Credit: © WFP/Naing Linn ShweIYCF-E and MAMI: Working together
to support the continuity of quality,
respectful care for at-risk infants
under six months and their mothersin humanitarian contexts
A collaborative initiative between the
Infant Feeding in Emergencies Core
1Group and MAMI Global Network

March 2024

Contents
1

Background

3

2 About IYCF-E

4

3 About the MAMI Care Pathway approach

5

4 	IYCF-E and MAMI services: sharedcommitments, complementary action

6

5 Key considerations for informed action

7

6 What to do

8

Annex: Key Resources9

Abbreviations and acronyms
BMS
ENN
GBV
IFE
IYCF
IYCF-E
MAMI
OG-IFE
PTSD
WASH
WHO

Breast milk substitutes
Emergency Nutrition Network
Gender based violence
Infant feeding in emergencies
Infant and young child feeding
Infant and young child feeding in emergencies
Management of small and nutritionally at-risk infants and their mothers
Operational Guidance for Infant and Young Child Feeding in Emergencies
Post-traumatic stress disorder
Water, sanitation and hygiene
World Health Organization

Acknowledgments
This brief was prepared by the Emergency Nutrition Network in addition to several members of the Infant Feeding in
Emergencies (IFE) Core Group and the management of small and nutritionally at-risk infants and their mothers (MAMI)
Global Network. They collaborated by forming a Technical Advisory Group (TAG) that shared experiences of integrating
infant and young child feeding in emergencies (IYCF-E) and MAMI approaches to inform this brief. We extend oursincere appreciation to the TAG, comprised of experts representing a diverse array of backgrounds in both MAMI and
IYCF-E programming. Their contributions were invaluable.
This work is made possible by the generous support of the American people through the United States Agency forInternational Development (USAID). The contents are the responsibility of its authors and do not necessarily reflect theviews of USAID or the United States Government.
Suggested citation
ENN, IFE Core Group & MAMI Global Network (2024). IYCF-E and MAMI: Working together to support continuity ofquality, respectful care for at-risk infants under six months and their mothers in humanitarian contexts. Emergency
Nutrition Network (ENN), Oxford, UK. https://doi.org/10.6084/m9.figshare.25161653

2

1

Background

This brief has been developed to help to improve understanding of the synergies between infant and young
child feeding in emergencies (IYCF-E)/infant feeding in emergencies (IFE) and the management of small
and nutritionally at-risk infants under six months and their mothers (MAMI) to catalyse collaboration andstrengthen practice in humanitarian contexts. This brief is not prescriptive as to what to do but identifies
avenues to explore to enable responsive, appropriate care.
The development of the brief involved consultation with members of the IFE Core Group and the MAMI
Global Network (see Box 1). This brief provides clarity on the key issues identified through the consultationand is, we hope, a first step towards a future more dynamic collaboration.

Box 1: IFE Core Group and MAMI Global Network
The IFE Core Group is a global collaboration of agencies and individuals that formed in 1999 toaddress policy guidance and training resource gaps that hampered programming on infant andyoung child feeding (IYCF) support in emergencies. The formation followed on from a key meeting,hosted by the International Baby Food Action Network in Geneva in 1995, which while recognising
the need for the provision of small amounts of breastmilk substitutes (BMS) in emergency situations,
identified the need to protect mothers and children from the indiscriminate distribution of BMS. The
IFE Core Group, coordinated by the Emergency Nutrition Network (ENN) and under the jurisdictionof a Steering Committee, does not directly implement programmes but rather develops guidance
and resource materials, documents lessons learned, and builds capacity for effective IYCF support
in emergency contexts. The IFE Core Group members bring challenges and issues to the collective
membership for peer support and guidance to facilitate the rapid application of up-to-dateexperience in operations and to connect on-the-ground experiences with the development of agency
and global policy guidance. For more information: https://www.ennonline.net/ife
The MAMI Global Network is a group of local, national, and international collaborators (programmers,
researchers, and policymakers) working to improve policy, programmes and practice for small andnutritionally at-risk infants under six months and their mothers. It was initially established as a Special
Interest Group in 2010, then later scaled up and formalised as a global network in 2020, coordinatedby ENN and co-led by ENN and the London School of Hygiene and Tropical Medicine. The MAMI
Global Network does not directly implement programmes but supports three broad areas of work:
evidence, policy and practice. For more information:
https://www.ennonline.net/ourwork/research/mami

Audience

This brief is relevant for those working with infants, young children, and their mothers at global, regional,
national, or sub-national level across nutrition and health in emergency preparedness, response, andrecovery. The relevant sectors and disciplines include, but are not limited to, the integrated managementof childhood illness, services that prevent or treat acute malnutrition/wasting, antenatal and postnatal
services, growth monitoring programmes, and women’s/maternal health and nutrition.

Context of emergencies

Emergencies disrupt systems of care in many ways at different levels of scale and consequence, may
be acute or chronic, and are often unpredictable. Emergencies particularly challenge the vision of care
continuity where systems of health (from formal to informal structures and at a household leveli) are alreadyinsecure or vulnerable, further disrupting services and capacities. The consequences of existing gaps in care
continuity and service provision may be further accentuated.
i	(described by Marten et alMarten R, Shroff ZC, Hanson K, Davies S, Reddy S, Vega J, Peters DH, Ghaffar A. Reimagining healthsystems as systems for health. BMJ 2022;379:o3025 doi: https://doi.org/10.1136/bmj.o3025

32 	About infant and young childfeeding in emergencies
IYCF-E concerns the promotion, protection, and support of appropriate and timely feeding for infants
and young children aged 0-23 months in the context of humanitarian emergencies. It includes
supporting the nutritional needs and concerns of both breastfed and non-breastfed children and thewellbeing of mothers and other caregivers.
The same recommendations for infant and young child feeding (IYCF) practice for stable contexts also
apply in emergencies, but the methods used to best support recommended IYCF practices may differ.
IYCF programmes delivered in an emergency are not necessarily different to those provided in stablesettings and often may involve existing services established in stable settings and through emergency
preparedness. What distinguishes IYCF and IYCF-E is the context; emergencies often generate new or
escalated challenges and risks and disrupt systems and services across multiple sectors, including nutritionand health, and at multiple levels, from household to service delivery. Emergency responses may involve
different providers of care as part of surge support.
Recent emergencies have expanded the scope of IYCF issues and modified the ways of working inhumanitarian contexts. Crises have occurred in more urbanised, middle-income countries where rates ofbreastfeeding were low (such as Syria) which has necessitated greater consideration and the adaptation of
guidance for how to support non-breastfed children and their carers including in camps and transit settings,
as well as remote support contexts. Safe and secure supplies of breastmilk substitutes and associatedsupport may be needed. Evidence shows the effect of stress and trauma (such as that due to conflict,gender-based violence (GBV), etc.) on IYCF practices and the need for coordination with mental health/psychosocial support and sexual and reproductive health services for infants and their caregivers. There isalso a need to sensitise frontline practitioners on post-traumatic stress disorder (PTSD), the symptoms andhow they can avoid exacerbating PTSD or re-traumatising families when providing direct IYCF services.
To help to address these contextual issues, the Operational Guidance for Infant and Young Child Feeding in
Emergencies (OG-IFE) provides an operational framework for the preparedness, response, and recovery of
IYCF in all emergencies (see also OG-IFE Briefing Slides). Since the development of this guidance, an IYCF-E
Infographic Series has been developed to help to operationalise the OG-IFE. In addition, specialised advice
for specific infant feeding problems is provided by the IFE Core Group, relevant for rapid-onset or ‘new’
emergencies or new risks and burdens. Areas of specific attention include IYCF and HIV; IYCF and Ebola;
IYCF-E and COVID-19; Impact on IYCF of chemical, biological, radiological and nuclear threats in war; IYCF
feeding support in transit; Breastfeeding counselling in emergencies. This Infant and Young Child Feeding in
Emergencies - Key Global Resources handout presents a collection of resources.

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3 About the MAMI Care Pathway approach
MAMI refers to the continuity of respectful quality care for small and nutritionally at-risk infants under six
months and their mothers across systems of health and nutrition. Babies may be born at-risk/vulnerable
or become so in the early months of life. These ‘at-risk’ mother-infant pairs include small vulnerable
newborns, including low birth weight, premature, small for gestational age, infants who are wasted, stunted,
and/or underweight, and infants at risk of poor growth and development, and considers the vulnerability of
their mothers (related to health, nutrition, or social circumstance).
The MAMI Care Pathway applies an integrated care pathway approach to the context of at-risk motherinfant pairs. It provides a framework on how to support, embed, integrate, connect, and facilitate continuityof quality respectful care for at-risk mother-infant pairs through the first six months of life within and acrossservices, sectors, and disciplines. A guide to how the MAMI Care Pathway fits and sits within existing services
is included in the MAMI Care Pathway Package (refer to figures 1, 2 and 3 on pages 4, 12 and 13). The MAMI
Care Pathway applies to all settings including, but not limited to, emergencies.
The MAMI Care Pathway approach is consistent withii, and supports the implementation of the World
Health Organization (WHO) 2023 recommendations on the management of infants under six months
at risk of poor growth and development, one of four sections of the WHO guidance for prevention andmanagement of wasting and nutritional oedema. The WHO 2023 guidance and the MAMI Care Pathway
approach combine prevention and treatment. The aim of care is to mitigate the immediate and future riskof mortality, morbidity, poor growth, and development and to restore and sustain healthy growth to at-risk
infants under six months (and beyond).
The MAMI Care Pathway Package provides guidance and resources that were collaboratively developed
under the MAMI Global Network to help to put this framework into practice for context-specific adaptation
to support the implementation of service quality and continuity. The MAMI Care Pathway has applied andbuilt upon existing materials such as the WHO integrated management of childhood illness and UNICEF/
WHO breastfeeding counselling materials to the context of at-risk mother-infant pairs. It embeds skilled
feeding counselling for breastfed and non-breastfed infants under six months as a core component ofmanagement for all mother-infant pairs enrolled in care. Clinical triage and medical care according to local
protocols are also fundamental components. Additional content expands on breastfeeding counselling
support, responsive growth monitoring, maternal mental health support, and early childhood development.
The key components of the MAMI Care Pathway are shown in Box 2. What is needed and how it works inpractice will vary by individual, service, crisis context, and time. Services and approaches to achieve
continuity of respectful quality care for at-risk infants under six months and their mothers come in manydifferent shapes and forms. The MAMI Care Pathway approach is not a standalone/one size fits all/the only
way to meet the needs of at-risk mother-infant pairs. It provides a framework to build on and strengthen
what exists in country already and requires adaptation according to context to facilitate the achievement of
the continuity of quality, respectful care for at-risk infants and their mothers.
The MAMI Communications Guide provides accessible information to help to understand what MAMI is
and its relevance to other sectors and disciplines including health, child protection, water, sanitation andhygiene (WASH) and neonatal services.

ii	McGrath M. MAMI and the new 2023 WHO recommendations on ‘at-risk’ infants under 6 months: we’re talking the same talk! ENN.

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Box 2: Core components of the MAMI Care Pathway approach•

Active screening for at-risk infants/mothers at all community contact points•

Assessment and support of the mother-infant pair•Comprehensive risk assessment using clinical, feeding, anthropometric, maternal factors•

Integrated management of childhood illness-based outpatient/community clinical care•

Individualised feeding counselling•Core support on maternal relaxation, infant crying and sleep, nurturing care, complementary
feeding, family and community support•

Active, responsive growth monitoring•

Refer to specialist services as needed•

Enrolment in care to six months of age (frequency of attendance according to need)

MAMI Care Pathway package Version 3 (2021) provides guidance with various templates, screening
tools and counselling cards.

4 	IYCF-E and MAMI services: sharedcommitments, complementary action
The OG-IFE recognises and recommends the prioritisation of “infants and their mothers or caregivers inexceptionally difficult circumstances”. The identification of at-risk mother-infant pairs through the MAMI Care
Pathway approach is a marker of such ‘difficult circumstances’ that may be due to medical, nutritional, and/or social factors.
The MAMI Care Pathway provides a framework for an integrated approach to secure the continuity ofquality, respectful care for small and nutritionally at-risk infants under six months and their mothers
within and across health and nutrition. It requires contextualisation to need, operational environment andcapacities. Skilled breastfeeding support is a critical component of care. Emergencies are a context that
often heighten infant and maternal health and nutrition risks and stretch existing personal and system
capacities. To help to both prepare and respond in such circumstances, collaboration is critical between thespecialities and sectors that respond in crises.
MAMI services are part of a maternal-infant health-centred approach to deliver timely care within which
nutrition (including IYCF) is core but not the only component. IYCF services target all mother-infant pairs,
whereas MAMI specifically targets a subset of mother-infant pairs who are identified as at risk of pooroutcomes (death, illness, poor growth, and development).
The ways and extent to which IYCF-E and MAMI support services are connected will vary by context
depending on the type of humanitarian emergency, the stage of the response, the available humanresource capacity, the caseload, the type of service providers, the services already existing, and the extent
of preparedness activities prior to the emergency. Regardless of the extent to which the services arelinked, it is essential to secure continued and effective communication between those managing andproviding the two services.

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5 	Key considerations for MAMI-sensitive
action in IYCF-E responses
Preparedness

Before an emergency happens, infants under six months may already be at risk, such as being underweightor growing poorly. The degree to which these infants are identified and managed varies greatly acrosscontexts. Building resilient mother-infant pairs and systems and services to support them in a crisis
is a critical emergency preparedness activity. Those working on IYCF in emergency-prone countries
can help to catalyse and deliver resilience-building services in both the interests of prevention and
MAMI response in crisis.

Coordination

Variation in emergency contexts will determine how care is coordinated and provided to all infant-motherpairs and by whom, including at-risk infants and mothers. Operational contexts may shift throughout
the emergency preparedness, response and recovery stages. In emergencies, securing the continuity ofrespectful, quality care for mother-infant pairs, including those more at risk, must involve health actors,
including reproductive and paediatric services and child protection. It should ideally be led or co-led bygovernment and health providers using an existing mechanism whenever possible. Where the cluster
mechanism is activated, IYCF-E and MAMI may be coordinated within the Nutrition or Health Cluster but
should involve both (in addition to other clusters as required to ensure a holistic package of services).

Practice

Integrated pathways of care for MAMI will vary by context in terms of what is needed and how it is provided.
Within such care pathways, different disciplines, sectors, and specialities have key roles to play. IYCF is one
such critical dimension for support. A core ‘non-negotiable’ component of the MAMI Care Pathway approachand IYCF programming is skilled feeding support to at-risk mother-infant pairs both for breastfed and nonbreastfed infants. Clinical triage and access to health care are also fundamental to the approach. Severalof the activities of the MAMI Care Pathway approach may feature to varying degrees in IYCF services/
programmes, including in emergencies, e.g., screening for feeding problems, problem-based one to one
breastfeeding counselling, active growth monitoring, and psychosocial support to mothers. Within the
MAMI approach, such activities must be embedded within health services to ensure critical clinical care isavailable to both infants and mothers. Once enrolled, infants reach six months and are then discharged from
MAMI care and continued follow up by IYCF and other services is needed to help to further build and sustain
continued healthy growth and to remain alert and responsive to any future growth problems.

Contextualisation

In every emergency, it is critical to adapt approaches and resources to the context. Support for IYCF and atrisk mother-infant pairs should be embedded in existing structures and mechanisms where possible, withsurge capacity and resources provided when required to ensure respectful quality care for infant-motherpairs. To help in preparedness and response, those dimensions of care/activities that need to (or could) be
strengthened and by whom should be mapped across services, including IYCF services. The MAMI Care
Pathway Package provides a framework to help to support adaptation and integration.

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6 What you can do
It is critical to consider the practical linkages that can be made between IYCF and MAMI services tostrengthen the quality and continuity of care provided to at-risk mother-infant pairs and to avoid siloedservices, which is even more important in the context of emergencies. Depending on where you work, withwhom and how, you can raise awareness and help to secure continuity of care through policy, research, andpractice actions. Here are some examples of what to do:•Understand your context – what are the contact points for the identification of and support to allmother-infant pairs in relation to IYCF and at-risk mothers and infants specifically? What services
already exist, how can these be strengthened, used, built upon, and connected.

•

Raise awareness with services to be alert for ways to integrate with and support IYCF services inemergencies – antenatal/postnatal services, growth monitoring, child protection, WASH etc.

•

Raise awareness with services to be alert for at-risk infants and mothers – child protection, surgical/
trauma services treating women, reproductive health services etc.

•

Identify practical entry points for connections and integration between IYCF-E and MAMI services.

•

Embed at-risk mother-infant pairs in policy and guidance documents, such as joint statements on
IYCF-E, referring to the WHO 2023 guidance and the MAMI Care Pathway.

•

Identify how you could support skilled service provision within and to support IYCF and MAMI
services in emergencies, e.g., training, mentoring, supportive supervision, secondment of staff,
provision of specialist breastfeeding counselling support within services etc.

•

Ensure all mother-infant pairs in an emergency receive IYCF support and identify at risk motherinfant pairs through IYCF services for targeted feeding counselling support and referral for clinical/
maternal/more specialist feeding care through MAMI services as needed.

•

Advocate for/negotiate/help to develop/provide access to capacity on skilled breastfeedingcounselling within inpatient and outpatient health services in emergencies that manage sick infants
and newborns (with particular attention to adolescent mothers and low birth weight infants).

•

Strengthen the provision of skilled breastfeeding counselling within existing health and nutrition
services through IYCF programmes and other services as a critical preparedness/resilience
initiative. Capacities developed in preparedness may be compromised in an emergency when
staff themselves are affected, facilities may be compromised (e.g., destruction) and health systems
generally overwhelmed. Surge support to capacity may be needed in such contexts in the interim.
Planning for such scenarios should also form part of preparedness activities.

For more information•

The IFE Core Group and MAMI Global Network provide platforms for responding to technical questions
arising and developing timely consensus-driven stop-gap guidance in response to key technical gaps
identified by the technical arm of the Global Nutrition Cluster.
IFE Core Group: https://www.ennonline.net/ife or write to ife@ennonline.net
MAMI Global network: https://www.ennonline.net/ourwork/research/mami or write
to mami@ennonline.net
En-net forums for IYCF and MAMI questions: this is a peer-to-peer free online platform for informal
technical discussions where people can pose questions, share experiences/research and challenges
faced, and offer potential solutions. Available in English and French.

8Annex: Key Resources
IYCF-E resources•

Operational Guidance on Infant Feeding in Emergencies (OG-IFE) version 3.0. (IFE Core Group, 2017).

•

An IYCF-E Infographic Series has been developed to help operationalise the OG-IFE.

•

Infant and Young Child Feeding in Emergencies - Key Global Resources and OG-IFE Briefing Slides.

•

Operational Guidance on Breastfeeding Counselling in Emergencies (ENN and the IFE Core Group,2021). Guidance is generally operationally based, step by step.

•

Specific technical briefs developed by the IFE Core Group or to which the IFE Core Group has
contributed include: IYCF and HIV; IYCF and Ebola; IYCF-E and COVID-19; Impact on IYCF of chemical,
biological, radiological and nuclear threats in war; IYCF feeding support in transit.

•

Infant and Young Child Feeding in Refugee Situations: A Multi-Sectoral Framework for Action (Save theChildren and UNHCR), plus roll out guide (2022).

•

Core Indicators endorsed in 2015 by the IFE Core Group and the Global Nutrition Cluster as part of the
IYCF-E Toolkit include 13 IYCF assessment indicators and 35 IYCF performance monitoring indicators.

•

The IYCF-E Hub is a global portal to the most relevant resources related to infant and young childnutrition in humanitarian contexts.

•

The IYCF repository has peer reviewed literature compiled by the IFE Group on a quarterly basis.

•

Operational learning and case studies (e.g., https://www.ennonline.net/cfecasestudynigeria) togenerate evidence globally and nationally, including grey literature. Current case studies include
relactation and wet nursing led by UNICEF.

MAMI resources•

MAMI Care Pathway Package (Version 3) https://www.ennonline.net/mamicarepathway (replaces
the C-MAMI package, 2015 and 2021 update) provides a framework and tools for context specificadaptation. The definition of MAMI was broadened beyond acute malnutrition to include prevention
and earlier detection.

•

MAMI Global Network Strategy 2021-2025, MAMI Communications Guide and MAMI Global Network
Communications and Advocacy Materials provide more detailed information.

•

MAMI YouTube catalogues videos and podcasts about country implementation and research.

•

Ongoing MAMI evidence is included on the MAMI section of the ENN website and a MAMI summary.

•

MAMI Technical brief: Identifying and supporting infants under 6-months with feeding difficulties anddisabilities: an overview of resources and evidences. MAMI Technical brief https://www.ennonline.net/
identifying-and-supporting-infants-with-feeding-difficulties-and-disabilities•

Mapping of global policy related to infants under 6 months and deep dive MAMI case studies are
ongoing and will be released in 2024.

9www.ennonline.net/ife
Emergency Nutrition Network (ENN) IFE Core Group Coordinating Agency
2nd Floor, Marlborough House, 69 High Street, Kidlington, Oxfordshire, UK, OX5 2DN
www.ennonline.net Contact: ife@ennonline.net

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