infants, and should be used only after rapidly exploring the viability of milk expression, relactation,breastfeeding by a healthy woman other than the child's mother and donor human milk.
Assess needs and context*Alerts that may trigger need for an in-depth assessment•	Monitor for alerts* in early needs assessments that may trigger the need for an in-depth assessment.
•	Determine infant and young child feeding (IYCF) practices using needs assessments and pre-crisis data (including non-breastfed prevalence).
•	Verify the acceptability and feasibility of safer feeding options (including donor human milk and wet nursing).
•	Check what systems were established in preparedness and assess operational capacity for artificial feeding support (including funding, trained
human resources, supply chain, WASH support, and availability of fuel, water and equipment for hygienic preparation of BMS at household level).

•	High rate of non-breastfed and other BMS-dependent children.
•	High risk of BMS donations (e.g. history of BMS donations, calls/offers ofBMS donations, weak WHO International Code legislation enactment orenforcement).
• Requests for BMS support.
•	Outbreak of an infectious disease for which temporary
cessation of breastfeeding is recommended for positive
cases (e.g. Ebola); refer to infographics on Infant
feeding during infectious disease outbreaks.
• High number of separated infants/maternal orphans.

Decide on scale of artificial feeding support• Determine the ages of infants in need of BMS: prioritise infants who are under six months of age.
•	Estimate duration of BMS provision: BMS should be provided for as long as the infant needs it (i.e. until breastfeeding isreestablished or until at least six months of age).

2 Design and plan artificial feeding management programme

3 Secure supplies and services

Develop Standard Operating Procedures

Procure feeding, preparation and storage equipment

In emergencies, the use of BMS requires a context-specific, coordinated package of sustainedcare and skilled support to ensure the nutritional needs of non-breastfed children are met and tominimise risks to all children (including breastfed children) through inappropriate BMS use.
•	Develop SOP in close consultation with the IYCF-E coordination authority and UNICEF.
•	Ensure SOP adequately addresses all elements of artificial feeding programming in line with theOperational Guidance on Infant and Young Child Feeding in Emergencies

Remember!  Developing Standard Operating Procedures (SOP) and establishing supply chains during preparedness
facilitates a timely, efficient and appropriate response.

Necessary supplies	Feeding cup and spoon (open, without spout, easy to clean)

Large storage container

Detergent

Clean water

Paper towel

Cooking pot with lid

Measuring tool for BMS

Heat source

Establish clear eligibility criteria
Safer alternatives are not possible

Short-term eligibility

Long-term eligibility	Mother's own expressedbreastmilk.	Re-starting supply to return tobreastfeeding (relactation).
AND	Breastfeeding by a healthy
woman other than the child’smother.	Donor human milk.

Mother severely ill.	Relactation (with infant
formula as the supplement).	Waiting for other saferORalternatives.	Increasing supply to returnto exclusive breastfeeding forchildren under six months.	Short-term separation frommother.	Not breastfed preemergency.	Replacement feeding for HIV.	Mother deceased or absent.
Rare medical condition.	Mother has rejected infant.	Survivors of Sexual andGender Based Violence(SGBV) who may not be
ready to breastfeed.

Collaborate closely with WASH sector. Ensure that a hygenic space and facilities for cleaningand preparation are available, including safe water.
Where necessary, cleaning equipment needs can be reduced by using disposable cups.
For Ready to Use Infant Formula, water needs are lower: there is no need for potable waterto reconstitute the milk.

Secure support services
Artificial feeding management should include the necessary support services:	Education and practical demonstration of hygienic preparation and storage of BMS, and cup feeding.1

Eligible age range depends on pre-emergency practices, resources available, adequacy of complementary foods,and government policies.	One-on-one counselling on IYCF, including complementary feeding, if applicable.

Specify appropriate BMS

Access to health services.	Growth monitoring.
1	Discourage use of feeding bottles due to high risk of contamination. Where bottles
are used by caregivers, act to help mitigate risks. Refer to 6.23 in the OG-IFE.

An appropriate BMS is Codex Alimentarius compliant and meets the provisions of the WHO International Code.
Ready toUse Infant
FormulaPowderedInfantFormulaPasteurised/boiled fullcream
animal milk

Ultra-High
Temperature
milk

Reconstituted
evaporated
milk

Fermented
milk/
yoghurtToddler/follow-on/
growingup milks

0-5 months

Priority group

6-11 months

Ensure adequate IYCF counsellor competencies through training and supportive supervision.

Collaborate closely with Health, Nutrition, Early Childhood Development, Mental Health andPsychosocial Support, WASH, Protection, Shelter and other sectors to establish referral pathways.

Supply the BMS programme

12-23 months

BMS (e.g. infant formula)should be procured andsupply sustained for as
long as needed under theprovisions of the Code.
Do not accept donations.

•	Products with generic labelling are preferred, followed by commercial (branded) products.
•	Each individual container should be labelled with information dictated by the WHO International Code, in the language
understood by the end user. If the label violates the Code, consider relabelling.

Estimate amount of BMS
BMS

Average amount per infant
0-5 months per day

Average amount per infant
0-5 months per month

Ready to Use Infant Formula

750-800ml

22.5L

Powdered Infant Formula

116g

3.5kg or 9 (400g) tins or 4.4 (800g) tins

• Supplies should have a six-month shelf life from point of delivery.

UNICEF can act as the provider of firstresort and procure BMS to meet its mandate.2
BMS suppliers should be identified following
transparent and clear procurement
procedures (ideally in preparedness).
2	In humanitarian contexts where BMS is needed and cannot be supplied within 48 hours,UNICEF commits to act as the provider of first resort and can procure BMS whether or
not the cluster has been activated.

Local vs international procurement depends on:•	Codex Alimentarius and WHO International Code product compliance.
•	Stock availability.
•	Cost.

Check expiry date.

• Ready to Use Infant Formula is a sterile product only until opened and requires refrigeration afterwards.

•	Importation legislation.
•	Language and labelling.
•	Risk of creating new markets.

• For Ready to Use Infant Formula, small volume units are preferred to prevent re-use and wastage.

4 Implement artificial feeding support
Decide on approach for provision of BMS
The right distribution system for
BMS will depend on the context.
Never distribute BMS or any milk products
through general or blanket distribution.
There should be no promotion of BMS at thepoint of distribution (e.g. displays of products
or items with company logos).

Options forprovision
include:Distribution should be carried out in a discreet
manner.
Cash/Voucher
AssistanceIndividual
prescription andpurchaseOn-sitepreparation

Direct provision
for preparation
at homeBe alert to unintended consequences of BMS
provision, such as sale of products.
Communicate clearly to caregivers andcommunities, including about eligibility criteria.
Ensure breastfeeding support services arealready in place.
Monitor and document artificial feeding
support experiences and lessons.

Part of the Infant Feeding in Emergencies Core Group infographic series.
Find out more at www.ennonline.net/ife

Funders of artificial feeding interventions
should ensure that all provisions of theOG-IFE and the Code are met.
Ensure that necessary policies andguidance are in place and in line with
OG-IFE and the Code.
Refer to infographic on SupportingInfants Dependent on Artificial
Feeding in emergencies for guidance
for frontline workers.