OPERATIONALGUIDANCE:
BREASTFEEDINGCOUNSELLING IN
EMERGENCIESJULY 2021

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Acknowledgements
This guidance was undertaken by Emergency Nutrition Network (ENN) in collaboration with the Infant andYoung Child Feeding in Emergencies (IFE) Core Group. Isabelle Modigell (Lead Researcher) and Dr. Linda
Shaker Berbari (Researcher) were the ENN consultants responsible for content development, overseen by
Marie McGrath (Technical Director, ENN).
The development of this guidance by the IFE Core Group was commissioned by the World HealthOrganization (WHO) to support the implementation of WHO (2019) Guidelines on Counselling of Women
to Improve Breastfeeding Practices and related implementation guidance in development when applied toemergency contexts.
We gratefully acknowledge the technical guidance received from members of the IFE Core Group Expert
Peer Review Group: Alessandro Iellamo (Save the Children), Dr. Aunchalee Palmquist, IBCLC (Universityof North Caroline Chapel Hill, Carolina Global Breastfeeding Institute), Brooke Bauer (Global Nutrition
Cluster Technical Alliance Support Team), Christine Fernandes (Save the Children), Deborah Wilson (WFP),Dr. Karleen Gribble (Western Sydney University), Lourdes M. Santaballa Mora, IBCLC (Alimentación Segura
Infantil), Maryse Arendt, IBCLC (IBFAN) and Rose Ndolo (World Vision).
We would like to express our gratitude to the practitioners and experts who agreed to be interviewed to
inform this guidance and to share case studies: Alice Burrell (Save the Children), Dr. Amin Ruhul (Save theChildren), Anne Marie Brennan (Independent), Abdul Mazid Azad (Save the Children), Didi Lee (AMURTEL
Greece), Getinet Amenu (World Vision), Alemshet Aschalew (World Vision), Hana Rabadi (World Vision),
Ma. Ines Av. Fernandez (Arugaan), Juliet Nduta Ngugi (Nutrition International), Kate Golden (Concern
Worldwide), Dr. Magdalena Whoolery (Independent), Md. Fhimuzzaman (World Vision), Michelle Pensa
Branco IBCLC (SafelyFed Canada), Millicent Kavosa Lusigi (UNHCR formerly CARE), Mjabuli Jamela (World
Vision), Dr. Mohammad Aleisa (Syrian American Medical Society), Pressila Derjany (IOCC), Rose Ndolo(World Vision), Sisay Tadesse (PLAN International), Dr. Sherin Alamo (Bahar), Sura Alsamman (Save theChildren), Suzanne Mboya (ECHO) and Thea Bohol (Independent).
We thank Kate Murphy (International Rescue Committee) for her contributions in ensuring key
considerations with regard to Early Childhood Development (ECD) were included in this document as well
as Dr. Justine Leach (Resilient Birth) for her guidance on trauma informed care.
We appreciate the collaborative efforts of Dr. Melissa Theurich, IBCLC (UNICEF Consultant), Fatmata
Fatima Sesay (UNICEF) and Grainne Moloney (UNICEF) to ensure alignment of this document with theimplementation guidance under development for non-emergency settings.
We would also like to thank members of the IFE Core Group for their contributions including case studies.
Finally, we extend thanks to WHO and to Irish Aid who funded the development of this guidance
through ENN.
Recommended citation: ENN, IFE Core Group (2021).
Operational Guidance: Breastfeeding Counselling In Emergencies.

COVER IMAGE: SAVE THE CHILDREN/EMNET DEREJEOPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

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CONTENTS

Acronyms	

6

1. BACKGROUND	7

2. INTRODUCTION	

8

3. BREASTFEEDING COUNSELLING	

9

3.1 WHAT BREASTFEEDING COUNSELLING IS (AND IS NOT)	
3.2 KEY ENTRY POINTS FOR BREASTFEEDING COUNSELLING IN EMERGENCIES	

910

4. PROVIDING BREASTFEEDING COUNSELLING DURING EMERGENCIES	

13

4.1 RECIPIENTS OF BREASTFEEDING COUNSELLING IN EMERGENCIES	
4.2 TIMING AND FREQUENCY OF COUNSELLING IN EMERGENCIES	
4.3 MODE OF COUNSELLING IN EMERGENCIES	
4.4 ANTICIPATORY BREASTFEEDING COUNSELLING IN EMERGENCIES	

14
24
28
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5. COUNSELLING CAPACITY IN EMERGENCIES	
5.1 PROVIDERS OF BREASTFEEDING COUNSELLING	
5.2 COUNSELLING COMPETENCIES	
5.3 CAPACITY ASSESSMENT AND MAPPING	
5.4 CAPACITY BUILDING PLANNING	
5.5 JOB AIDS	
5.6 WHAT TO DO WHEN THERE IS NO BREASTFEEDING COUNSELLING CAPACITY	

39
39
44
50
51
54
54

6. KEY RESOURCES	56

Glossary	

58

Endnotes	

61

References
Annex A – Simple Rapid Assessment	Annex B – IYCF Full Assessment Form: 0-23 months	
Annex C – Strategies for Overcoming Barriers to Remote Breastfeeding Counselling 	Notes	

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66
67
72
73

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESList of Tables
Table 1	Key recommendations for breastfeeding counselling in emergency andnon-emergency settings
Table 2	Strategies for overcoming common challenges with breastfeeding counselling inemergencies
Table 3Key considerations for referral systems in emergency settings	Table 4
Timing and frequency of counselling by priority group	
Table 5
Possible challenges faced by caregivers during emergencies and their potential
implications for breastfeeding	
Table 6
Breastfeeding counselling competencies for emergencies	

13
15
24
26
33
45

List of Case Studies
Case Study 1
Case Study 2
Case Study 3
Case Study 4
Case Study 5
Case Study 6
Case Study 7
Case Study 8
Case Study 9
Case Study 10
Case Study 11
Case Study 12
Case Study 13
Case Study 14
Case Study 15
Case Study 16
Case Study 17
Case Study 18
Case Study 19
Case Study 20

Counselling of a breastfeeding mother during an emergency response	Counselling as part of MAMI programming	Counselling as part of Early Childhood Development programming	Counselling of men	Community-based support to increase reach	Mobile health teams to increase reach	Screening for counselling needs using an SRA	
Increasing contact frequency through household visits	Counselling during mass displacement	Counselling around the time of birth	Mixed group counselling	Remote breastfeeding support	
Experiences of breastfeeding during a public health emergency	A psychosocial approach to breastfeeding counselling	Supporting IYCF in the context of Ebola Virus Disease (EVD)	
Cascade training	Supportive supervision	
Remote monitoring and supportive supervision	
Adapting counselling cards	Home-based counselling for low-literacy refugee mothers	

10
12
12
14
19
20
23
25
27
28
29
31
38
39
49
52
53
54
55
55

Prioritisation for counselling, by category	Possible providers of counselling: roles and responsibilities	
Example of a 3-tier system for provision of counselling and support at multiple levels
Example of multi-tiered approach to trauma-informed care	

21
40
43
48

List of Figures
Figure 1
Figure 2
Figure 3
Figure 4
List of Boxes
Box 1
Guiding principles	
Box 2
MAMI Care Pathway	
Box 3	Key messages on identifying and reaching mothers and caregivers forbreastfeeding counsellingBox 4
Key messages on timing and frequency of breastfeeding counselling	
Box 5
Examples of technology options for remote counselling	
Box 6
Programmatic considerations for anticipating barriers to breastfeeding
during emergenciesBox 7
Programmatic considerations: integrated MHPSS and counsellingBox 8Desired characteristics of counsellors	
Box 9
Important topics to cover during training	Box 10Key considerations for training in an emergency

9
11

32
38
41
50
52

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

5

20
28
29

Acronymns
ANC		
BMS		
BFC		
BFHI		BFS		BSFP		CMAM		
CP		
ECD		
ENC		
ENN		
FA		
GBV		
HIV		
iCCM		
IEC		IG-BFC		IMCI		IYCF		IYCF-E		
LBW		
M-Health
MAMI		MHPSSMISP		MIYCN		MNCH		
MtMSG		MUAC		NGO		
OCHA		
OG-BFC/E
OG-IFE		PFA		PMTCT		PNC		SGBV		
SRA		
TBA		
TIC		
UN		
UNHCR
WASH		WFP		WHO 		

antenatal carebreastmilk substitutebreastfeeding counselling
Baby Friendly Hospital Initiative
baby friendly space
blanket supplementary feeding programmecommunity based management of acute malnutritionchild protection
Early Childhood Development
essential newborn care
Emergency Nutrition Network
Full Assessment
gender based violence
Human Immunodeficiency Virus
integrated community case management
Information Education and Communication
Implementation Guidance on Counselling to Improve Breastfeeding Practices
integrated management of childhood illness
infant and young child feeding
infant and young child feeding in emergencies (also referred to as IFE)
low birth weight
Mobile HealthManagement of small and nutritionally at risk infants under six months and their mothers
Mental Health and Psychosocial Support
minimum initial service package
maternal, infant and young child nutritionmaternal newborn and child healthmother to mother support group
mid-upper-arm circumference
non-governmental organisation
Office for the Coordination of Humanitarian Affairs
Operational Guidance on Breastfeeding Counselling in Emergencies
Operational Guidance on Infant and Young Child Feeding in Emergencies
psychological first aid
prevention of mother-to-child transmission
postnatal caresexual and gender based violence
Simple Rapid Assessment
traditional birth attendant
trauma informed care
United Nations
United National Higher Commissioner for Refugees
Water, sanitation and hygiene
World Food Programme
World Health Organization

A list of terms and definitions can be found in the GLOSSARY.

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OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES

1. BACKGROUND
Scope and purpose

In 2018, the World Health Organization (WHO) published Counselling of Women to Improve Breastfeeding
Practices, a guideline with recommendations and best practice statements for breastfeeding counselling.
The guidelines are complemented by the WHO and UNICEF (2021) Implementation Guidance on Counsellingto Improve Breastfeeding Practices (IG-BFC) which explains how to execute the recommendations inpractice. Due to the particular complexities of operating in emergencies, the need for specific and separate
guidance was identified in a WHO-convened meeting in November 2019.
This Operational Guidance on Breastfeeding Counselling in Emergencies (OG-BFC/E) is a pragmatic guidewhich covers key considerations and potential adaptations when applying WHO’s 2018 guidelines in an
emergency setting. This guidance is intended to be used by policymakers and other decision makers andprogrammers working in emergencies (both local/national emergencies and humanitarian emergencies)
including governments, United Nations (UN) agencies, national and international non-governmentalorganisations (NGOs), as well as donors, volunteer groups and providers of care to pregnant women andfamilies with infants and young children.
This document recognises that how and when to introduce complementary foods in a manner that
does not disrupt exclusive breastfeeding until six months of age and the subsequent continuation ofbreastfeeding are an important part of counselling. It acknowledges the critical importance of ensuring
access to adequate amounts of appropriate, safe, complementary foods and associated support during
emergencies. However, this document does not cover complementary feeding counselling specifically.

Development process

The guidance was developed using a structured approach combining 1) interviews with key informantswith experience and expertise in implementing breastfeeding counselling in emergency settings, 2) casestudies of breastfeeding counselling interventions in emergency settings and 3) a desk review of grey andpeer reviewed literature. Successes, challenges, gaps, required resources, compromises and adaptations
for implementing counselling interventions in emergency settings were identified. The development of thisdocument was guided by an expert peer review group comprised of IFE Core Group members and drew
upon the WHO’s guidelines on Counselling of Women to Improve Breastfeeding Practices and Improving Early
Childhood Development i. The guidance is considered an addendum to the WHO and UNICEF (2021) IG-BFC.

How to use this guidance

The guidance is divided into three main sections. The first section, BREASTFEEDING COUNSELLING,
discusses what breastfeeding counselling is and the entry points for breastfeeding counselling. The
second section, PROVIDING BREASTFEEDING COUNSELLING IN EMERGENCIES, covers the application offive of WHO’s recommendations in emergency settings including who to prioritise for counselling, when,
how often and how to provide counselling. For each recommendation, first consult the 'Challenges andSolutions' section to consider which challenges may be present in your context and to identify possible
solutions. If there are no feasible solutions, move to 'Adaptations and Compromises'. The third section,
COUNSELLING CAPACITY IN EMERGENCIES, provides guidance on WHO’s recommendation on who canprovide counselling services and how to operationalise counselling services through ensuring adequate
capacity is in place. Refer to the IG-BFC for guidance which applies to both emergency and non-emergency
settings as well as further considerations on advocacy and policy, service planning, coordination,
leadership, monitoring and evaluation, special populations and emergency preparedness.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

72. INTRODUCTION
An emergency is an event or series of events that represents a critical threat to the health, safety, security
or wellbeing of a community or other large groups of people, usually over a wide areaii . Emergencies
can be natural disasters (e.g., earthquake, drought, epidemic) or human-made (e.g., civil war, explosion,
nuclear spill), sudden or slow onset and short-term or protracted. Anderson and Gerber (2018) describe
an emergency as an event disruptive enough to affect the normal function of a community (e.g., town ornation) and significant enough that the affected community cannot cope with the impact using its own
resources. In more developed countries, support usually comes from national or local organisations (local/
national emergency). Where international support (humanitarian assistance) is required to meet the basic
needs of a population, it is a humanitarian emergencyiii .
The impact of an emergency depends on the nature of the event and the preparedness and vulnerabilityof the population. Emergencies are commonly characterised by human suffering, loss of life and adeterioration in living conditions. Mass population movement and/or displacement may occur, increasing
the risk of family separation. Public health infrastructure may be destroyed and health systems andservices disrupted, partially because healthcare professionals – including those who normally provide
breastfeeding counselling – may themselves be affected. Community networks and family support areoften disrupted. Breastfeeding support – including counselling – may therefore be limited, discontinued or
become inaccessible1, iv. Daily stressors and increased exposure to traumatic events, including gender based
violence (GBV), often cause mental health and psychosocial wellbeing to decline, impacting caregiving
capacity. Access to food, shelter, safe water, sanitation and medical care may be limited and the basic
necessities required to keep infants and young children safe from harm, illness and death may not bereadily available or accessiblev. The possible impact of an emergency on breastfeeding is further discussed
in 4.4 – ANTICIPATORY BREASTFEEDING COUNSELLING.
Women and children, especially pregnant girls and women, infants and young children and postpartum
women, are populations that are extremely vulnerable in emergenciesvi . Breastfeeding provides children
with hydration, comfort, connection, high quality nutrition and protection against disease, shielding themfrom the worst of emergency conditions. This ability has been described as empowering and healing bysome breastfeeding womenvii, viii . Breastfeeding also has important consequences for maternal mental
health, physical health and caregiving capacityix, x, xi , as well as long-term child development and educational
attainmentxii . Emergency contexts increase the importance of breastfeeding and increase the morbidity andmortality risks associated with not breastfeeding. Yet breastfeeding practices are often negatively impacted
by emergencies and undermined by emergency respondersxiii, xiv (see 4.4 – ANTICIPATORY BREASTFEEDINGCOUNSELLING).
Breastfeeding is a human rightxv. Women and their children also have the right to support that enables
them to breastfeedxvi . Breastfeeding counselling is a lifesaving intervention as it helps to mitigate theimpact of an emergency and ensure that breastfeeding is started and continued. Failure to protect
breastfeeding during emergencies has detrimental consequences. Providing skilled support forbreastfeeding is therefore a priority action during emergencies as outlined in the Sphere Humanitarian
Charter and Minimum Standards in Disaster Response2 .

1 Brown and Shenker (2020) report that 67% of 1,219 new mothers surveyed in the UK during the COVID-19 pandemic felt
they had less breastfeeding support during the UK’s lockdown measures in response to COVID-19. A very strong association
between perception of support and feeding practice was found (χ2 = 125.75, P = 0.000).

2 

For further details on why breastfeeding counselling matters in emergencies, refer to the brief which complements thisguidance: IFE Core Group (2021). Brief: Breastfeeding Counselling in Emergencies.

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OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESBOX 1 Guiding principles
i.	The protection, promotion and support of breastfeeding, in accordance with international guidance, standards
and policies, is essential in emergency settings. Planning for provision of breastfeeding counselling should be
an integral part of emergency preparedness plans for infant and young child feeding (IYCF) and integrated into
formative assessments and initial and sustained responsesxvii .
ii.	All interventions should be centred around the principle to “do no harm” which requires humanitarian actors
to avoid exposing emergency-affected people to additional risks or suffering through their actions. The
International Code of Marketing of Breastmilk Substitutes and subsequent World Health Assembly resolutions3 (“TheWHO International Code”) protects both breastfed and non-breastfed infants; strict adherence to The WHO
International Code (or its national policy equivalent, where relevant) by humanitarian actors is therefore a vitalstep in preventing harm. Counselling programmes should also apply a trauma-informed approach to care to
avoid doing harm.
iii.	Possible adaptations of WHO’s recommendations are suggested in this document to guide those working in
exceptional circumstances in acknowledgement of the complexities of delivering breastfeeding counsellinginterventions in emergency settings. However, an emergency alone does not justify falling short of WHO’s
recommendations; responders must strive to meet the recommendations to the greatest extent possible.
Decision-making on appropriate adaptations and acceptable compromises should be informed by criticalanalysis by the infant and young child feeding in emergencies (IYCF-E) coordination authority, government,
UNICEF, WHO and, where applicable, UNHCR, in consultation with service providers and affected communities,
including mothersxviii . The consequences and risks of such decisions should be used to advocate for humanitarianaccess and adequate resources for counselling programmes. Appropriate monitoring and evaluation should be
conducted to monitor, guide, inform and learn from response.

3. BREASTFEEDING COUNSELLING
3.1 WHAT BREASTFEEDING COUNSELLING IS (AND IS NOT)• Breastfeeding counselling is a two-way interaction between a trained breastfeeding counsellor andone or more pregnant women, mothers or other caregivers of children (most typically) under two yearsof age. The process involves listening to concerns, discussing questions, teaching about breastfeeding
and observing and assisting with the normal process of breastfeeding and breastfeeding challenges.
The aim of breastfeeding counselling is to empower women to breastfeed and to strengthen responsive
caregiving practices while respecting their personal situations and wishesxix .
• Breastfeeding
counselling includes support for relactation, cup feeding and increasing milk supply which
are actions that are carried out with infants who may be breastfed or fully or partially artificially fed.
Caregivers may transition between artificial feeding and breastfeeding or practice both (mixed feeding).
Therefore, counselling to reduce the risks of artificial feeding and ensure it is carried out hygienicallyand responsively should not be seen as separate from breastfeeding counselling and adequate supportshould be provided for both breastfed and non-breastfed children as part of any emergency responsexx, xxi.
• I nfant and young child feeding (IYCF) counselling is acommonly used term in both emergency and development
settings. It describes comprehensive counselling thatencompasses breastfeeding counselling and – if applicable –counselling on complementary feeding and artificial feeding.
The term counselling used throughout this document refers toboth breastfeeding counselling and IYCF counselling.

IYCF counselling includes – atminimum – counselling on:❑ Breastfeeding❑ Complementary feeding❑ Artificial feeding

3 

View the WHO International Code here: https://www.who.int/nutrition/netcode/resolutions/en/

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

9• Counselling
is different from basic breastfeeding education or sensitisation and the sharing of key or
generic messages. A key difference is the listening, learning and skills-building interactions that take place
during counselling to support the person receiving the counselling in their decision makingxxii .
• C ounselling can happen face-to-face or – particularly during an emergency – remotely. Counselling
can be done one-to-one but can also take place in a group setting such as a peer support group (see
4.3 – MODE OF COUNSELLING IN EMERGENCIES). Whether a group activity can be categorised as group
counselling depends on the facilitation style (listening and learning) and participants' interaction andengagement. Lecture or classroom-style sessions should be reported as breastfeeding education, notgroup counselling.

CASE STUDY 1 Counselling of a breastfeeding mother during an emergency response
During the European Refugee Crisis, a Lingala speaking
mother from the Democratic Republic of the Congoand her four month old infant presented at the refugee
shelter where CHEERing works in Athens. She washomeless and had not seen a health worker since birth.
The baby appeared sick with vomiting, diarrhoea andlethargy. The mother said she was formula feeding,
not breastfeeding, could not understand the formula
instructions (a donation from Spain) and was looking
for support. She had with her an unsanitised feeding
bottle containing water. CHEERing's peer counsellor,
who also speaks Lingala, discussed feeding with themother. When she returned after briefly leaving themother, the mother was breastfeeding. The mother said
that she thought, because of her poor diet and living
conditions, her milk was bad and could not nourish
the baby. The counsellor assessed breastfeeding,including frequency. She reassured the mother that

she could breastfeed and that her milk was the safest
and healthiest option for her baby. She explained thatgiving the baby other milks would make her baby more
vulnerable to infection and diarrhoea while breastfeeding
would protect her baby. During the following week, thepeer counsellor reinforced learning and offered daily
support, slowly increasing breastfeeding frequency
and reducing the number of artificial feeds. She also
supported the mother with safer formula preparationand sanitation. Within one month, the mother was
exclusively breastfeeding. At six months, she continued
to breastfeed while introducing complementary foods.
The child’s health improved within days. Over time,weight for age improved, indicating that at intake thebaby was undernourished. An informed and culturally
sensitive approach relying heavily on a trained peer
counsellor successfully led to exclusive breastfeeding anda healthier mother-infant dyad.
Source: CHEERing, Greece. Email discussion (2020)

3.2 KEY ENTRY POINTS FOR BREASTFEEDING COUNSELLING IN EMERGENCIESThe structures and services (entry points) through which the emergency affected population can bereached with counselling will depend to some degree on where breastfeeding counselling was delivered
pre-crisis, how those services have been affected and – if applicable – which clusters (sector groups) andtheir respective services have been activated in response to the emergency-affected population’s needs.
Wherever possible, it is preferable to integrate breastfeeding counselling into planned or existing services
and structures rather than as a stand-alone/vertical intervention. Potential advantages of an integrated
approach4 include greater effectiveness and efficiency and the more cost-effective use of resourcesxxiii, xxiv.
By combining services in one package, and in one location, both children and their caregivers can receive
the services they need in a manner that eases the burden on caregivers and creates confidence. This caninvolve the placement of a dedicated breastfeeding counsellor within a structure or service or capacitating
service providers to deliver counselling themselves (see 5 – COUNSELLING CAPACITY IN EMERGENCIES).

4 

The intentional combining of one or more sector interventions to achieve improved humanitarian outcomes. Services arejointly designed, planned and delivered by teams from all sectors involved.

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OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESThe following are key steps for governments, the nutrition sector and agencies to undertake duringservice planning:
1. Identify and map pre-existing breastfeeding counselling services and structures5 . These are typicallypart of the health system and may also include community-based services such as local breastfeeding
support groups.
2. D etermine how pre-existing breastfeeding counselling services and structures can be re-establishedor scaled up. Emergency response services should, to the greatest extent possible, build on existing
systems and breastfeeding support services and support long-term recovery. (See 5 – COUNSELLINGCAPACITY IN EMERGENCIES for guidance on how to examine the current level of capacity and how tostrengthen capacity).
3. E
 nsure that counselling is part of the minimum package of emergency health and nutrition services.
This will require engagement with both health and nutrition coordination mechanisms, if activated.
a. As a priority, ensure adequate counselling capacity and service planning among minimum initialservice package (MISP)6 providers.
b. Determine if infants under six months are being identified with growth faltering (underweight,
wasted, stunted). Strengthen/embed skilled breastfeeding support within services that manage
these infants and promote an integrated pathway of care approach to support these higher risk
infants and their mothers (see Box 2).
c. Identify other planned and ongoing health and nutrition services that are part of the emergency
response. These may be different from routine health and nutrition services delivered pre-crisis
such as acute malnutrition treatment or communicable disease outbreak services.

BOX 2 MAMI Care Pathway
The MAMI Care Pathway is an integrated care pathway approach to the management of small and nutritionally at risk
infants under six months and their mothers. It is consistent with and supports implementation of Integrated Managementof Childhood Illnesses (IMCI) guidelines. It Includes screening and assessment using existing health system contact
points, strengthening existing health and nutrition services to manage the mother-infant pair in outpatient andinpatient facilities, connecting to relevant services through referral pathways, active growth surveillance of small andnutritionally at risk infants and assessment and support to maternal nutrition and health including mental wellbeing.
The MAMI Care Pathway Package (formerly the C-MAMI Tool) comprises a framework, user guides, assessmentand management tools, adaptation guide and support materials. Its development and updates are managed by ENN
as MAMI Global Network Coordinator.

For more information: https://www.ennonline.net/ourwork/research/mami

Possible entry points for counselling7 within health and nutrition services include reproductive healthincluding essential newborn care (ENC), sexual and gender based violence (SGBV), prevention of motherto-child transmission (PMTCT), family planningxxv, antenatal carexxvi (ANC) and postnatal care (PNC); childhealth including paediatric services treating wasted infants, immunisation services, well-baby clinics,
integrated community case management (iCCM)xxvii , integrated management of childhood illness (IMCI)
and growth monitoring; mental health and psychosocial support (MHPSS); communicable disease
outbreak response interventions including clinical care and case management, nutritional care and infant
feeding support; community health; infant and young child feeding in emergencies (IYCF-E) and wastingtreatment including community based management of acute malnutrition (CMAM) and MAMI services.
5 

Tool: Save the Children, UNICEF and the GNC (2020). ESAR IYCF-E Capacity Mapping and Assessment Toolkit. https://www.
nutritioncluster.net/resource_IYCF-E_Capacity_Mapping_Assessment_Tool

6 

The MISP is a priority set of lifesaving activities to be implemented at the onset of every emergency (within 48 hours
wherever possible). To prevent morbidity and mortality, essential services for all newborns (essential newborn care) include
support for skin-to-skin contact, immediate and exclusive breastfeeding and not discarding colostrum.
Note that these are possible entry points to consider for the delivery of counselling – it is not necessary to provide
counselling within every service for every response. However, where these services are in place they should – at a minimum –be capacitated to identify counselling needs and make referrals.

7 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

114. I ntegrate counselling into other humanitarian sectors and services to increase reach and coverage.
Consider which services work closely with pregnant women and girls, mothers and other caregivers ofinfants and young children and are sensitised to the issues they face in emergencies. While protecting
and supporting breastfeeding is the responsibility of all emergency responders across all sectors,
emergency services that operate at scale and/or have frequent but short contacts with the emergencyaffected population (e.g., food assistance, child friendly spaces, vaccination campaigns, hygiene
promotion activities, reception and registration services) are likely better placed to identify counsellingneeds and make referrals than to deliver counselling itself (see Case Study 7). Pre-existing community/
women’s groups can also be effective entry points for counselling (see Case Study 5).
Possible entry points, by sector, include: PROTECTION (MHPSS, SGBV services including women andgirls’ safe spaces, child protection including case management) and EDUCATION (ECD, education foradolescent mothers).

CASE STUDY 2 Counselling as part of MAMI programming
Gambella refugee camp, open since 2014, hosts up
to 330,000 South Sudanese refugees at any one
time. GOAL provides MAMI services to small andnutritionally at risk infants under 6 months and theirmothers in two of seven camps (Kule and Tierkidi) as
part of a wider package of preventative and curative
nutrition interventions. At-risk mother and infant
pairs are identified by community health workers
who undertake screening in the community, assessing
anthropometric, clinical, feeding and maternal risk
factors. Under COVID-19 adapted services, 1,500
households with infants < 6m have also been trained
to measure mid-upper-arm circumference. Referral tothe health facility is followed by a detailed assessment(including breastfeeding) to determine classification andsubsequent enrolment based on the risk status of themother-infant pair. High risk mother-infant pairs arereferred to inpatient care and moderate risk pairs arereferred to MAMI outpatient care. Both outpatient andinpatient care encompass weekly, or daily if required,tailored counselling, support and monitoring. Thisis delivered by MAMI-trained IYCF counsellors andnurses in dedicated IYCF spaces within health facilities.
Counsellors provide one-on-one targeted support using
MAMI counselling tools including a support booklet
and Global Health Media videos (see Key Resources),translated into the Nuer language. Care also includes
maternal mental health support. The service wasconceived using ‘admission’ and ‘discharge’ criteria but it
is agreed that transition to an ‘enrolment’ approach withde-escalated monthly follow-up is more suitable whenboth mother and infant are no longer at-risk. Motherinfant pairs are only discharged once the infant reaches
six months of age. Between May 2019 and October
2020, 267 infant-mother pairs were being managed
within the GOAL Ethiopia MAMI programme.

Source: GOAL, Ethiopia. E-mail correspondence (2020); Further reading: www.ennonline.net/fex/62/goalexperiencesofmanagement

CASE STUDY 3 Counselling as part of Early Childhood Development programming
World Vision implements the ‘Go Baby Go’ model
once a month to provide nutrition and ECD counsellingwhich aims to build knowledge, skills and resilienceand psychosocial support. Breastfeeding counselling
promoting techniques to improve parenting practices
is part of every household visit. Visits are increased asat the household level. Using an integrated approach,needed. Caregivers also participate in interactive groupcaregivers’ awareness of the interrelatedness of health,sessions at primary health care centres. Therefore, eachnutrition, protection and development is strengthened. In household benefits from two to three activities every
2017, World Vision started implementing a programmemonth. A RCT evaluating the impact of the integration ofwith integrated breastfeeding and ECD counselling
IYCF counselling with ECD’s “Nurturing Care Framework”
in the West Bank. Following recruitment of pregnant
showed a 30% increase in exclusive breastfeeding
women at the start of the project cycle, each household amongst the intervention group.
is visited by community health workers a minimum of
Source: World Vision, West Bank Palestine. Key informant interview (2020)

12 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES4. PROVIDING BREASTFEEDING COUNSELLING
DURING EMERGENCIESCore characteristics of breastfeeding counselling in non-emergency settings, and potential adaptations
and compromises during emergencies, are summarised in Table 1 below and elaborated further throughout
this document.
Table 1: Key recommendations for breastfeeding counselling in emergency and non-emergency settings

Recipients

TimingFrequency

Mode

ProviderQualities

Key recommendations for counselling women to improve breastfeeding practices8
ALL pregnant
women andmothers with
infants and young
children

Pregnancy
Directly after
birth and up to
2-3 days afterbirth

At least six
contacts andadditional
contacts asneededUp to 28 days
after birth(neonatal period)

In-person
counselling
Individual
counselling ispreferredGroup
counsellingis useful as acomplement
to individual
counsellingFirst 3-4 monthsof ageAt 6 monthsof age (start ofcomplementary
feeding)

Remotecounselling may
complement but
not replace
individual
face-to-facecounselling

After 6 months(late infancy andearly childhood)

Healthcare
professionals• Physicians• Nurses• Midwives• Lactation
consultants
Paraprofessionals• Peercounsellors• Communitybased healthworkers

Person-centred• Sensitive• Culturally
appropriate• Traumainformed• Participatory• Anticipatory
Quality-focused• Timely• Efficient• Equitable

Any age, as
neededAdaptations of key recommendations for breastfeeding counselling in emergencies
Prioritisation of
those requiring
immediate help
(Priority Group 1e.g., mothers withbreastfeeding
difficulties,
all newborns,
BMS-dependent
infants, sickor prematureinfants) and thoseat increased riskof developing
breastfeedingproblems (Priority
Group 2 e.g.,adolescents, firsttime mothers,
pregnant womenwith risk-factors)

The priority is toprovide timely
counselling togroups requiring
immediate help
and high-risk
groups (any age,as needed)
For all otherpregnant andbreastfeeding
women, the sametiming as nonemergencies withpriority given to
the time aroundbirth (before andafter)The priority
is to provide
counselling forgroups requiring
immediate help
and high-risk
groups as often
as needed andthe emergency
context allows
For all otherpregnant andbreastfeeding
women, thesame as nonemergencies, if
possibleGroup
counselling may
be appropriate
to address
high needs
but individual
counsellingshould also be
available
Remotecounselling may
fully or partiallyreplace face-toface counselling

Similar to routine
providersSurge capacityand dedicatedcounsellors may
be needed
Providers require
additionalcounsellingcompetencies(refer to Chapter
5 – Table 6)Same as above
Anticipatory
counsellingalso involves
anticipatingbreastfeeding
challenges related
to the emergency
context

Programmes
should proceedand provide
counselling asoften as possible
when it is not
feasible to achieve
six contacts

8 

Further guidance: WHO and UNICEF (2021). IG-BFC.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

13

4.1 RECIPIENTS OF BREASTFEEDING COUNSELLING IN EMERGENCIESWHO Recommendation 1

Breastfeeding counselling should be provided to all pregnant women and mothers with young children.
Key Considerations
The primary populations that breastfeeding counselling interventions aim to reach during emergencies are
pregnant girls and women, mothers and other caregivers9 of infants (0-11 months) and young children(12-23 months).
It is also beneficial to include fathers/co-parents10, 11 , grandmothers12 and mothers-in-lawxxviii or otherfamily members in counselling or to reach them with related activities, depending on the specific culturalcontext and who the decision makers and influencers are with regard to infant feeding and care seeking
behaviours. Inclusion of family members in antenatal counselling (see 4.2 – TIMING AND FREQUENCY
OF COUNSELLING IN EMERGENCIES) can help identify specific ways to assist the mother postnatally in amanner that is supportive of breastfeeding. It may be even more appropriate to include family members
when the number of possible counselling contacts is limited as they can help to remember information andprovide ongoing support such as in transit and evacuation settings.

CASE STUDY 4 Counselling of men
During the Rohingya response, community and religious
leader consultations and community meetings conductedby Save the Children highlighted the influential role offathers on breastfeeding practices within the Rohingya
community. As a result, Save the Children recruited andtrained male counsellors to counsel men/fathers onmaternal, infant and young children nutrition (MIYCN),
including breastfeeding, via courtyard meetings. This
inclusive approach is particularly pertinent in settings
with high rates of domestic violence given the known
impact of such violence on breastfeeding and carepractices.
Source: Save the Children, Bangladesh. Key informant interview (2020)

Challenges and Solutions
Various barriers to reaching pregnant women, mothers and other caregivers with counselling may bepresent during emergencies. Many of these challenges can be addressed through adequate preparedness,
as described in the IG-BFC. Possible solutions to consider during an emergency response are presented
in Table 2.

9 

Note: For the sake of brevity, where appropriate, the term caregiver (rather than mothers and other caregivers) will be usedfrom this point forward while acknowledging that children who are breastfed or primarily cared for by someone who is nottheir biological mother/the person who gave birth to them may be more vulnerable and that programmatic distinctions
should therefore be made. The term caregiver refers to a child’s primary caregiver and encompasses mothers, adoptive/foster
mothers, carers working in institutions such as orphanages, temporary carers (e.g., in Ebola treatment centre nurseries) etc.
and may also include fathers and other family members acting as the child’s primary caregiver.

10 

Azad et al. (2019) report that during the Rohingya Refugee Crisis, 91.97% of women who adopted infants born as a result ofrape reported having to receive permission to breastfeed from their husbands or other family members.

11 

Emerson et al. (2017) identified husbands as a significant source of distress for women living in the DRC, noting that engaging
fathers through responsible parenting interventions may reduce psychological distress and have a positive impact on child health.

12 

De Young et al. (2018) identified strong family influences on feeding choices in post-earthquake Nepal which suggested thatinterventions post disaster should include grandmothers and other members of the extended family.

14 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESTable 2: Strategies for overcoming common challenges with breastfeeding counselling in emergencies including barriers
to reaching caregivers with counselling

Supply of services (Availability of skilled human resources, financial resources and organisational capacity)
Possible barrier

Possible solutions

1. Lack of financial resources– Lack of adequate planningor financing by national
governments, donors andagencies– Lack of prioritisationof IYCF-E by agencies
applying for funding• E nsure that counselling is part of the minimum package of health andnutrition services for the emergency (preparedness plans, humanitarian
response plans etc.) (Refer to 3.2 – KEY ENTRY POINTS FOR BREASTFEEDINGCOUNSELLING)• E
 nsure that the lead coordination authority on IYCF-E is meeting their
responsibilities with regards to financing13 (e.g., inclusion in needs
assessments, advocacy strategies, funding calls e.g., Country Based PooledFunds (CBFP), Central Emergency Relief Fund (CERF))• E
 nsure breastfeeding counselling is included and adequately costed in
preparedness and response plans, strategies and funding proposals14.
• E
 xplain clearly and simply what breastfeeding counselling is and its added
value. Communicate the needs of pregnant and breastfeeding women todonors, governments, etc.. Share the existing evidence base on the impact ofbreastfeeding counselling on breastfeeding practices and the consequencesof neglecting breastfeeding during emergencies.
• A dvocate to donors for flexible funding mechanisms that are able torespond to different and changing needsxxix.

2. Gaps in organisational
capacity– Lack of/ disruption ofpre-existing breastfeedingcounselling (BFC)
programmes– Lack of capacity totransition from nonemergency to emergency
BFC programming(inadequate preparedness)– Poorly defined institutional
responsibilities, lack oforganisational policies– Lack of available competent
partners to implement
programmesxxx– Poor quality or
inappropriate services
including poor
communication, lack ofservices that take into
account MHPSS or are
not trauma informed,
inappropriate counsellingin terms of culture/
language/lack of privacy
for counselling services/lack of inclusive services– Poor coordination• S ensitise decision makers and planners on the importance of IYCF-E/BFC
in emergencies.
• S trengthen organisational capacity to deliver appropriate and effective
counselling services (See 5 – COUNSELLING CAPACITY IN EMERGENCIES).
• E
 nsure IYCF-E /breastfeeding policies and guidance that are in line with the
Operational Guidance on Infant and Young Child Feeding in Emergencies(OG-IFE) are in place and enforced. Develop a joint statement which,in addition to addressing the prevention of breastmilk substitute (BMS)
donations, addresses counselling and is signed by relevant stakeholders.
Agencies should have a written policy that is communicated to all staff while
funders can integrate policies into partner agreements.
• E nsure adequate IYCF-E coordination capacity15,16, (e.g., assess government
coordination capacity and support if necessary, determine/clarify
coordination roles and responsibilities, put in place adequately resourced
coordination mechanisms – such as IYCF-E technical working groups – for
IYCF-E specific and sensitive programming, share information about pregnant
and breastfeeding women and their children in a timely manner).

continued...

13 Further guidance: IFE Core Group (2017). Operational Guidance on Infant and Young Child Feeding in Emergencies Section 3.

14 

Further guidance: UNICEF and WHO (2021). Implementation Guidance on Counselling to Improve Breastfeeding Practices.

15 

Further guidance: IFE Core Group (2017). Operational Guidance on Infant and Young Child Feeding in Emergencies Section 3.

16 

Further guidance: UNHCR and Save the Children (2018). IYCF Multisectoral Framework for Action.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

15

Table 2 continued...
Possible barrier

Possible solutions

3. Human resource availability,
motivation and individual
capacity– Lack of trained humanresourcesxxxi, xxxii, xxiii(no pre-emergency
counselling capacity,
counsellors impacted
by emergency, shortageof women on staffxxxiv,
shortage of staff withrequired language skills
or cultural understandingor who are accepted by
the emergency-affected
population, highstaff turnover)– Lack of health worker time(high needs for curative
services override deliveryof preventative services)– Low counsellor motivation(de-prioritisation by
personnel for whom
counselling is one ofmany tasks, mothers’
resistance to recommended
practices17, lack of
incentives for peer
counsellors)• D efine roles and service standards i.e., the time necessary for trained, skilled
and motivated personnel to perform an activity to professional standards inthe local circumstances. Where breastfeeding counselling is a defined partof a provider’s role, allocate an adequate amount of time for this workload
component when planning services.
• E nsure adequate numbers of counsellors18 by 1) recruiting trained
counsellors (e.g., lactation consultants) or those who can be trained todeliver counselling (e.g., healthcare professionals, peers, traditional birthattendants (TBAs), 2) deploying surge counselling capacity from other areas/
national or emergency response teams (see 5 – COUNSELLING CAPACITY IN
EMERGENCIES).
• B
 uild the capacity of the available workforce to deliver counselling Note
this will only be effective if counselling is built into their role during service
planning. Regular training is essential to address staff turnover (see 5 –COUNSELLING CAPACITY IN EMERGENCIES).
• B
 uild communities’ capacity to provide counselling (e.g., train peer
counsellors). This can increase resilience and reduce reliance on external
resources and aid.
• T ask shifting e.g., hygiene promoters can teach cup feeding insteadof counsellors, peer counsellors can provide basic counselling so that
counsellors with more advanced competencies can focus on complex cases.
• P lace dedicated breastfeeding counsellors within services to provide indepth counselling (see 5.1 – PROVIDERS OF BREASTFEEDING COUNSELLING).
• R
 aise awareness of the importance/impact of breastfeeding in emergencies
and the risks of neglecting breastfeeding in emergencies to address motivation.
• I nclude standard counselling indicators in the indicator set used formonitoring provider/facility/implementing partner performance.
• P lan for adequate incentives/remuneration (if appropriate and sustainable)and provide support and recognition for community volunteers and peer
counsellors.
• D emonstrate duty of care and support counsellors to work in a safe working
environment.
• P ut in place family/breastfeeding-friendly policies to recruit and maintain afemale workforce (see Box 8 for further guidance).

Demand for and utilisation of services
Possible barrier

Possible solutions

1. High case load
– High needs (populationinflux due to mass
displacement, increase inbreastfeeding difficulties,
increase in birth rates oroverall increase in needs –such as during an epidemic)• P rioritise counselling for those in need of immediate help (Priority 1) andat-risk groups (Priority 2) (see Adaptations and Compromises below).
• P revent breastfeeding problems:– Prioritise counselling in pregnancy and around the time of birth(see 4.2 – TIMING AND FREQUENCY OF COUNSELLING IN EMERGENCIES)– Ensure immediate skin-to-skin and early initiation of breastfeeding• C reate a breastfeeding-friendly environment, (e.g., prevent and rapidly
handle any donations of BMS, facilitate multi-sector support for pregnant
and breastfeeding women19, implement interventions which are supportiveof good breastfeeding practices) to reduce the number of women withbreastfeeding difficulties requiring skilled counselling.
• E nsure appropriate support for BMS dependent infants to protect andsupport both breastfed and non-breastfed children.
• E nsure postnatal care and growth monitoring services (well-baby clinics)
are in place so problems can be caught early before specialised support
is needed.
continued...

17 Sami et al. (2017) found that mothers’ resistance to practices such as exclusive breastfeeding and breastmilk expression
lowered health workers’ intention to promote these practices.

18 

Further guidance: Sphere staffing standard: 23 skilled birth attendants (doctors, nurses, midwives)/10,000 population. Notethat these are minimum standards which are context dependent; where reproductive health consultation rates are highdespite minimum standards being met, consider readjusted staffing levels.

19 

Further guidance: Save the Children and UNHCR (2017). IYCF in Refugee Situations: A Multisectoral Framework for Action.

16 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESTable 2 continued...
Possible barrier

Possible solutions

2. Low demand for services– G ender inequality andsocial norms (women’s lackof decision making power
to attend services, womenrequired to stay athome etc.)– L ow awareness of services(poor communication, lackof inclusive communicationthat is accessible andunderstood by all
caregivers)– L ack of time (women
have increased workloads
and multiple competing
priorities)– M aternal motivation andprioritisation (caregivers
may not value counsellingor see follow-up as
important, programmesthat do not offer material
assistance may be of lessinterest to aid-dependent
populations, caregiverpreference for artificial
feeding e.g., due toaggressive marketing by
BMS manufacturers)– Declinein health seeking
behaviour (deteriorationin maternal mental healthand wellbeing, lack ofacceptance or trust in inavailable services (e.g., due
to poor or inappropriatequality including culture,
language, lack of privacyetc.), fear of attending
face-to-face counselling
during infectious disease
outbreaks)xxxv, 20• C onduct a barrier analysis to understand why uptake of services is low.
• R aise awareness and improve community acceptance of counselling services
Engage and sensitise responders, caregivers, influencers and decision makers– including community leaders – on the value of breastfeeding, theimportance of counselling and available services. Use the media and othercommunication outlets to raise awareness. Use participatory approaches todesign culturally appropriate counselling services and solicit community
feedback. Deliver information via multiple communication modes (e.g.,posters and audio speakers) to ensure caregivers with disabilities can accessand understand information.
• I ncrease convenience and reduce the burden on caregivers Deliver
counselling at multiple levels (household, community and facility) and delivery
platformsxxxvi. Ensure service hours, outreach activities and household visits
are at times that are convenient for mothers (i.e., not when they are typicallyoccupied with childcare or preparing food). Ensure trained counsellors
conduct household visits, particularly for caregivers who may have difficulties
travelling to breastfeeding counselling sites (e.g., caregivers living withdepression or a disability, mothers who have recently given birth). Liaise withMHPSS services on identification and referral of caregivers living with mental
health difficulties to counselling services or capacitate MHPSS providers todeliver counselling themselves.
• B uild trust in health services Solicit and take on board community feedback.
To address fears related to communicable disease, create an environment inwhich the disease and its impact can be discussed and addressed openly.
• C onsider provision of remote breastfeeding counselling if caregivers fear
attending in-person services such as during communicable disease outbreaks(see 4.3 – MODE OF COUNSELLING IN EMERGENCIES)• M
 otivate caregivers to prioritise counselling services Provide holistic
support that takes into consideration the different components required for amother-baby dyad’s health, wellbeing, development and happiness. Co-locate
or integrate breastfeeding counselling services into services with high uptake
by pregnant and breastfeeding women (see 3.2 – KEY ENTRY POINTS FOR
BREASTFEEDING COUNSELLING IN EMERGENCIES). Consider integrating
counselling with services providing material assistancexxxvii (e.g., food aid),
cash assistance or, where appropriate, provide incentives that enable
recommended behaviours (e.g., soap, hygiene kit, menstrual hygiene
products, nutritious snacks)xxxviii, xxxix. Provide support for BMS dependent
infants as a means to bring their caregivers into contact with services
including BFC. Understand what drives appeal for mothers and othercaregivers e.g., through human centred design and behavioural mapping.
• P rotect and support maternal mental health and psychosocial wellbeing
Collaborate with MHPSS actors to design and deliver counselling services
and counsellor training in a way that promotes mental health andpsychosocial wellbeing21. Build community counselling capacity (e.g., motherto-mother support groups and peer counsellors) as a means of strengthening
community self-help and social support networks. Within counselling
services, promote and support practices that are supportive of maternal
mental health such as skin-to-skin contact.
• E ncourage follow-up Collaborate on defaulter tracing efforts.
Consider use of mobile health (M-Health) to issue reminders to caregivers(e.g., by phone).
• E nsure services are inclusive e.g., accessible, appropriate and understood bya person with impairments (physical, sensory,
mental, intellectual).
• R aise awareness about the WHO International Code and establish a system
to monitor for and respond to Code violations.
continued...

20 

Brown and Shenker (2020) reported that 58.8% of new mothers surveyed in the UK during the COVID-19 pandemic (n= 1,218) reported that they were concerned, or would be, if they needed to see a healthcare professional face-to-face.
Anxieties over the pandemic affected some mothers’ decisions whether to contact a health professional; a significant
association was found between not contacting a health professional and stopping breastfeeding.

21 Further guidance: Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines on Mental Health and Psychosocial
Support in Emergency Settings. Geneva: IASC.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

17

Table 2 continued...

Humanitarian accessPossible barriers

Possible solutions

1. Lack of access to counselling
services by affected population(physical barriers e.g., insecurity,
restrictions on freedom of
movement, destruction ofcivilian infrastructure, long ordifficult distances to travel,climatic conditions, physicaldisability and social barriers e.g.,
stigmatised and underserved
groups, restriction of women’s
movement, language and literacy
barriers, financial barriers, lack orloss of documentation)• Establish/strengthen community-based counselling capacity e.g., train
mother-to-mother support groups, peer counsellors, community healthworkers in hard-to-reach areas, including for underserved or stigmatised
populations. This can decrease reliance on external aid and help overcome
e.g., language and cultural barriers to accessing support.
• U
 se a person-centred approach when designing and planning services
Imagine how a caregiver might engage with and access services and whatchallenges might arise at each step in order to pre-empt challenges andmitigate risks.
• C onsider the use of translators and/or remote counselling if counsellors who
speak the same language as the affected population are not immediately available.
• C onsider the provision of remote counselling services (see 4.3 – MODE
OF COUNSELLING IN EMERGENCIES) where face-to-face counselling is notpossible or recommended.
• S end counsellors to mothers/families (e.g., community outreach andhousehold visits), prioritising women who are unable or for whom it isespecially difficult to travel to counselling sites (e.g., mothers with a disabilityor who are severely depressed or injured).
• E stablish central places where caregivers can access counselling Establish
supportive spaces22 in e.g., transit or evacuation centres or camps. Set amaximum acceptable distance to the nearest counselling service point near/within communities. Where applicable, sheltering families with infants andyoung children in a dedicated area can reduce the overall number of spacesthat are needed and/or improve access to mothers and other caregivers.
• C o-locate or integrate services to save travel time and costs.
• F acilitate safe access to counselling services through coordinating withprotection actors and engaging in dialogue with communities about basic
safety concerns and safety measures including those related to GBV.
• T
 ake older siblings into consideration23 Ensure caregivers can access services
with older children or there are provisions for their safe care nearby (e.g., colocate with child friendly space).
• P ut in place well-managed referral pathways (see Referrals)• R emove financial barriers (e.g., universal healthcare, cover transport costs)• M eet the minimum standards for disability inclusion in humanitarian action24.
• E nsure that services are adolescent-friendly including through offeringadolescent-only service hours, training providers and adapting counselling
approaches to meet the needs of young counselling clients.

2. Lack of access to theaffected population byhumanitarian actors (insecurity,
obstructions/ interference bystate and non-state actors,
bureaucratic restrictions,movement restrictions, targetingof humanitarian personnel
and facilities, destruction oftransport infrastructure etc.)
3. Forced relocation and mass
displacement/evacuation

continued...

Community nutrition promoter doing
family IYCF counselling in BangladeshWORLD VISION/BANGLADESH

22 

GNC Technical Allicance (2020). Supportive Spaces for IYCF-E. https://www.ennonline.net/supportivespacesiycfetechbrief2020

23 

Hull, Kam and Gribble (2020) reported how, during the COVID-19 pandemic, a mother in Australia with a suspected breast
infection was prevented from accessing a doctor by IPC policies which did not account for mothers having multiple children(only two people were allowed at a consultation).

24 

HelpAge International on behalf of the Age and Disability Consortium (2015). Minimum Standards on Age and Disability
Inclusion in Humanitarian Action.

18 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESTable 2 continued...

Lack of data on pregnant and lactating womenPossible barrier

Possible solutions

1. Absence or interruptionof pre-existing information
management systems• W ork with local actors and authorities to gather pre-crisis data.
• E nsure inclusion of IYCF-E/breastfeeding indicators in needs assessments
including early multi-sector needs assessments. Disaggregate data (0-5months, 6-23 months, at a minimum)25.
• C onduct in-depth assessments using qualitative and quantitative
approaches when possible.
• M onitor programmes using standardised indicators26 and disaggregateddata. Share relevant information in a timely manner.
• Identify ways to record as many pregnant women as possible. This can include
accessing antenatal records, working with TBAs and work with child protection(CP) actors to ensure birth registration of newborns within two weeks.
• I n stable populations, conduct a community mapping exercise with blanket
registration of all mothers and caregivers of infants and children.

2. Inaccuracy/irrelevance of precrisis demographic data (highdeath toll, population influx)
3. Data sharing sensitivities orlimitations

The humanitarian architecture: BF counselling/IYCF-E siloed within the nutrition sector
Possible barrier

Possible solutions

1. Siloed approaches toprogramming (separate
management, supervision or
funding streams for counselling/
IYCF-E and other services,cluster approach and structure
results in perception of IYCF-E
as the nutrition sector/cluster’s
responsibility alone)• A dvocate for relevant stakeholders across sectors to consider the needs ofpregnant women, children under two and their caregivers including IYCF
counselling27.
• U
 se a person-centred approach to design and operationalise an integrated
emergency response or programme from the beginning whenever more than
one sector is involvedxl. While programmes may be funded separately, theiractivities should contribute to shared objectives/a common goal which takesbreastfeeding into consideration. Consider defining a minimum package forinter-sector collaboration and integration.
• T rain programme planners and designers to recognise linkages and entry
points for counselling within humanitarian services across sectors (IYCF-E,
ENC etc.). Strengthen counselling capacity within these services rather thandelivering alone standing counselling interventions.
• P lan for counselling trainers and supervisors to work across sectors rather
than only within the nutrition sector.

2. Low capacity for integration(limited familiarity of thenutrition sector with approaches/interventions by other sectors
resulting in missed opportunities
for integration, low awarenessby other sectors of IYCF-E
interventions, concerns about
overwhelming inexperienced
frontline personnel with multisector responsibilities)
3. Lack of tailored tools (limited
counselling training packages
and programming tools tailoredto humanitarian sectors otherthan nutrition)

25 

https://ir.hpc.tools/indicators

26 

Tool: Humanitarian Indicators Registry. https://ir.hpc.tools/

27 

Further guidance: Save the Children and UNHCR (2017). IYCF in Refugee Situations: A Multisectoral Framework for Action.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

19

CASE STUDY 5 Community-based support to increase reachIn 2005, an interagency initiative known as the Dadaab
IYCF Team began to implement IYCF-E activities
at various levels within Dadaab refugee camp. At
community level, mother-to-mother support groups(MtMSG) were established, building on pre-existing
women’s gatherings. Group facilitators were peers
who spoke the same language as other mothersin the community and were known and trusted by
the community.

Within four years, 610 peers were trained as groupfacilitators and 679 groups established. Each month,
peer counselling was provided to thousands of pregnant
women and mothers in a supportive group setting.
Grandmothers, mothers-in-law and fathers were invited
to participate each quarter. Between 2005 and 2009,
exclusive breastfeeding rates rose from under 4.1%
to 47.6%.

Source: UNHCR and CARE, Kenya – Key informant interviews and email correspondence with former staff (2020)
Lung’aho and Stone-Jimenez (2009). Mother to Mother Support Groups in the Dadaab Refugee Camp.
https://www.waba.org.my/pdf/mstfnl_V7N2_MtMSG_Dadaab.pdf
Training Package: https://windowofopp.files.wordpress.com/2010/12/mtmsg-instructional-training-package1.pdf

CASE STUDY 6 Mobile health teams to increase reach
Mobile health teams (MHTs) were rolled out in
Afghanistan (complex protracted crisis) by UNICEF witha local partner to reach pregnant women and children
under five years of age with reproductive, maternal andnewborn child health and wasting treatment services
in remote hard to reach communities (populations
living far from fixed health facilities). Teams consistedof a midwife, vaccinator, nurse or doctor and nutrition
counsellor. The nutrition counsellor delivered nutrition
services including MIYCN counselling. MHTs visiteddesignated service delivery points on a monthly basis fora period of 10 months to increase reach and sensitise
the community on health and nutrition services. As aresult, coverage increased by 10% and the project wasable to reach 89% of its ANC target. MHTs were foundto be successful in improving coverage, reach and accessto services. However, sustainability was a challenge dueto the high cost. Outreach services delivered by mobile
teams can improve counselling coverage in contexts
where communities live far from fixed facilities.

Source: Qarizada et al., Afghanistan (2018) Scale up of I-MAM services in Afghanistan. Field Exchange 57.

BOX 3 Key messages on identifying and reaching mothers and caregivers forbreastfeeding counselling
1. Cover as many different levels (household, community, facility) and sectoral entry points as possible to reach women
2. Ensure or establish mechanisms to have all pregnant women on record and to track them
3. Bring services to the women, rather than expecting them to come to you
4. Make it as easy and appealing as possible for women to access breastfeeding counselling services (Table 2)

Adaptations and Compromises
When unable to provide counselling to all, consider prioritising specific groups for counselling (Figure1). Through rapid screening and triage, those requiring immediate support or who are at high risk ofdeveloping breastfeeding problems can be identified and referred for further assessment and counselling,
as discussed below. Mothers not experiencing difficulties can be provided with less intensive forms ofbreastfeeding support (e.g., education, enabling environment) that can help to prevent breastfeedingproblems and reduce the need for counselling in the future.

20 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES

Figure 1: Prioritisation for counselling, by category

Frontline SRA or referral from other services

Mother-baby dyad in need of IMMEDIATE HELP
BMS-dependent infants (non-breastfed or mixed fed)
Lactating women with existing breastfeeding difficulties (e.g., engorgement, sore orcracked nipples, pain, thrush, mastitis, perceived/documented low milk supply andbreast refusal)
Dyads with urgent individual needs
Breastfeeding mothers or other primary
Breastfeeding women who are:caregivers of infants and young children• Malnourished
who are:• Severely ill• Newborns (0-28 days)• Survivors of SGBV• Premature/LBW• Living with a disability which• Less than six months with
impacts feeding
growth failure• Breastfeeding someone else’s baby
• Multiples (e.g., twins)• Living with a mental illness or showing• Sicksigns of distress/trauma• Malnourished• Living with HIV• Living with a disability which• Recovering from a Caesarean/high
impacts feeding
intervention/ traumatic birth• Showing signs of extreme distress• Separated or unaccompanied• Maternal orphansYES

PRIORITY 1YESPRIORITY 2YESPRIORITY 3NO
AT RISK
Vulnerable groups and groups who are at higher risk of feeding difficulties
Breastfeeding mothers or other primary• History of breast surgery
caregivers of infants who are:• Current/history of depression or anxiety• Under six months of age (excluding• Likely or confirmed Caesarean birth
newborns)• Diabetic, overweight or obese
Caregivers who are:• Mother or fetus has an impairment• First time mothers
which may affect breastfeeding (e.g.,• Adolescent mothers
cleft palate)Pregnant women with risk factors identified • SGBV survivor
during antenatal care including:• HIV positive• Nulliparous (first time mother)• Maternal malnutrition• Multiple pregnancy• Past history of breastfeeding difficulties
or of artificial feedingNO
PREVENTION AND PROMOTION
All other pregnant and breastfeeding women andcaregivers with infants and young children
OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

21

Prioritisation Process
1. Screen all primary caregivers of children under two using a Simple Rapid Assessment. To the greatest
extent possible, all (100%) of pregnant women and caregivers of children under two should be screened
as soon as possible after the onset of a crisis. This can be done using a standardised triage28 tool such asa Simple Rapid Assessment (Annex A: SRA). The purpose of the tool is to rapidly assess children under
two and their caregivers to decide who should be referred for a full assessment and counselling or toother forms of breastfeeding support. All frontline workers who frequently interact with children under
two and their caregivers should be trained on how to use the SRA so that it can be used whenever theopportunity arises such as when processing new arrivals at a reception centre, as part of a household
survey (active screeningxli), as part of child protection case management processes, upon presentation ata health care facility and during food assistance registration (Case Study 7).
2. Progress to full assessment and counselling if indicated by the SRA. During the first counselling
contact, the counsellor will conduct a more thorough individual-level assessment of the caregiver-baby
dyad known as a Full Assessment (Annex B: FA). This should include an assessment (listen and learn)of baby’s behaviour, mother’s behaviour, positioning, attachment, effective feeding, health of the baby,
breast health and mother’s perception of how breastfeeding is goingxlii, 29. A breastfeeding woman’s
nutritional health (HIV status, infectious diseases e.g., Ebola, COVID-19) and psychological wellbeing
are also important considerations in emergency settings. Counsellors should therefore be trained onvoluntary disclosure and relevant referral mechanisms. The counsellor will then determine30 (analyse andact) what type of support is needed e.g., rapid resolution of a simple issue (e.g., positioning), continued
skilled breastfeeding counselling (e.g., relactation support) and/or referral to other forms of support (e.g.,malnutrition treatment, MHPSS, health services). Where more than one counselling cadre is responsible
for carrying out a full assessment (e.g., peer counsellors at community level and lactation consultants at
facility level), different tools, or different versions of the same tool, may be necessaryxliii .
3. Monitor those referred to other forms of breastfeeding support. Problems may develop after the
SRA is conducted or initially be missed. Therefore, train educators, supportive space facilitators, group
counsellors and other breastfeeding support service providers to remain vigilant and identify caregivers
who may be in need of individual counselling.
Note that the SRA is a simple screening tool designed so that laypersons can easily identify the majorityof dyads to be prioritised for counselling. Not all groups requiring urgent help and high risk groups can be
identified with the SRA. For example, it may not be possible or appropriate for a layperson to identify low
birth weight (LBW) infants or infants with growth failure, breastfeeding survivors of SGBV or breastfeeding
women who are HIV positive. It may also not be possible to rapidly reach all breastfeeding women with an
SRA (e.g., when a refugee population is dispersed within a host community).
Therefore, alongside screening using the SRA, it is important to put in place different routes throughwhich caregivers can access counselling including self-presentation (see Table 3). Ideally, counselling isdirectly integrated into services used by vulnerable groups who may be missed bycouns` the SRA. Priority
services include maternity, those that support small and nutritionally at risk infants including malnutrition
treatment programmes, MHPSS, HIV (especially PMTCT) and adolescent services (Figure 2) If it is notpossible for these service providers to directly provide counselling, at a minimum ensure that these service
providers are trained to identify and refer caregivers who may require counselling.

28 The primary goal of triage is to do the greatest good for the greatest number of people. In an overwhelming emergency,
triage also assists in guiding decisions about allocation of scarce resources (Jorgensen et al. 2010).

29

For a review of available breastfeeding assessment tools, refer to the MAMI Project: Chapter 7.
Job aids such as decision flow charts can assist counsellors to decide next steps. Tool: UNHCR Infant and Young Child
Feeding Standard Operating Procedures for Handling of Breastmilk Substitutes (BMS) in Refugee Situations for children 0-23
months (page 11): https://www.unhcr.org/55c474859.pdf

30 

31 

Infant feeding counselling is a required component of a minimum HIV response when initiating antiretroviral therapy for
pregnant and lactating women and their infants in an emergency (WHO and UNICEF, 2018).

22 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESCounsellors and counselling programme managers should also be aware of key services for priority groups
and make proactive attempts to establish contact with pregnant and breastfeeding women accessing these
services (Case Study 10).

CASE STUDY 7 Screening for counselling needs using an SRA
In the Democratic Republic of the Congo, malnutrition
remains a public health problem with chronicmalnutrition rates at 42% and wasting at 6.5% (MICS2018). IYCF practices are low with only 8% of children
6-23 months of age having a minimum acceptable dietand 53.5% of children under six months of age who are
exclusively breastfed (MICS 2018). The World Food
Programme (WFP)'s emergency assistance programmes(such as cash-based transfers, in-kind food) targetingvulnerable families have great potential to act as
platforms for supporting and promoting IYCF practices,
especially in emergency contexts. Since 2019, WFP
DRC has piloted a nutrition- sensitive approach within

its emergency cash-based transfer interventions. At
distribution sites and community level, activities haveincluded conducting simple and rapid individual levelassessments of IYCF practices, providing guidance andsupport for IYCF problems with referral to appropriate
IYCF services as appropriate, mass sensitisation on IYCF
and malnutrition through dissemination of contextspecific messages and screening for malnutrition withcases of concern referred to the healthcare facility.
Additional community level activities have included
establishing or revitalising IYCF support groups andconducting cooking demonstrations.
Source: UWFP, DRC (2020) email correspondanceReferral Systems
The diverse and multiple needs of emergency-affected populations reinforce the need for collaborationand coordination between services and sectors (referrals to and from counselling services). It is important
for a counsellor to try to identify issues (e.g., missing family members, food insecurity, violence in thehome) which may be indirectly impacting a caregiver’s ability to responsively care for and feed their childand to provide practical assistance with accessing relevant services. Referrals also occur within counselling
services such as upward referral of complex problems to more experienced and skilled counsellors. To
ensure continuity of care, referral systems should be developed as described in the IG-BFC. Key considerations
for referral of caregivers or infants and young children in emergencies are outlined in Table 3.

CHEERing team screening andreferring refugees in Greece.
FOODKINDOPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

23

Table 3: Key considerations for referral systems in emergency settings

Referrals within counselling services

Referrals fromcounselling services

Referrals tocounselling services

Shortage/lack of counsellors with advanced counsellingcompetencies. Specialist counselling capacity may not
be immediately available. To improve access, maximise
the use of technology for remote counselling32 (see 4.3– MODE OF COUNSELLING IN EMERGENCIES), taking into
account time zones and the need for remote specialists
to be equipped with context-specific competencies (see5 – COUNSELLING CAPACITY IN EMERGENCIES).

Counsellor awareness ofavailable services. To conduct
effective referrals, providers
should have the following upto-date, written information:
admission criteria, location,
opening hours and days for
new admissions, costs.

By empowering health workers and paraprofessionals
to provide basic counselling, more time is created foravailable counsellors with more advanced competencies(e.g., lactation consultants) to focus their attention on
caregivers with more complex counselling needs.

Health services. Ensure
provision of breastfeeding
friendly clinical services (e.g.,prescription of breastfeedingcompatible medication,
including contraceptives).

Referral routes.
Referrals tocounselling services
may take placethrough i) proactive
screening using an
SRA tool, ii) detectionof risk factors
for breastfeeding
difficulties during
ANC, iii) referral bysensitised service
providers (e.g., healthworkers providing
HIV services), iv)
self-presentation bycaregivers33(see 4.1 – RECIPIENTSClarity in scope of work. The roles and responsibilities
of different cadres need to be clearly delineated (see
5.1 – PROVIDERS OF BREASTFEEDING COUNSELLLING).
Particularly in settings where services are overloaded
and specialist capacity is unavailable, there is a risk that
counsellors may step outside their scope of practice;
it is essential that counsellors are trained to recognise
and acknowledge their limitations and to know whento refer.
Clinical lactation management. The presence of
health professionals who are equipped with advanced
counselling competencies (see 5.2 COUNSELLINGCOMPETENCIES) to appropriately support breastfeedingproblems requiring clinical skills is important.

Multi-sector sensitisation.
Conflicting information
and advice can undermine
confidence and cause
frustration. At a minimum,
ensure all services thatbreastfeeding women may bereferred to are oriented on
IYCF-E and equipped with aminimum set of standardisedcompetencies.

OF BREASTFEEDINGCOUNSELLING IN
EMERGENCIES for

further details).

4.2 TIMING AND FREQUENCY OF COUNSELLING IN EMERGENCIESWHO Recommendation 2

Breastfeeding counselling should be provided in both the antenatal period and postnatally,
and up to 24 months or longer.
WHO Recommendation 3

Breastfeeding counselling should be provided at least six times, and additionally as needed.

32 

Further guidance: Save the Children with support from IFE Core Group Members (2021) Conducting and supporting IYCF-E
e-Counselling: Considerations for Planning and Implementation.

33

 argest-Slade and Gribble (2015) describe how awareness about available counselling services was raised through media
H
messages following the 2011 Christchurch earthquake.

24 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESThe minimum six counselling contacts are not spread out equally over the suggested timeframe but
planned for key moments and milestones34 within the first thousand days. Suggested counselling content
during timed and targeted contacts includes information that is relevant to the life stage and anticipatory
guidance for the next stage, to prepare caregivers and prevent future problems. These recommendations
refer to services designed to reach all pregnant and breastfeeding women including those who are notexperiencing breastfeeding difficulties. In addition, the WHO guidelines recommend that additional
contacts take place “as necessary” (for instance, when concerns or challenges related to breastfeedingarise) or when opportunities for breastfeeding counselling occur. See IG-BFC for further guidance.
Challenges and Solutions• An important barrier to achieving scheduled contacts as planned is lack of humanitarian access(difficulties in reaching emergency affected populations with counselling services or inability of affected
population to access counselling services e.g., due to insecurity). Community-based peer counselling mayhelp to enable basic counselling to continue at recommended times when access is restricted and fortransient populations (see 5 – COUNSELLING CAPACITY IN EMERGENCIES).
• O
 ther barriers are similar to those for attempting to reach everyone with counselling (See Table 2).
These include resource constraints, high caseloads and provider lack of time, lack of information on
caregivers and counsellor and caregiver motivation and prioritisation. Community outreach (CaseStudy 6) and household visits (Case Study 8) can be effective at reaching caregivers in a timely andfrequent manner but are resource-intensive. “Client-led” counselling can also help to ensure thatbreastfeeding concerns are addressed on time. Refer to Table 2 for a breakdown of possible challenges
and further solutions for consideration.

CASE STUDY 8 Increasing contact frequency through household visits
Between 2012 and 2017, Save the Children’s counsellors
worked with health services to identify women attending
ANC or PNC at health facilities and requested theiraddress in Zaatari refugee camp. Rather than waiting

for mothers to return to the health facility, counsellors
then visited women requiring counselling at home.
This resulted in higher uptake of counselling services
compared to facility-based ANC and PNC services.

Source: Save the Children, Jordan. Key informant interview with former staff (2020)• A n emergency may be shorter than the timeframe covered in the guidelines, though the average
humanitarian crisis now lasts nine yearsxliv. During protracted or chronic crises lasting more than
two years, breastfeeding counselling programmes are often hampered by short-term funding andhumanitarian planning cycles. Best practice is for emergency and non-emergency programmers to work
together from preparedness to recovery and transition to ensure continuity of care for the breastfeeding
dyad. Multi-year response and organisational strategies, and preparedness plans that embedbreastfeeding counselling, can help to ensure that counselling remains available as recommended.
Adaptations and Compromises
During emergencies, the priority is to provide counselling when it is most needed (timing) as often as
needed (frequency).
Responders should not be discouraged from planning and delivering breastfeeding counselling services
even if it may not be feasible to achieve the recommended minimum of six counselling contacts andshould provide counselling as often as possible instead. While not ideal, a single counselling contact can
34 

1. Before birth; 2. During and immediately after birth (first 3 days); 3. 1-2 weeks after birth; 4. 3-4 months (early infancy);
5. Around 6 months (at the start of complementary feeding); 6. After 6 months (late infancy/early childhood) (WHO, 2018).

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

25make a differencexlv, particularly during difficult or stressful times when positive feedback and emotional
support is especially valuable in supporting women’s confidence and self-efficacy in breastfeeding. The
counselling approach will need to be adapted to focus on the most urgent issues and biggest risks (seeCase Study 9). During mass displacement, counselling contact frequency can be increased throughinforming caregivers about available services along their onward journey and communicating with these
services about incoming high-risk cases. Counsellors can also request caregiver’s contact details, if
available, so that follow-up can be done remotely. Impact can be maximised by combining counselling withother forms of multi-sector breastfeeding protection, promotion and support.
Particularly when population movement is low, such as in an established refugee settlement, providing
counselling at least six times in both the antenatal period and postnatally, up to 24 months or longer, islikely to be feasible and no adaptation of the recommendations is necessary. Timely, scheduled counselling
contacts are encouraged as they contribute to a sense of normalcy and predictability that is supportive of
psychosocial wellbeing. To facilitate continuity of care, it is also important to ensure the same counsellor
sees the caregiver at each contact whenever possible35 .
However, when timed and targeted counselling is not feasible, the priority is to ensure groups requiring
immediate help and high-risk groups are counselled on time. For these dyads, counselling contacts shouldtake place as detailed in Table 4 below.
Table 4: Timing and frequency of counselling by priority group

Group

TimingFrequency

Immediate help (Priority 1)

Counselling needs to urgently occur to address thecurrent problem.

As often as needed.

At risk (Priority 2)

Counselling should take place as soon as possible after
counselling needs are identified to prevent potential
problems from developing.

As often as needed.

All pregnant andbreastfeeding women(Priority 3)

As per the IG-BFC, counselling can take place during
planned contacts (e.g., during a scheduled antenatal visit
or group counselling36 session). Counselling may also be
spontaneous or ad hoc (e.g., when a caregiver is admitted tohospital). Regardless of whether counselling takes place atsuggested time-points or not, content relevant to the dyad’s
life stage is covered37. Counselling around the time of birthis prioritised38.

At least six times,
to the extent the
emergency timeframeand context allows.

• It is common for breastfeeding problems (e.g., difficulties latching, damaged nipples, engorgement,
worries about milk supply) to occur in the immediate and early postnatal period which, if not overcome
with adequate support, can lead to early infant supplementation or premature weaningxlvi, 39. Therefore,
antenatal anticipatory counselling is important for all pregnant women. Support in the postnatal period
is especially important in emergencies where increased rates of distressing birth experiences, adverse
birth outcomes and/or postnatal separation (see Table 5) may increase difficulties with establishing36 

Note: In settings where activities can be scheduled (e.g., established camps) but human resources are limited, organisinggroup counselling by cohort (e.g., pregnancy/0-5 months/6-23 months) can facilitate the delivery of relevant and timely
counselling content and appropriate activities (e.g., play and stimulation) for large numbers of caregivers (see 4.3 – MODE OF
COUNSELLING IN EMERGENCIES).

37 

Further guidance: Refer to IG-BFC. Job aids can also be used to guide the counsellor in selecting relevant content.

38 

Further guidance: IFE Core Group (2021). Infographic on Early Initiation of Breastfeeding in Emergencies.

39 

Brown and Shenker (2020) reported that of 1,219 surveyed new mothers living in the UK who had given birth just before or
during the start of the COVID-19 pandemic, mean infant age at the introduction of infant formula was 2.79 weeks and 3.15
weeks for breastfeeding cessation. Of those participants who had stopped breastfeeding, only 13.5% described themselves
as ready to do so. The most common reason for cessation was insufficient professional support.

26 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES

breastfeeding. As outlined in Chapter 4, Section 4.1 on recipients of counselling, newborns and highrisk pregnant women are groups who are prioritised for comprehensive counselling in emergencies.
This can be achieved by ensuring adequate counselling capacity within services in frequent contact
with pregnant women and new mothers such as maternity/perinatal services (see 5 – COUNSELLINGCAPACITY IN EMERGENCIES).
• Which additional moments and milestones should be prioritised for counselling will depend on
the context and prevalent feeding practices as determined during needs assessment and throughmonitoring. Scheduling may be further adapted to align with other available services (e.g., ANC or
immunisation schedules).
• When counselling a caregiver with existing challenges or concerns, counselling is provided as frequently
as needed40 . The priority is to provide care based on actual individual needs rather than aiming to meet a
set number of counselling contacts with each caregiver.
• F ollow-up is important, both to address problems and encourage successxlvii . Stress can reduce a
caregiver’s ability to absorb and retain information. Multiple difficulties are often present and time isneeded to build a trusting relationship under difficult circumstances. Therefore, counselling contacts
may take place frequently at short intervals to maximise impact. Standard practice in emergencies
involves regular (weekly or monthly) contact with some form of breastfeeding support which may include
counselling. This practice acknowledges the value of investing in counsellor-caregiver relationships
beyond their impact on breastfeeding practices alone and is particularly appropriate when the breadthof support provided during contacts is wider and more holistic than breastfeeding counselling alone (e.g.
MAMI or ECD programming).

CASE STUDY 9 Counselling during mass displacement
In spring 2015, Save the Children launched a frontline
IYCF-E response as overwhelming numbers of refugees
and migrants (up to 8,000 people per day) arrived at
the Croatia/Serbian border. Mothers were in distressand facing significant barriers to feeding their children
safely and adequately. They were observed giving
cows’ milk to infants under six months of age, notmeasuring water and formula quantities when preparing
a feed and re-using unclean feeding bottles. The
government’s approach aimed to minimise transit times,
hindering humanitarian assistance. Caregivers were
often exhausted and highly stressed by the constant
movement, compromising their ability to process
information. During the short stay in the transit camp,
caregivers had multiple needs to address in a very
limited time. Stress levels were often exacerbated by alack of information on departure times and processes.

As a result, caregivers tended to be rushed and focusedon leaving. Efforts were made to create a calming andcomfortable environment in the counselling spaceby staff trained in psychological first aid. Counsellors
reassured caregivers and facilitated access to otherservices. Save the Children also developed kits to rapidly
provide essentials. A lack of cross-border and regional
coordination of actors implementing IYCF-E – and asubsequent lack of consistency and standardisationof services – compromised what could have beenachieved in terms of minimising risk and supporting safer
practices. Caregivers were often tired and confused by
the many different actors providing varying messages,
materials and products. Save the Children’s approach tocounselling was therefore to accept feeding behaviours
and to focus on risk management and minimisation (e.g.,bottle sanitation when cup feeding was refused).

Source: Modigell, Fernandes and Gayford (2016) Save the Children’s Rapid IYCF-E Response in Croatia. Field Exchange 52.

40 

For example, counselling protocols may indicate that a caregiver undergoing the process of relactation should at first be
followed-up on a daily basis, reducing as confidence grows (Burrell et al., 2020). In their description of GOAL’s C-MAMI
programme in Ethiopia, Murphy et al. (2017) note that acutely malnourished infants may be required to present daily if more
intensive support is required to help rehabilitate the child and support the mother, or may be followed up on a weekly basis
prior to blanket supplementary feeding programme (BSFP) distributions. Counselling contacts for wet nurses (Burrell et al.,2020; Azad et al., 2019), and BMS-dependent may occur on a weekly basis. Using their best judgement, a counsellor may
determine that it is necessary to follow-up more frequently.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

27

CASE STUDY 10 Counselling around the time of birth
Early initiation of breastfeeding and skin-to-skincontact play a vital role in reducing newborn andmaternal mortality and improving both breastfeeding
outcomes and maternal caregiving capacity. In Lebanon,International Orthodox Christian Charities (IOCC) has
been implementing breastfeeding protection, promotion
and support as part of their health and nutrition
programme for Lebanese nationals and (predominantly
Syrian) refugees since 2012. Through close collaboration
with primary health care centres, lactation specialists aim
to reach pregnant women two to three times antenatally.
Counselling is tailored if a Caesarean birth has beenplanned. IOCC has collaborated with the Ministry of
Public Health (MOPH) on the implementation of theBaby Friendly Hospital Initiative (BFHI) in selected
hospitals. IOCC’s lactation specialists, whose professional
background is midwifery, visit hospitals on a daily basis
to provide breastfeeding support to women as soon
as possible after birth. If permitted by the hospital,
they attend the birth. If not, they attend as soon as
possible afterward, on the maternity ward or upondischarge, to assess and support breastfeeding. Postnatal
breastfeeding difficulties are usually addressed within
two to three contacts, but may require more.
Source: IOCC, Lebanon. Key informant interview, 2020.

Duration
The time required for an individual counselling session varies depending on the type of contact, thebreastfeeding dyad’s needs, state and availability, the setting, the counsellor’s skill and experience,translation requirements and the breadth of support provided. Counselling contacts may be longer
or more frequent in emergencies compared to non-emergency settings as multiple needs41 and issues
often need to be addressed. Under intense stress, instructions and guidance are less likely to be heard
or fully understoodxlviii and may need to be repeated during the contact. Traumatised caregivers’ ability
to communicate effectively may be jeopardised. Patience is required to establish trust and rapport withcaregivers whose trust may have been eroded, who have undergone – and want to disclose – distressing
experiences or who find themselves in an unfamiliar setting.
For service planning purposes in emergencies, ideally allow for sufficient time to establish rapport andconduct a Full Assessment (Annex B) during the first contact. Shorter contacts without Full Assessment
may be necessary in certain settings (e.g., during mass displacement – see Case Study 9).

BOX 4 Key messages on timing and frequency of breastfeeding counselling
1. Screen all mothers or caregivers of infants and young children using SRA within a set short period of time
2. The priority is to ensure groups requiring immediate help and high-risk groups are counselled on time
3. Frequency and duration of counselling contacts will vary per case
4. Follow-up is important and is likely to take place frequently with short intervals during emergencies

4.3 MODE OF COUNSELLING IN EMERGENCIESWHO Recommendation 4

Breastfeeding counselling should be provided through face-to-face counselling. Breastfeedingcounselling may, in addition, be provided through telephone or other remote modes of counselling.

41 

Note: Including needs beyond breastfeeding support; caregivers may not be receptive to breastfeeding counselling until acounsellor links them to other services to ensure their basic survival needs are met.

28 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES

Face-to-face counselling may occur at household, community42 or facility level and in a one-to-one(individual) or group counselling format (see Case Study 11). Group counselling is particularly appropriate
for addressing common concerns and sub-optimal practices in resource limited settings with high needs,
such as humanitarian contexts. It can have important benefits for maternal wellbeing by creating an
opportunity for experience sharing and mutual support. One-on-one counselling should remain accessible
to address individual needs.

CASE STUDY 11 Mixed group counselling
Following Typhoon Ondoy in 2009, Arugaan’s
Breastfeeding Experts Supports Team (BESTeam)
visited affected communities with their mobile unit.
All community members, including fathers (who weretypically the decision makers) as well as adolescents andcommunity leaders, were welcomed as observers. All
mothers, regardless of how their children were fed, were
included in group counselling. Women of non-breastfedchildren who were inspired to relactate by information

shared by the BESTeam and positive experiences
shared by breastfeeding mothers were provided withimmediate relactation counselling and support using
the drip-drop relactation method43 . Once the motherwas relaxed following a lactation massage, the baby wasoffered the mother’s breast. Witnessing these activities
reportedly strengthened fathers’ and community leaders’
acceptance and support for breastfeeding.
Source: Arugaan, Philippines. Key informant interview, 2020

Telephone counselling and other technologies (Box 5) are identified in the guidelines as “very useful
options as adjuncts” which “may empower end-users, as well as health workers and lay or peer counsellors.”
Information shared face-to-face can be reinforced through sharing of information, education andcommunication (IEC) materials such as video linksxlix,44 to caregiver’s mobile phones.
IOCC

BOX 5 Examples of technology options for remote counselling
Using voice only

Using voice and pictures– Telephone– WhatsApp/Facebook– Skype/Zoom/WhatsApp/FaceTime/
Messenger/Instagram/Telegram
Facebook Messenger/Signal/Telegram– Voice messages

Using voice and video

Challenges and Solutions Related to Delivering Face-To-Face Counselling in Emergencies• D uring displacement and when living in crowded conditions (e.g., camps or evacuation shelters), space
may be lacking for women to be counselled comfortably and privately which can negatively impact thecounselling process. For mass sheltering scenarios, preparedness and response plans should ensure
resources are allocated for the establishment of supportive spaces (e.g., mother baby areas or baby
friendly spaces (BFS)) where women can safely and privately breastfeedl,li . Such supportive spaces canalso be used to provide face-to-face breastfeeding counselling45 .
• W here access is limited or sporadic (e.g., insecure or hard to reach areas), follow-up may be conductedby community based counsellors (e.g., peer counsellors) or remotely using technology.
Other factors that may impede reaching caregivers with face-to-face counselling and potential solutions toenable the continuation of counselling are detailed in Table 2.
42 

Note: For example, during mobile outreach services or within a supportive space for IYCF-E placed within the community.

43

Further guidance: https://www.llli.org/drip-drop-feeding/44 Tools: https://globalhealthmedia.org/videos/breastfeeding/45

Further guidance: GNC Technical Alliance (2020) Technical Brief: Supportive Spaces for IYCF-E.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

29

A nutrition facilitator shows a colourful flipchart
depicting breastfeeding positions to mothers at
a Mother and Baby Area in the Rohingya refugee
camps in Cox’s Bazar, Bangladesh
SAVE THE CHILDREN/DAPHNEE COOK

Adaptations and Compromises
Full and unimpeded humanitarian access is a fundamental prerequisite to effective humanitarian actionlii .
However, attacks on humanitarian personnel and active hostilities have increasingly contributed tolimited access to conflict affected populations in recent yearsliii . WHO’s guidelines state that face-to-facecounselling may be complemented but not replaced by telephone counselling and/or other technologies.
During emergencies where:i) There is no humanitarian access and there are no immediate solutions46ii) Suitable47 counsellors cannot be immediately operational in the affected locationiii) P hysical distancing public health measures are in place (e.g., during an infectious disease outbreak,see Case Study 12),
remote counselling may fully or partially48 replace face-to-face counselling, if feasible49. Remaining incontact with caregivers who may otherwise feel isolated or abandoned can positively impact wellbeing andconsequently also feeding and caregiving practices. Remote counselling may facilitate the rapid recruitment
and training of counsellors in areas not affected by the emergency and facilitate support by experienced
counsellors with advanced skills for dyads with complex counselling needs. As it appears to be better
appreciated by caregivers and more effective50, liv, 51 efforts should be made to establish or resume face-toface counselling as soon as possible.
For an overview of key considerations and strategies to overcome possible challenges related to using
remote technologies for counselling, refer to Annex C.

46 

Note: For example, remote training of peer counsellors to establish counselling capacity within communities is a solution that
may take some time to establish and implement to an adequate standard if capacity was not established in preparedness.

47

Note: Meaning those with the required characteristics and competencies, including language skills (see Chapter 5).

48 

Note: Meaning that basic counselling continues to be provided face-to-face but counselling requiring advanced competencies
is provided remotely.

49 Further guidance: Save the Children with the Collaboration of IFE Core Group (2021). Conducting and supporting IYCF-E
e-Counselling: Considerations for Planning and Implementation.

50

Research that is specifically related to virtual care in lactation is limited (Dhillon and Dhillon, 2020).

51 

Brown and Shenker (2020) reported that 72.6% of surveyed mothers who gave birth in the UK during the COVID-19
pandemic attributed stopping breastfeeding to a lack of face-to-face support caused by COVID-19 restrictions.

30 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESCASE STUDY 12 Remote breastfeeding support
At the start of lockdown measures implemented in
the Philippines during the COVID-19 pandemic, amother noticed a need for breastfeeding supportin her community. In response to a post on a local
Facebook group (a shopkeeper had lost her income
and could no longer buy infant formula for her infant)she shared information about relactation; within twohours, she had received 35 queries. A remote teamof five peer counsellors and two trained pediatricians
were assembled. Rapid assessment and triage was done
through Facebook messenger using a set of simple
questions to determine who in the team would be
best suited to support each woman. The majority ofwomen wanted help increasing their milk supply andsome wanted to relactate. Those reaching out weregenerally in the lowest wealth quintile and did not own
breast pumps: hand expression and breast massage
were taught remotely. The counsellors called every day
to two days, depending on needs. In between calls,
the counsellors would answer questions via Facebook
messenger. This intensive support and 24/7 availability

usually lasted around two weeks. The peer counsellors
noticed that women were often panicked or agitatedwhen they reached out so they would start by providing
reassurance, making practical suggestions to improvematernal wellbeing (e.g., establishing how mothers could
improve their diet with limited financial resources) anddiscussing how to calm and soothe the baby. Many ofthe mothers had not been the baby’s primary caregiver
prior to the pandemic; the counsellors realised that
although it was difficult to describe the technicalities ofbreastfeeding over the phone, breastfeeding often camenaturally once bonding and closeness was established.
They therefore adapted their approach to focusing
on bonding and building mothers’ confidence. Cost,
connectivity and lack of camera phones were barriers;
the counsellors covered the cost of phone calls, useddescriptive language (building on training on how to
support people who are visually impaired) and asked
specific questions (e.g., “where are your hands?”). A low
resolution graphic was developed to overcome the costof downloading videos.
Source: Philippines. Key informant interview, 2020

4.4 ANTICIPATORY BREASTFEEDING COUNSELLING IN EMERGENCIESWHO Recommendation 5

Breastfeeding counselling should anticipate and address important challenges and contexts forbreastfeeding, in addition to establishing skills, competencies and confidence among mothers.

Adaptations and Compromises
In non-emergency settings, anticipatory guidance focuses on educating families about the normal
anatomy and physiology of lactation and prepares them for normal and expected infant development andbehaviourslv, lvi . Suggestions are provided in the IG-BFC on anticipatory guidance to provide at specific life
stages such as preparing to introduce complementary foods. During emergencies, anticipatory guidance
also involves (and may prioritise) anticipating and addressing challenges related to infant and young childfeeding specific to the current emergency context.
By understanding a specific emergency context or imminent threat and anticipating how it may undermine
or complicate breastfeeding (Table 5), counsellors can help to reduce potential risks and problems52 .
For example:• D uring any emergency, it can be assumed that concerns about milk supply will be commonlvii .
Breastfeeding women should therefore be provided with anticipatory guidance concerning how stressful
and difficult circumstances impact infant behaviour, that stress does not impact milk productionlviii; the52 Note: Particularly in geographic regions with predictable, seasonal natural disasters, an important preparedness action
is to ensure that counsellors are equipped with the skills and knowledge required to provide anticipatory guidance. The
competencies required to appropriately support emergency-specific challenges are listed in 5 – COUNSELLING CAPACITY IN
EMERGENCIES .

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

31importance of effective (good positioning and attachment) and frequent milk removal to maintain supply
and reliable signs that the infant is receiving enough breastmilk.
• If a counsellor is aware that uncontrolled distributions of BMS are taking place, she can counsel on
the dangers of introducing BMS in the current setting and focus on building confidence to exclusively
breastfeed.
• To help prepare for evacuation (e.g., during natural disasters such as wildfires), counsellors can provide
anticipatory guidance on the basic supplies caregivers of BMS-dependent infants should bring with them53 .

BOX 6 Programmatic considerations for anticipating barriers to breastfeeding
during emergencies
It is also important for decision makers and programme planners across all sectors to understand what factors
facilitate breastfeeding and why breastfeeding problems may increase in a particular emergency context so that they
can address the underlying causes to the greatest extent possible (Hirani et al., 2019). For example, in a camp setting,a programme planner can anticipate the problems that uncontrolled BMS distributions can cause and work with camp
management to prevent BMS distributions in the camp to complement a breastfeeding counsellor’s efforts. Numerous
underlying causes can be addressed via multi-sector collaboration to create an environment that protects and supports
breastfeeding, as outlined in Save the Children and UNHCR (2018) IYCF-E Multisectoral Framework for Action.

Breastfeeding counselling
during emergencies
ARUGAAN/PHILIPPINES

53 

Further guidance: Gribble and Chad (2019). Evacuating with a baby? Here’s what to put in your emergency kit.
Online article – The Conversation.

32 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESTable 5: Possible challenges faced by caregivers during emergencies and their potential implications for breastfeeding

Individual level (mother, caregiver, infant, young child)
Possible challenge related
to the emergency

ExamplePossible implications for breastfeeding andbreastfeeding support

1. Poor child health andnutritional status

Increased rates or diarrhoeal
disease in infants following
uncontrolled BMS distributions,increased rates of malnutritionin children, poor health andnutrition status at birth e.g.,
low birth weight or prematurelix,poor pre-emergency IYCF
practices• Infants and young children who are severely
ill or malnourished may be too weak to suckle
effectively at the breast.
• Beliefs about need to supplement infants (e.g.,with formula) during illness may be prevalent.
• Premature and/or LBW infants often require
skilled breastfeeding support to overcome
challenges such as fatigue and increased
sleepiness, reduced feeding volume, longfeedings, disorganised feedings, physicalchallenges, oral motor challenges (weak suck)and growth and nutrition concerns.

2. Poor maternal physicalhealth and nutritional
statuslx

High exposure to aggravating
factors including foodinsecurity, disease and poor
sanitation, increased rates
of morbidity and mortality,
including increased rates of
HIV infection among girls andwomenlxi• Decline in maternal wellbeing reduces amother’s ability to responsively feed and carefor children. Mother may breastfeed less often
or for shorter durations. This leads to milk stasis,increased risk of engorgement, blocked ducts
and mastitis and, eventually, a gradual decline inmilk production.
• Breastfeeding women whose nutrition has been
compromised are likely to have concerns about
the quality and quantity of breastmilklxii, lxiii, lxiv
despite milk production and quality being largely
unaffected by diet unless malnutrition is severe.
• Maternal malnutrition in pregnancy increases
the rate of pregnancy complications andadverse birth outcomes (e.g., pre-term birth)and subsequent difficulties in establishingbreastfeeding (see 1).
• Mothers who are incapacitated by severe illness
or malnutrition may require physical support tobreastfeed/express milk.
• During illness or disease outbreaks, caregivers
may have concerns about the transmission of
a communicable disease to their childlxv (e.g.,
Ebola, cholera, etc.).
• During infectious disease outbreaks, mothers
may wish to continue or restart breastfeeding toprotect their infantslxvi, lxvii• Increased rates of maternal mortality result inincreased numbers of non-breastfed infants.
• Possible need for increased PMTCTinterventionslxviii. Mothers living with HIV
will require counselling on infant feeding
recommendations within the emergency
context. In the absence of antiretroviral (ARV)drugs, mothers living with HIV may needadditional counselling to maintain confidence
in the importance of breastfeeding for childsurvival and support on making it safer.
• Fear of HIV transmission among families andhealth workers may result in inappropriate
responses including avoiding breastfeeding(of biological/non-biological children) in theabsence of testing and demand for, or offersof, BMSlxix.
continued...

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

33

Table 5 continued...
Possible challenge related
to the emergency

ExamplePossible implications for breastfeeding andbreastfeeding support

lxxiii

Poor understanding of IYCF-E
recommendations among
response providers including
health workers supporting
MNCHlxxiv, provision of
conflicting advice and/or
inappropriate promotion andprescription of BMS, harmful
and disempowering media
messageslxxv, spread of myths
and misconceptions• Women’s confidence in their ability tobreastfeed their child safely and adequately isshaken, impacting breastfeeding self-efficacy
and maternal wellbeing.
• Poor understanding of the needs ofbreastfeeding women and their children during
emergencies leads to calls for donations of BMSe.g., by the media (see 14).
• Inappropriate information/advice is given
to mothers leading to inappropriate feedingpractices.

Possible challenge related
to the emergency

ExamplePossible implications for breastfeeding andbreastfeeding support

4. Increased numbers ofcaregivers and infants
with disabilities whichcause feeding difficulties

Temporary disabilities e.g.,
injuries which prevent a motherfrom holding/breastfeedingher childlxxvi; environmental or
nutritional factors may resultin increased rates of congenitalabnormalities in newborns e.g.,cleft palateslxxvii, lxxviii• Increased levels of non-breastfed infants if
specialist breastfeeding support is not available.
• Children with disabilities impacting feeding
may require skilled breastfeeding support
to overcome difficulties which may include
inefficient feeding, increased risk of aspiration,oral motor challenges, sensory sensitivities andgrowth and nutrition concernslxxix.

5. Maternal mental
health and psychosocial
wellbeing negatively
impactedlxxx, lxxxi, lxxxii

Increased levels of exposure
to trauma, rise in GBV, lossof loved ones, high levelsof caregiver concern about
their/their child’s immediate
physical needs e.g., food, water,
shelter, medical care, lack ofaccess to growth monitoring/infant weighing services forreassurance, breakdownof social networks/family
structures and social isolation,
breakdown or lack of access topostpartum support services
and social networks55• Caregiver’s ability to responsively feed and carefor their child is reduced. Mother may breastfeed
less often or for shorter durations.
• Maternal adrenaline inhibits the let-down reflex,
slowing milk flow and mistakenly resulting inconcerns around breastmilk supplylxxxiii, lxxxiv, lxxxv.
• Maternal distress may result in increased infantfussiness, more frequent feeds, night waking andintolerance of maternal separation, commonlyinterpreted by mothers as signifying milk supply
problemslxxxvi.
• Beliefs about impact of breastfeeding whilestressed or upset on infant wellbeing and breastmilk
quality may be prevalentlxxxvii, lxxxviii, 56, lxxxix• Depression may interfere with mother-baby bondand result in early cessation of breastfeedingxc.
Depressed mothers are less likely to seek care,including help with breastfeeding.
• Increased levels of concern may cause mothers
to keep babies closer than usual, resulting in
more frequent breastfeeding and (in the case ofnewborns) earlier onset of lactogenesis IIxci/ .
• Trauma, fear and anxiety make it harder to learn
how to breastfeed and care for a baby (mothers
are in survival mode)xcii.

3. Low breastfeedingknowledge andspread of myths andmisconceptions aboutbreastfeeding54, lxx, lxxi, lxxii,

continued...

54 

Brown and Shenker (2020); 4.3% of surveyed mothers in the UK were told by a health professional that breastfeeding might
not be safe during COVID-19 which was associated with stopping breastfeeding.

55 Brown and Shenker (2020) found that a high proportion of new mothers who had stopped breastfeeding perceived thata lack of social and emotional support had negatively impacted their breastfeeding experience. Many participants talked
about missing meeting other breastfeeding mothers and socialising in baby groups or out with friends. Many talked about theisolation they felt which was impacting their wellbeing and mental health.

56 Pantanella (2018) notes that while research demonstrates that dietary insufficiency rarely affects the amount or quality ofbreastmilk that a woman produces, this maternal perception represents a powerful barrier to enabling a lifesaving intervention.

34 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESTable 5 continued...

Household and social level
Possible challenge related
to the emergency
6. Changes in routine
and family structures,increased burden on
mothers

Possible challenge related
to the emergency
7. Lack of privacy andovercrowdingxcvii, xcviii, xcix,
c, ci, cii

ExampleDisruption of daily routine, longqueues for services (e.g., food
distribution), constant or frequent
movement during displacement,
increased demands on womene.g., assuming additional role ofhead of householdxciii, xciv and/or
caring for the elderly andinjuredxcv and/or caring for older
children at home57, xcvi, changes
in family structures and familyliving arrangements
ExampleChanges in family living
arrangements and conditions,lack of privacy while on themove during displacement/
evacuation, overcrowding incamps and shelters, longqueues for services

Possible implications for breastfeeding andbreastfeeding support• Mothers whose routine has been disrupted/
whose workload has increased may feed lessoften or for shorter durations.
• Maternal exhaustion reduces mother’s ability torecognise and respond to infant needs.
• Mothers may experience pressure to wean fromfamily members58 and providers who perceive
breastfeeding as a burden.

Possible implications for breastfeeding andbreastfeeding support• Mothers who do not feel comfortablebreastfeeding in the presence of others (e.g., inqueues, shared shelters) may feed less often orfor shorter durations• Mothers may feel pressured to introduce abottle or BMS at night when sleeping in close
proximity to others (e.g., in crowded shelters)
due to the false perception that this will reducebaby crying at night.
• Lack of privacy can increase mothers’ stresslevels and feelings of dignity, impacting milk letdown reflex and maternal wellbeing (see 5).
continued...

57 

Brown and Shenker (2020) reported that many new mothers surveyed in the UK during the COVID-19 pandemic experienced
stress related to establishing breastfeeding while having to care for older children who would usually not be at home.

58 

De Young et al. (2018) note pressure to wean from family members was a stressor frequently listed by breastfeeding women
evacuating during the Fort McMurray wildfire in Canada.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

35

Table 5 continued...

Institutional (service provision) level
Possible challenge related
to the emergency

Possible implications for breastfeeding andbreastfeeding support

Example8. Increased levels of
mother-child separation59,

e.g., lack of evidence and/or
poor understanding of infant
feeding and carerecommendations during
outbreaks of new infectious
diseases results in unnecessary
separation, recommended
separation and temporary
cessation of breastfeeding e.g.,in certain cases during Ebola
outbreaksciv; accidental
separation during displacement
or at the onset of a natural
disaster, forced separation in
detention centres.

• Increased needs for support with regularbreastmilk expression, storage andtransportation (if feasible). Women may find theprocess emotionally and physically challenging,particularly if separated due to illness.
• Separation disrupts breastfeedingcv resulting in
an increase in the number of non-exclusively
and non-breastfed infants.
• Absence of skin-to-skin contact, proximity andbreastfeeding influences early maternal-infantinteraction and caregiving capacity and therefore
infant mental health and developmentcvi.
• Separation limits breastfeeding’s protection
against infectious diseasecvii.
• Mothers may experience negative emotions (e.g.,loss of identify, feelings of failure, regret, shame,
disappointment, grief and feeling let down) when
the breastfeeding relationship ends prematurelycviii.
Separation magnifies the maternal healthconsequences of insufficient breastfeedingcix.

9. Increased rates ofdifficult/traumatic birthand postnatal experiences
and practices that are notsupportive of successfulbreastfeedingcx, cxi

Increased rates of pregnancy
complications and adverse birthoutcomes e.g., LBW orpremature, increased rates of
distressing or traumatic birthexperiences e.g., birthing in an
unfamiliar setting, birthing
without family/partner support,
increases in obstetricviolencecxii, lack of access to
skilled birth support andemergency obstetric care,increased rates of Caesarean
birthscxiii, cxiv

• Decline in maternal wellbeing reduces amother’s ability to responsively breastfeed andcare for child(ren)• A traumatic birth may cause breastfeeding to bedifficult, including through delaying lactogenesis
II, negatively impacting cognition and moodand interfering with bonding and attachment.
Breastfeeding may also trigger flashbacks oftraumatic birth or sexual violencecxv.
• Caesarean births, birth complications andunsupportive practices may delay initiation ofbreastfeeding and skin-to-skin contact and lower
newborn breastfeeding frequency, resulting inincreased difficulties in establishing breastfeeding.
• Increased rates of maternal mortality result inhigher numbers of non-breastfed infants.

60, ciii

continued...

59 

Brown and Shenker (2020) reported that of 103 mothers surveyed in the UK who had a baby in the neonatal intensive
care unit (NICU) during the COVID-19 pandemic, 19.4% (n = 20) were told they could not visit their baby in the NICU due
to Infection Prevention Control (IPC) measures. Not being able to visit their baby in NICU was associated with no longer
breastfeeding (χ2 = 44.645, P = 0.000). At the time of survey completion, 80.0% who were told they could not visit their baby
were no longer breastfeeding compared with 9.6% of those who could.

60 

Gribble et al., (2020) found that during the COVID-19 pandemic, although many countries followed WHO guidance to keep
mothers and their newborns together, others implemented IPC policies that imposed postpartum separation and discouraged
or prohibited breastfeeding.

36 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESTable 5 continued...

Environmental level
Possible challenge related
to the emergency

ExamplePossible implications for breastfeeding andbreastfeeding support

10. Insecure accessto supplies for BMSdependent infantscxvi

Security constraints maketravel to markets/shops
dangerous to purchase BMS,
supply chains interrupted/
damaged, besiegement,
shortages due to panic buying
following emergency measuresdeclarationscxvii; reduced
purchasing powercxviii• Mothers may wish to restart breastfeeding totransition from mixed to exclusive breastfeeding
to reduce infant formula usecxix.

11. Increased gender
based constraints, control
and violencecxx, cxxin/a• Abandonment of children born as a result of
unwanted pregnancies or rapecxxii can result inincreased number of non-breastfed infants.
• Survivors of sexual violence may findbreastfeeding distressing (e.g., experience
flashbacks) or difficult.
• Intimate partner violence is associated withbreastfeeding difficultiescxxiii.
• Increased rates of early/child marriage increase
the risk of birth complications and adverse
birth outcomes and subsequent breastfeeding
difficulties in young mothers.

12. Inadequate Water,
sanitation and hygiene(WASH)

n/a• Women may minimise fluid intake due to lack ofaccessible drinking water or lack of acceptable
toilet facilities (e.g., at border crossingscxxiv andon evacuation transport) resulting in severe
dehydration and a temporary drop in breastmilk
volume.
• Difficulties adequately cleaning BMS
preparation and feeding equipmentcxxv andbreast pumpscxxvi and hygienically preparing
powdered infant formula.
• Higher risk of malnutrition and diarrhoea in infants.

13. Increased levelsof environmental
toxinscxxvii (e.g., in flood
water) or radioactive
contamination61

n/a• Mothers may have concerns about the safety ofbreastfeeding62, cxxviii• Mothers may have concerns about the safety ofavailable foods.

14. Donations anduncontrolled distributionsof BMScxxix, cxxx, cxxxi, cxxxii,

n/a• Blanket distribution of infant formula conveys
negative message about breastfeeding,undermining maternal confidence in ability tobreastfeedcxxxix.
• Women who would normally breastfeed
may introduce BMS and/or discontinue
breastfeeding.
• Increased rates of diarrhoeal disease among
infants consuming donated BMScxl impacts childhealth and maternal wellbeing (stress).

cxxxiii, cxxxiv, cxxxv, cxxxvi, cxxxvii,
cxxxviii

61 

Ishii et al., (2016) found that out of 16,001 women who had given birth around the time of the Great Japan Earthquakeand subsequent Fukushima nuclear power plant incident, 20.3% of women who formula fed their babies did so becauseof concern regarding radioactive contamination of breastmilk. The use of formula was associated with residence in theevacuation zone and interruption of antenatal care. The authors noted the importance of breastfeeding support following thenuclear accident.

62 

Brown and Shenker (2020) reported that 22% of surveyed mothers who gave birth in the UK during the COVID-19 pandemic
stated that worries about the safety of breastfeeding had affected their decision to stop breastfeeding.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

37

CASE STUDY 13 Experiences of breastfeeding during a public health emergency
During the COVID-19 pandemic, lockdown and social
support during lockdown (e.g., no visitors, baby groups
distancing measures were imposed in the United
cancelled) had negatively impacted their breastfeeding
Kingdom to limit the spread of the virus. An online
experience. Other negative impacts included a lack ofsurvey of 1,219 breastfeeding mothers of infants
face-to-face breastfeeding support, stress of trying torevealed two very different experiences: 41.8% ofjuggle caring for older children without family support,
mothers felt that breastfeeding was protected due
intense focus on breastfeeding (feeling overwhelmed),
to lockdown but 27.0% had a negative experience.
no experience of breastfeeding in public (feeling worried
Reported positive impacts of the lockdown included
about future breastfeeding in public) and work pressures.
more time to focus on breastfeeding, fewer visitors, more These work pressures were particularly felt by healthprivacy, increased responsive feeding, greater partner
professionals who reported that very busy schedules
support and a delay of return to work outside the home. and cumbersome personal protective equipment (PPE)
18.9% of respondents stopped breastfeeding (mean age resulted in engorgement or lowered milk supply. The
for cessation was 3.15 weeks) yet only 13.5% of thisresearchers concluded that their findings were vital ingroup described themselves as ready to do so. A highunderstanding how to support those women who may be
proportion of the group who had stopped breastfeeding grieving their loss of breastfeeding and are affected byfelt that the lack of access to social and emotional
their negative experiences.
Source: Brown and Shenker (2020) Experiences of breastfeeding during COVID‐19: Lessons for future practical and emotional support.

BOX 7 Programmatic considerations: integrated MHPSS and counselling
Pregnant women, mothers and infants are at increased risk of MHPSS difficulties during emergenciescxli . A woman’s
experience of breastfeeding and the breastfeeding support she receives can positively or negatively impact her
mental health and her mental health can impact her ability to responsively feed and care for her child. Given how
closely mental health and breastfeeding are connected, consider integrating MHPSS and counselling servicescxlii .
Embedding MHPSS activities within wider systems tends to increase access, carry less stigmacxliii and may amplify
sectoral outcomes.
Tending to a caregiver’s emotional health is an important component of counselling. Breastfeeding counselling
programmes should be designed and implemented in a way that takes the psychosocial wellbeing of caregivers into
consideration. Counselling should be conducted in comfortable and welcoming spaces which aid relaxation. It is
important for counsellors to concentrate on being calm and kind, helping caregivers feel safe, giving realistic
reassurance and not compelling caregivers to talk but actively listening when they docxliv. Tools that assess both the
caregiver-baby dyad’s feeding practices and psychosocial wellbeing will give a more complete picture of their needs(Annex C). Where capacity exists, MHPSS support can be provided directly by counsellors. For example, simple
relaxation interventions for breastfeeding mothers can positively impact infant behaviour and growthcxlv. An
alternative is for MHPSS and counselling services to be co-located and well-coordinated so that caregivers can easily
access both services. Group counselling activities can be co-facilitated by IYCF-E and MHPSS personnel. Even whenreferral mechanisms arein place between
counselling and MHPSS
services, it is helpful forbreastfeeding counsellors
to be trained on theprovision of trauma
informed care andpsychological first aid(see 5 – COUNSELLINGCAPACITY IN
EMERGENCIES). Local

culture brokers should be
consulted to understandand navigate the cultural
understanding of mental
health issues in theemergency-affected area.

38 

Mothers share their experiences during Typhoon
Haiyan in a Women and Young Children SpaceWORLD VISION/MONALINDA KADIZOPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESCASE STUDY 14 A psychosocial approach to breastfeeding counselling
Since 2017, ACF has implemented Baby Friendly Spaces(BFS) in refugee camps in Ethiopia. Attendees benefit
from tailored psychosocial interventions in order toimprove maternal and child health and wellbeing. In the
BFS, psychologists and psychosocial workers ensure
the safety of the space. This allows breastfeedingpractices and the provision of psychosocial support tobe optimised within a holistic mother and child friendly
environment. In this context, the BFS programme isalso considered as a nutrition-sensitive intervention
aimed at preventing child undernutrition and supporting
the recovery of malnourished children under two.
Upon admission, intake interviews are conductedwith mothers to obtain details about issues related
to breastfeeding, pregnancy and wellbeing as well asother significant health-related information. Elementsof the MAMI approach are integrated. Based on theinterview, mothers and babies are invited to participate
in recommended activities such as relaxation focus

group discussions on child development, baby bathing
and massaging and breastfeeding counselling. Beyond
breastfeeding practices, a psychosocial approach tobreastfeeding involves critical observation of mothers’
daily routine practices such as child stimulation,
hygiene, emotional attachment and bonding. All mothers
receive regular one-to-one follow-up meetings that
explore their psychosocial wellbeing and how it may
be affecting their ability to provide care to their babiesor themselves. Trained staff provide emotional support
and build mothers’ confidence in their abilities. In
2018, a studycxlvi conducted in collaboration with Johns
Hopkins University showed that within a two-month
period, improvements were observed in all domains ofbreastfeeding and statistically significant reductions wereobserved in signs of breastfeeding difficulty in terms ofbody positioning, response, emotional bonding, anatomy
and suckling. Maternal mental health also improved.
Source: Action Against Hunger, Ethiopia. Email correspondence, 2020

5. COUNSELLING CAPACITY IN EMERGENCIESThis section focuses on how to identify and develop the capacity of human resources who can deliver
counselling during an emergency. In order to ensure adequate capacity for counselling, it is necessary
to understand 1) who can deliver counselling (service providers) and 2) what knowledge and skills(competencies) are required to counsel effectively during an emergency. Another important step is toconduct a capacity assessment and mapping to understand who is available to respond to the emergency
and what competencies they have compared to what is needed. The final step is to implement a
counselling capacity building plan to address any gaps identified during the capacity assessment. These
steps are described within this chapter.
While capacity building activities such as training can effectively contribute to the timely restoration andstrengthening of services during emergenciescxlvii (Case Study 16), capacity development efforts must go
beyond training alone to support and empower counsellors in their rolescxlviii. Examples include putting
in place breastfeeding policies, incorporating breastfeeding indicators into health information systems,
ensuring the availability of counselling and referral protocols, ensuring counsellors have access to adequate
technical support and improving the supply of key products, including BMS when necessary. Further
guidance on capacity development can be found in the IG-BFC.

5.1 PROVIDERS OF BREASTFEEDING COUNSELLING
WHO Recommendation 6

Breastfeeding counselling should be provided as a continuum of care by appropriately trained
healthcare professionals and community-based lay and peer breastfeeding counsellors.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

39Counsellors, supervisors and trainers will be needed to deliver counselling during an emergency. Bothhealth professionals (e.g., midwives) and paraprofessionals (e.g., peers) can be breastfeeding counsellors(Figure 2). Who should deliver breastfeeding counselling as part of an emergency response will varyconsiderably depending on which providers and services offered counselling before the emergency andhow they have been impacted. There may be 1) existing cadres who were already providing counselling
before the emergency, 2) existing cadres who can add counselling to their tasks and 3) new cadres that canbe established.
Figure 2: Possible providers of counselling: roles and responsibilities

Healthcare professionals

Paraprofessionals

Other breastfeeding supporters

Professionals within the healthsystem such as physicians,
midwives, perinatal nurses,
lactation consultants, nutritionists,
psychologists etc.
• Trained and tasked to provide
counselling, mostly at facilitylevel• May also work at household
and community level• May have multiple other
responsibilities in addition tocounselling• May have advanced counsellingcompetencies including aspectsof lactation management that
require clinical knowledge
and skills• Good knowledge of, andlinkages to, the health system

Lay and peer breastfeedingcounsellors such as mother-tomother support group facilitators,
community health workers,
traditional birth attendants,
psychosocial workers, etc.
• Trained and tasked to provide
counselling, mostly at household
and community level• May also work at facility level• May have advanced counsellingcompetencies that do not
require clinical knowledge
and skills• Good knowledge of, andlinkages to, the community

Frontline workers such as IYCF
educators, volunteers, mobilisers,
hygiene promoters, childprotection case workers, first
responders, etc.
• Trained and tasked withdelivering general breastfeedingpromotion and support including
identification and referral (SRA)

Identification & counselling

Identification & counselling

In circumstances where the local
system cannot cope, consult
available preparedness plans andconsider deploying counsellors
through emergency surge
mechanisms (e.g., counsellor
rosters, civil society groups),
temporarily relocating national
staff from unaffected areas and/or recruiting new personnel.
Desired characteristics ofcounsellors are outlined inBox 8 below.

40 

Identification, education &general support

A health worker supports a mother tobreastfeed her malnourished childWORLD VISION/CHRISTOPHER LETEOPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESBOX 8 Desired characteristics of counsellors
Preferred characteristics of individuals who provide counselling are outlined in the IG-BFC including a preference forfemale providers with similar characteristics to those counselling is intended for; who speak the same language andare familiar with local cultural and social customs. Personal breastfeeding experience can be helpful. Additional key
considerations in emergency settings include:• M otivation. Willingness and commitment to respond to the crisis are critical requirementscxlix .
• A cceptance. It may be challenging to identify counsellors who are accepted by both the local authorities and theaffected population. For example, in some contexts TBAs are well accepted by communities but not by national
health systems. A possible solution that may enhance community acceptance of counselling services is to engage
with communities and local authorities to task shift TBAs to work alongside (accompany) counsellors.
• C onflict and context sensitivity. Consider the safety and security of counsellors in their expected role. Where surge
capacity is provided through mobilising counsellors from other locations, pay close attention to nuances in culture,
custom and language. Particularly in the context of conflict, be sensitive to the drivers of the conflict when
deploying counsellors (do no harm) and be aware of potential community mistrust of staff with certain profiles.
• G ender. Staffing a programme that relies on a majority of female staff can be challenging in contexts where
husbands may prevent their wives from working or it may not be seen as socially acceptable for women to work,
travel or visit homes unaccompanied. Potential solutions include engaging community and religious leaders,planning for counsellors to work in pairs and channelling recruitment through local partners who are trusted andaccepted by the community. Counselling services should anticipate and accept that a proportion of female
counsellors will require maternity leave and that some may not return to work after marriage or childbirth and plan
accordingly. Particularly when working in emergency conditions, it may be challenging for counsellors themselves
to breastfeed as recommended. Family and breastfeeding friendly policies – such as paid maternity leave, access tochildcare, breastfeeding breaks and dedicated breastfeeding/breastmilk expression spaces – promote genderequality and support women’s participation in the workforcecl .
• E
 xpatriate counsellors. Dependence on expatriate providers raises concerns about long-term sustainability, costeffectiveness and cultural appropriateness of services. If they are temporarily necessary as a last resort (e.g., during
international mass displacement), ensure they are culturally competent (see 5.2 – COUNSELLING COMPETENCIES)
and that part of their role is to strengthen local capacity.
• L anguage. When available counsellors do not speak the same language (or dialect) as the emergency-affected
population (as may be the case in IDP or refugee contexts), translators or a remote counselling modality may be
used as an interim solution. Both may hamper communication and the establishment of the counsellor-caregiver
relationship. When recruiting translators, pay close attention to the demographics (e.g., gender, age, ethnicity) oftranslators. It is important that translators are trained on concepts such as “exclusive breastfeeding” which may not
be easily translated and understood in other languages. Counselling capacity should be established within theaffected community as soon as possible.

Establishing capacity in a way that ensures IYCF practices are protected, promoted and supported athousehold, community and facility level will have the greatest impact (see Figure 3 for an example of a
3-tier system).

Key considerations for counsellors (service providers) at facility level
Health workers play a critical role in minimising disruption to and supporting breastfeeding63,64,cli, clii, a lowcost, high-impact child survival intervention that is especially relevant during emergencies. Breastfeedingcounselling is an important component of treatment and recovery in certain clinical settings (for example,
when treating infantile diarrhoea or malnutrition, particularly in infants under six monthscliii). However,good counselling takes time and skill. During emergencies, health workers may:

63 

Castillo et al., (2016) report on experiences from the Philippines following Typhoon Haiyan which demonstrated that inemergency settings, training of health workers can lead to improved IYCF practices; three months following training on an
Essential Intrapartum and Newborn Care (EINC) package breastfeeding initiation rates had improved from 50% to 86%.

64 

Brown and Shenker (2020) reported that significant associations were found between being told that breastfeeding may
not be safe and feeding practices; surveyed new mothers living in the UK during the COVID-19 pandemic who had stopped
breastfeeding were more likely to have been told by a healthcare professional that breastfeeding was not safe (X2 = 18.84,
P = 0.000)

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

41

• L
 ack the time to meet all counselling needs• D eprioritise breastfeeding support due to increased need for curative services• L ack necessary counselling competencies or knowledge of lactation
Possible ways to overcome these barriers are suggested in Table 2. If health professionals have not beenadequately trained in preparedness (as recommended in the IG-BFC), given the time required for adequate
training, it may not be possible or advisable to remove health workers from their posts for training in
the acute phase of an emergency. Instead, health workers should be rapidly and regularly oriented on
key infant and young child feeding recommendations and general breastfeeding promotion and supportand instructed on how to identify and refer dyads requiring counselling (e.g., using the SRA). This helps
to ensure pregnant and breastfeeding women receive accurate and consistent information and prevents
breastfeeding from being underminedcliv. It is important for some health workers to be equipped withcounselling competencies that require clinical skills as soon as possible to enable appropriate clinicalmanagement of lactation (e.g., prescription of antibiotics to treat mastitis, if necessary).
The immediate availability of counselling services at facility level can be ensured through placing a
dedicated IYCF/breastfeeding counsellor within services65 . Placing counsellors within health teams brings
clinical and counselling services together and can help to avoid the creation of parallel systems that may
diminish community trust in health services or weaken the health system. If counselling services aredelivered through sectors other than health, it is important to ensure clear linkages to health services.
The protection, promotion and support of breastfeeding in facilities providing maternity/perinatal
services need to be maintained and, where necessary, strengthened during emergenciesclv. Maternity
service providers are in contact with priority populations for counselling at critical times; their actions
can significantly influence the breastfeeding journey of a mother and her infant66 . Even when dedicatedcounsellors are needed within maternity services, maternity care providers (e.g., midwives, maternity
nurses) must be enabled (through service planning and capacity building) to provide basic counselling andto support early initiation of exclusive breastfeeding67, 68, 69, 70 . In line with global guidance, the Ten Steps toSuccessful Breastfeeding of the WHO/UNICEF BFHI should be integrated into maternity/perinatal services
during emergencies71, 72 . Health facilities that are BFHI-accredited should ensure BFHI standards aremaintained to the greatest extent possible, even when the emergency context does not allow for external
assessment, accreditation and monitoring.

65 Hargest Slade and Gribble (2011) describe how, following the 2011 Christchurch earthquake, the first author worked asa breastfeeding adviser in the maternity unit of a hospital located in the area most of the emergency-affected population
evacuated to. After the earthquake, she worked within the health system to provide support to breastfeeding women who
had evacuated. The presence of individuals within the health system who had the skills to provide appropriate breastfeeding
support and were supported to do so was identified as a key factor that made it possible to provide effective support
to breastfeeding evacuees. This is an example of how health systems can respond effectively in emergencies to support
breastfeeding mothers.

66 

Note: Maternity care providers are usually also well suited to support breastfeeding in emergencies (used to working withmothers and infants, familiar with their needs, motivated to support them) and have typically already received some preservice breastfeeding education.

67 

Further guidance: IFE Core Group (2021). Infographic: Early Initiation of Breastfeeding in Emergencies – Guidance forMaternity Service Providers.

68 Note: Similar considerations can be applied to traditional birth attendants who can play an important role in contexts withhigh rates of community births.

69 

Further guidance: https://www.healthynewbornnetwork.org/resource/newborn-health-humanitarian-settings-field-guide/70 https://resourcecentre.savethechildren.net/node/11145/pdf/iafm_on_reproductive_health_in_hs_2018.pdf

71 

Further guidance: IFE Core Group (2017). Infant and Young Child Feeding in Emergencies. Operational Guidance for
Emergency Relief Staff and Programme Managers

72 

A cluster-randomised controlled trial by Yotebieng et al. (2015) in Kinshasa, DR Congo, found that a basic two-day (16h)training of health workers on BFHI Steps 1-9 significantly increased exclusive breastfeeding (36% compared to 12% in thecontrol group) and decreased diarrhoea rates at age six months. The study found this low-intensity, low-technology short-cut(without accreditation) intervention was suitable for rapid scale-up in maternity settings and can be considered as a means torapidly reduce under five child mortality.

42 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESKey considerations for counsellors (service providers) at community levelCounsellors at the community level are commonly known as peer counsellors or paraprofessionals.
Emergency response primarily occurs at the local level with community members who are serving as first
respondersclvi. If present, counsellors from breastfeeding community support organisations are an importantresource who can be rapidly mobilised. In many emergency contexts73 , members of the affected community
can also be trained to become breastfeeding counsellors. Motivated, experienced mothers can provide
peer counselling to a set number of households in their community and/or facilitate mother-to-mothersupport groups.
Strengthening counselling capacity at community level via peer counsellors is importantclvii given that:• P eer counsellors often have similar experiences to those of other emergency-affected women which
can facilitate relationship and rapport building and can be an important source of social support at times
when social networks and structures are disrupted.
• When privacy is lacking, peers can help to build confidence to breastfeed in the presence of others.
• It has been found that training and deployment of peer counsellors can prevent unnecessary use of BMS
in emergencies (see Case Study 16)clviii.
• E stablishing counselling capacity within emergency affected communities can potentially improve accessand coverageclix, alleviate pressure from overwhelmed health systems, help overcome language barriers(particularly in refugee contexts), allow for increased trust and improved understanding of culturallysensitive topicsclx, permit simultaneous focus on local capacity strengthening and creating moresustainable servicesclxi and empower communities to help themselves.
It is essential that linkages with the health system are maintained (see Figure 2), that lay counsellors
are recognised and appreciated, have access to technical support and the equipment and resources
needed to counsel safely and effectively and that they know when and how to refer complex cases(see REFERRAL SYSTEMS).
Figure 3: Example of a 3-tier system for provision of counselling and support at multiple levels74

Healthcare
professionals
Nutrition Officer

ReferralParaprofessional
Mother-to-mothersupport group facilitator

Breastfeeding supporter
Health and Nutrition Promoter

EXAMPLE ACTIVITIES• Provide basic and advanced counselling andsupport for more complex needs• Provide basic counselling and support• Identify need for more advanced counselling• Screen caregivers in the community using the SRA• Disseminate key messages on IYCF-E

73 

Note: A significant investment in time, training and supportive supervision is required to establish quality peer counsellinginterventions. This is unlikely to be feasible during the acute phase of a rapid onset emergency or in contexts with highpopulation movement.

74 

Note: This is an example for provision of counselling and support that starts with SRA at the community level with mothers
referred to different levels based on difficulties and counselling needed. Other scenarios also exist that may include SRA at
different levels.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

43

5.2 COUNSELLING COMPETENCIESTo ensure continuity of care, all counsellors, across and within any sectors and agencies who are engaged ininfant and young child feeding as part of the emergency response, should be equipped with a consensusdriven set of core counselling competencies (knowledge and skills). Such a set can be agreed upon withincoordination mechanisms such as the nutrition cluster. Informed by needs assessment, this set should
focus on the essential counselling skills and knowledge needed to address the most urgent needs of theemergency-affected population.
Competencies are considered basic or advanced. Competencies that require specific skills or medical
knowledge are considered advanced competencies. Basic competencies are required to achieve advanced
competencies. The basic and advanced competencies that can be considered for inclusion in the set of core
counselling competencies are listed in Table 6 below.
The following should be considered when defining the set of core counselling competencies required foran emergency response:
1. In resource-limited settings, the focus should be on equipping counsellors with the competencies
required for simple, effective, low-cost, low-technology interventions such as listening andreassurance, skin-to-skin contact, hand expression and cup feedingclxii. So that the greatest numberof caregiver-baby dyads can be helped, competencies should aim to address the most common suboptimal practices that carry the greatest risk75 , the most widespread IYCF problems and caregiverconcerns76 and prevalent myths and misconceptions that may be relevant during counselling77, clxiii.
2. Regardless of setting, most counselling needs can be met with the basic counselling competencies
required for both emergency and non-emergency settings. These competencies should always be
included in the set of core competencies for all counsellors and put in place as a first step.
3. Some counsellors may also be trained and evaluated on advanced counselling competencies.
Relactation is an important advanced competency in emergenciesclxiv. Depending on their role,counsellors may require further competencies (e.g., supportive supervision or mother-to-mothersupport group facilitation) not specified in this guidance.
4. In emergency settings, counsellors are likely to need additional competencies in order to provide
appropriate support and fully meet the needs of the emergency affected population. These additional
basic and advanced competencies are listed in the right hand column of Table 6 below.
a. S
 ome competencies, such as help a mother to breastfeed when stressed, are applicable to all
emergency settings and should therefore always be included in the set of core counsellingcompetencies. Rapid training may be needed to equip existing counsellors with thesecompetencies if this was not done in preparedness.
b. Some competencies, such as help a mother to breastfeed during infectious disease outbreaks, areapplicable to some emergency settings and should therefore sometimes be included in the set ofcore counselling competencies, depending on the specific cultural and/or emergency context.
Whether they will be needed can be decided during scenario-planning in preparedness orduring needs assessment. These are listed in italics.

75 

Note: For example, non-exclusive breastfeeding is particularly risky in emergency settings where sanitation and hygiene are poor.

76 

Note: Across emergencies, the research conducted for this document found that the most common concern caregivers haveis “not enough milk”.

77 

Note: There will always be diversity within communities and cultural contexts and it is therefore essential to practice active
listening to adapt counselling to an individual’s needs and beliefs.

44 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESA breastfeeding counsellor supports amother to relactate using the drip drop
method with donor human milk
ARUGAAN/PHILIPPINES

Considering the diverse and multiple needs of breastfeeding women during emergencies, it may notalways be possible to have immediate support available for all breastfeeding problems. Start by ensuring
basic counselling competencies are in place. Additional counselling competencies can gradually be added
according to a phased capacity building plan as counsellors’ knowledge, skills and confidence improve andthe response progresses.
Table 6: Breastfeeding counselling competencies for emergencies

Basic breastfeeding counselling competencies

Considerations for emergencies

Use listening and learning skills (1)• Ask open ended questions• Use responses and gestures that show interest• Reflect back what the mother says
• Empathise – show that you understand how the other person feels• Avoid words that sound judgemental• Use helpful non-verbal communication• Adapt communication style and content to the caregiver e.g.,
particular barriers, challenges, needs, preferences and values.

Same as in non-emergencies

Use skills to build confidence and give support (1)• Acknowledge what a mother thinks and feels• Recognise and praise what a mother and child are doing right• Give practical help
• Give relevant information• Use simple language• Make one or two suggestions, not commands

Same as in non-emergencies

Assess and document• Feeding histories of healthy and sick infant(s) or young child(ren)• Learn the mother’s history, present difficulties and possible
future challenges• Breastfeeding of healthy and sick infant(s) and young child(ren)• Observe the mother feeding and interacting with her baby
• Observe the infant(s) general condition, measure and assess growthusing growth chart(s)• Observe general condition of the mother, check and palpate
breast(s) as needed• Conduct an SRA and FA for a breastfed
infant (Annexes A and B)• Conduct an FA for an artificially fed
infant and calculate an infant’s caloric
and volume requirements to prescribe/
provide BMS to a BMS dependant infant

continued...
OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

45

Table 6 continued...
Assist mothers to:• Initiate breastfeeding within an hour of vaginal or Caesarean birth• Position themselves and their infant(s) for breastfeeding• Attach their infant(s) to the breast• Understand how breastfeeding works• Respond to feeding cues (understand and practice responsive
feeding)• Hand-express breastmilk• Cup or spoon-feed their infant(s)• Manage flat or inverted nipples• Manage sore or cracked nipple(s)• Manage engorgement of their breast(s), recognise mastitis• Recognise the signs of adequate milk transfer, swallowing andinfant satisfaction• Manage perceived insufficient milk supply• Manage low or excess milk supply• Breastfeed and soothe infant(s) who cry frequently or have
sleeping difficulties• Overcome concerns about breastmilk
quality and safety78• B reastfeed in crowded public spaces/in thepresence of others79• B reastfeed at night80• Understand the heightened risks ofusing feeding bottles, pacifiers or BMS
in the current context and the risks ofnot breastfeeding81• Breastfeed when stressed82• Breastfeed when busy83• Feed a non-breastfed child• B reastfeed someone else’s infant(wet nurse)• B reastfeed during infectious disease
outbreaks and take appropriate infection
prevention control measures84• R eject donations of BMS, feeding bottles
and teats

Prepare:• Pregnant women for breastfeeding• Mother(s) to breastfeed exclusively for six months• Mother(s) who are returning to work or having periods away fromtheir infant to maintain breastfeeding• Mother(s) for timely, appropriate, adequate and safe
complementary feeding• Mother(s) who wish to wean their infants or young children frombreastfeeding• C aregivers to feed and care for infants andyoung children during an expected crisis/
natural disaster

Refer:• Recognise when to refer mothers and infant(s) to breastfeedingcounsellors with advanced competencies or healthcare
professionals with specialised skills, as needed• Identify needs beyond counselling andmake appropriate referrals85
continued...

78 Note: In humanitarian settings, it is very common for breastfeeding women to be concerned about the quality of their breastmilk,
particularly when their diet has changed due to the emergency. They may also be concerned about the safety of their breastmilk– for example, if they have been exposed to chemicals in floodwater.

79 

Note: Although the preference is to build confidence to breastfeed in public, there may not be sufficient time or contact
opportunities to achieve this (e.g., during mass displacement). Where appropriate, shawls may be provided e.g., as part ofdignity kits.

80 

Note: For example, counselling on safe sleep arrangements and breastfeeding positions can be helpful in overcrowded conditions
where mothers may feel pressure to supplement a crying baby at night.

81 ote: Particularly in settings where artificial feeding was common prior to the onset of the crisis, interest in breastfeeding may
N
be low. Counsellors need strong interpersonal and communication skills to bring attention to breastfeeding as well as analyticalskills to understand a caregiver’s needs and current situation. In accordance with global guidance (OG-FE), BMS should only
be provided to infants who meet set eligibility criteria. However, maternal choice is an issue counsellors may find difficult tonavigate. This is particularly common for peer counsellors (who are “close” to the mother) or counsellors who normally work in
non-emergency, high resource settings. Training on the ethics of maternal choice, drawing comparisons between the pre-crisisand the current context with its increased risks and mechanisms for referral to experienced counsellors may be helpful82 

Note: Listen, build confidence about milk supply and information on reassuring signs that baby is getting enough breastmilk,
discuss stress management techniques, counsel on skin-to-skin and responsive breastfeeding, counsel on positive aspects ofbreastfeeding (e.g., calming hormones and bonding).

83 

Note: For example, show a mother how to use a (provided) baby sling, counsel on responsive breastfeeding and how to breastfeed
while queuing or walking, explore possible ways to decrease workload (including during family discussions/home visits).

84 

Note: For example, hand and breast hygiene, use of a face mask (e.g., respiratory illness outbreak), handling expressed breastmilk(e.g., of a mother recovering from Ebola Virus Disease).

85 

Note: For example, malnutrition treatment services, food assistance, SGBV services, MHPSS support can be considered as theaction principles of look, listen and link which are part of psychological first aid.

46 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESTable 6 continued...

Advanced breastfeeding counselling competencies

Considerations for emergencies

Assist mothers to:• Manage mastitis• Manage candida• Manage tongue tie (ankyloglossia)• Breastfeed a LBW, pre-term or sick infant(s)• Successfully breastfeed despite deeply inverted or very large
nipple(s)• Breastfeed infant(s) or child(ren) with disabilities• Breastfeed infant(s) through difficult personal circumstances orpostpartum depression• Breastfeed infant(s) who are refusing to breastfeed (nursing strike)• Induce or re-establish lactation (relactation)• Manage feeding an infant who needs fluids other than breastmilk• Breastfeed a malnourished infant• Rapidly stop breastfeeding86• Suppress lactation following infant loss
or stillbirth• Maintain lactation while separated fromtheir infant• Reduce or stop supplementation anduse of bottles, nipple shields and teats• Hygienically prepare and responsively
feed a breastmilk substitute87• C ost and maximise available food to
support maternal diet88• Practice Lactation Amenorrhea Method(LAM) for family planning• Feed their infant while living with HIV89

Prepare:• Pregnant women at high-risk for low milk supply• Pregnant women who are HIV positive to breastfeed• Pregnant women at high-risk to breastfeed a small, sick or preterm
infant(s)Same as in non-emergencies

Refer:• Recognise when to refer mothers and infant(s) to counsellors withbasic breastfeeding competencies for follow-up with healthcare
professionals with specialised skills, as needed

Same as in non-emergencies

Additional competencies required for emergencies• P sychological first aid. Because mental health services are often lacking or overwhelmed during
emergencies, psychological first aid is an important skillset that all counsellors should possess to support
caregivers in the aftermath of crisis events and to prevent trauma from taking root in the first place.
• Trauma informed care. To avoid doing harm, provide effective care and improve access to services, it isimportant that breastfeeding counselling programmes serving populations with high levels of exposure
to trauma apply a trauma informed approach (see definitions). This includes equipping counsellors withtrauma informed care competencies. The first tier of trauma-informed care (TIC) is universally offered
to all counselling clients on the assumption that anyone may be a survivor of trauma (universal care)and is a basic competency required for all counsellors. The second tier of TIC is trauma-specific carefor clients identified as survivors of trauma and is considered an advanced competency. Finally, somecaregivers will require specialised support from trained mental healthcare providers. Where traumaspecific and trauma-specialist care is available, it is important that counsellors are trained on when torefer (see Figure 4).
86 Note: This competency is rarely required. It is particularly relevant during outbreaks of infectious diseases for whichbreastfeeding cessation is recommendation if infected e.g., Ebola Virus Disease. Support should include counselling on breastcare, safely discarding breastmilk (if recommended), providing emotional support and facilitating replacement feeding for the
infant. Note that breastfeeding cessation should be done gradually rather than rapidly whenever possible.

87 

Note: Including provision of information on preparation, feeding and storage.

88 

Hashmi et al. (2019) describe how counselling in Mae La refugee camp in Thailand was tailored for mothers by providing cheaperfood options for infants and specific examples of low cost meals to meet minimum acceptable diet requirements based onhousehold expenditure data collected during monthly home-based counselling sessions.

89 Further guidance: WHO (2018). Operational Guidance: HIV and Infant Feeding in Emergencies.

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

47

Figure 4: Example of multi-tiered approach to trauma-informed care

Traumaspecialist care
• Provided bysome mental
healthcare providers• Provided to some caregivers
Examples (for counsellors): referrals

Trauma specific care
• Provided by some counsellors• Provided to some caregivers(identified trauma survivors)
Examples: Compassion e.g., avoid victim-blaming (e.g., asking
why something happened) and minimising language, use affirming
language (e.g., "I believe you"); Care e.g., react appropriately to a
trauma response, support alternative feeding options for survivors of rape.
(Note: Universal trauma informed care still applies)

Universal trauma informed care
• Provided by all counsellors• Provided to all caregivers
Examples: Consent e.g., explaining and obtaining consent for any necessary touch; Compassion
e.g., responding with understanding when someone appears to be triggered by breastfeeding, using
inclusive language, protecting modesty and dignity; Care e.g., using verbal instructions and/or props
rather than touch (“hands-off” technique), helping a client to feel physically and psychologically safe.

• C ultural competency. Counsellors must be culturally competent as an important component of trauma
informed care. Key to the design of culturally sensitive interventions is an understanding of caregivers’
perceptions and other factors driving feeding practicesclxv. Examples of culturally informed knowledge
about infant feeding include the traditional use of natural galactagogues90 , traditional newborn carepractices and postpartum traditions, communal caretaking practices91 , maternal perceptions of factorsthat can impact breastmilk supply92 and quality93 , myths and misconceptions that have arisen during the
emergency, attitudes towards modesty, maternal beliefs about BMS and to what extent breastfeeding

90 

De Young et al. (2018) identified jwano as a spice traditionally used to boost lactation in Nepalese families. Evidence is limitedon the impact of natural galactagogues (“milk boosters”) on infant weight gain and milk production in mothers of healthy, term
infants (Foong et al, 2020). However, facilitating access to locally known galactagogues (with no known adverse effects) may
benefit women’s confidence and emotional wellbeing. Counsellors’ priority should be to identify and correct the causes for low
milk production.

91 

De Young et al. (2018) noted that caretakers in the post-earthquake settlements in Nepal expressed that infant care was acommunal activity and the responsibilities of infant and childcare were shared. This kinship of breastfeeding was reflected in theways in which women supported one another in the villages and tent camps.

92 

Emerson et al. (2017) found that mothers in the DRC often perceived that stress caused milk insufficiency and frequently
made associations between poor maternal nutritional status and difficulties breastfeeding (pain while breastfeeding or perceived
milk insufficiency).

93 

Dorneman and Kelly (2013) found that mothers in post-earthquake Haiti believed the quality of their breastmilk would
deteriorate if their diet was poor or the mother was afflicted by a psychosocial condition known as “bad blood”. To protect
children in these situations, early supplementation was introduced.

48 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES

is a part of maternal or religious identity. Where counsellors are not from the emergency-affected
population, additional knowledge and skills will be required to enable them to understand caregivers’
cultural, ethnic, religious, linguistic and socioeconomic needs so that they can operate effectively andethically in a multicultural environment.
• C ounsellors who normally work in non-emergency settings are likely to be aware of, but may have little
practical experience of, practices such as relactation and wet nursing94 or issues such as malnutrition
in infants. Lactation professionals deployed from high-resource settings may be accustomed toworking with tools such as feeding bottles, breast pumps and nipple shields and must be supported toadjust their practice to the context. Even when working in high-income settings, it is imperative that
counsellors are aware of the increased risks of using such tools during emergencies and supported toadapt their practice to simplified, safer approaches (e.g., using the drip-drop relactation method rather
than a supplementary feeding device, using hand expression as a safer alternative to breast pumps, cupfeeding as a safer alternative to bottle feeding).
• E arly Childhood Development. Counsellors should have basic knowledge of ECD including the skills
and capacities that children acquire in the first years of life and the critical role of responsive caregiving,
including responsive feeding. The responsive interactions that naturally occur during breastfeeding andthat can be extended through playful communications lay the foundation for the child’s future health,behaviour and intellectual abilities.

CASE STUDY 15 Supporting IYCF in the context of Ebola Virus Disease
In August 2018, an Ebola Virus Disease (EVD) outbreakand inflammation, instructions on how to handle andwas declared in the Democratic Republic of the Congo
discard expressed breastmilk of mothers with EVD(DRC). By the time the outbreak ended in June 2020,
according to Infection Prevention Protocols. Upon
3,470 confirmed and probable cases had been reported. discharge, caregivers were counselled on hygienic
Women and infants were disproportionately affected.
artificial feeding and cup feeding. Mothers who had
In line with global and national guidance, breastfeeding
survived Ebola were also counselled on the possibility
women were recommended to stop breastfeeding if they, of re-starting breastfeeding once two consecutiveor their child, developed EVD-like symptoms. Ebola islaboratory tests confirmed that the virus was no longer
an exception to global breastfeeding recommendations
detectable in her breastmilk. At community level, trained
because available evidence indicates that the risks ofpsychosocial workers (supervised by nutritionists)
EVD infection outweigh the risks of not breastfeeding.
followed-up and supported women to increase or reMother-baby dyads admitted to a facility for testing were start breastmilk production once it was deemed safe
jointly counselled by a nutritionist and a psychosocial
to do so. Relactation was found to be a challenging
worker on the recommendation to temporarily beprocess. Mothers expressed worries around restarting
separated and stop breastfeeding. No cases of refusal
breastfeeding after EVD infection and the availability ofwere reported, attributed to the counselling process and nutritionists to support the intensive relactation processintegration of psychosocial support. Infants received
was limited. A key lesson learned from this experience
BMS as part of a comprehensive package of support.
was that, if not yet in place, it is vital to focus on building
Gaps in national guidance for this stage of care included breastfeeding counselling competencies from the start of
how to support a mother to rapidly stop breastfeeding,an EVD response.
hand expression as a technique to prevent engorgement
Source: Global Nutrition Cluster (GNC) Technical Alliance (2020). Supporting Non-Breastfed Children
as part of an Ebola Response. Experiences from the Democratic Republic of the Congo.

94 

Palmquist and Gribble (2018) identify lack of education and support for relactation and wet nursing as one of the most common
barriers to an effective IYCF-E response.

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BOX 9 Important topics to cover during training• H ow to provide breastfeeding counselling services in practice during emergencies. Where, when, how often andhow to counsel (i.e., the content of this guidance). Counsellors should also be trained on when and how to correctly
use job aids and other tools.
• The lifesaving importance of breastfeeding in emergencies as well as the risks associated with use of BMS95 . Thisis key to solidifying provider motivation.
• H ow breastfeeding practices may be undermined or damaged by the emergency (see Table 5) to enable theprovision of anticipatory counselling.
• H ow breastfeeding works. Counsellors should have an excellent understanding of how breastfeeding works and its
robustness so that they can confidently counsel mothers who are malnourished or stressed. It can be particularly
challenging to counsel a caregiver whose diet is compromised due to food insecurity; counsellors should be awareof what foods are available and at what cost to enable sensitive and practical counselling on maternal diet.
Adequate time and attention should be given to ensuring that counsellors understand the relationship between
breastfeeding and infant and maternal mental health and caregiving capacity, that stress does not directly impact
breastmilk production and how to effectively convey this knowledge to a caregiver.
• Complementing the above with knowledge of the potential mental health consequences of emergenciesclxvi has
the potential to ensure compassionate counselling of stressed or traumatised caregivers.
• H ow behaviour change works. Changing behaviour can be particularly challenging in emergencies, given thevarious stressors present and the potentially short duration of an emergency. Understanding how to effectively
bring about behaviour change and that it is a stepwise processclxvii that takes time and repeated contacts canprevent counsellor demotivation and frustration.
• T he basics of the humanitarian system. To make effective referrals and successfully advocate for the needs ofcaregivers and their children, counsellors should be equipped with a basic understanding of humanitarian
coordination mechanisms, the package of humanitarian services being delivered and referral pathways.
• H ow the OG-IFE and the WHO International Code applies to emergency settings in general and a counsellor’srole specifically and how to report Code violations.

5.3 CAPACITY ASSESSMENT AND MAPPINGCapacity assessment and mapping is an important activity to identify learning and human resource
planning needs. It should ideally be conducted in preparedness and rapidly updated at the start of an
emergency. If this has not been done, a rapid capacity assessment and mapping should be conducted assoon as possible after the onset of the emergency.
1. I dentify how many counsellors are needed and where they are needed (needs assessment). In addition
to existing services, new services and structures requiring counselling services may be set up in
response to new or heightened needs (e.g., malnutrition treatment or psychosocial support services,cholera treatment centres – see 3.2 – KEY ENTRY POINTS FOR BREASTFEEDING COUNSELLING IN
EMERGENCIES). Counsellors may also be requested to provide services in temporary locations where theaffected population is sheltering such as camps or evacuation centres.
2. Identify who is available to deliver counselling and where they are. At the start of the response, rapidly
verify how many existing counsellors in the area are able to work/function. Many countries have a
pre-existing supply of breastfeeding counsellors who should be viewed as an important resource inan emergencyclxviii. However, they may have been affected by the emergency themselves. Counsellingsupervisors and trainers can also be identified through reviewing and updating any existing local
database of counselling trainers as well as national expertise and breastfeeding support networks.

95

Tool: IFE Core Group (2021). Brief: Breastfeeding Counselling in Emergencies.

50 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES3. U
 nderstand what level of knowledge, skill and confidence to provide counselling during emergencies
exists96 . At the start of the emergency, rapidly review capacity assessments conducted in preparednessor – if these are not available – rapidly consider the overall level of pre-emergency support forbreastfeeding and whether health professionals and other responders interacting with infants, young
children and their caregivers have adequate breastfeeding knowledge and skills (e.g., through examining
pre-service and in-service training materials and reports) and experience of counselling in emergency
contexts. Consider the education and literacy levels and professional background97 of those available toprovide counselling.
At later stages of the emergency response, more in-depth individual level capacity assessments98 can be
carried out to assess which competencies counsellors already have and which need to be developed. Thesemay be different for different cadres. Multiple choice quizzes99 and observation of counselling contacts
using performance checklists can be used to assess pre-training knowledge and skills respectively.
Note individual capacity assessments should be part of a broader capacity mapping exercise100, 101 that also
examines programming and coordination capacity, amongst othersclxix.

5.4 CAPACITY BUILDING PLANNING
Depending on the number of trained and available counsellors and their level of emergency preparedness,
as determined during the capacity assessment and mapping exercise, there may be a need to rapidly but
carefully plan and implement orientation and training102 for those tasked with counselling as part of the
response (see Box 8 for additional training guidance).
• W ithin 72 hours/as soon as possible: provide a generic, pre-positioned orientation for early response
teams. Rapid orientation on new or heightened breastfeeding challenges can support existingcounsellors to deliver appropriate services to the affected population.
• W eek 2–4/once the capacity assessment and mapping exercise is complete: Develop and roll out atailored capacity building plan with measurable learning objectives which plans for comprehensive
training for new counsellors/further orientation and training for existing counsellors. The plan should
include government and partner plans for training, practical skills building, training follow-up, refresher
training, ongoing learning, supportive supervision (see 5.5 – JOB AIDS) and monitoring the impact of the
training. Update pre-positioned training materials based on the results of the capacity assessment andthe agreed upon core set of counselling competencies. Where available, ensure that lessons captured
during previous emergency responses are also integrated into training packages.
• O ngoing: Continue system strengthening and building local capacity to ensure sustainability of services
after the emergencyclxx. In addition to regular supportive supervision, provision of reference materials(e.g., educational videos) and opportunities for ongoing learning can reinforce learning for providers
working under pressure. It is recommended to organise refresher training every six months to refresh
existing skills and knowledge and to share new evidence, tools, and experiences.
96 

Tool: Tech RRT and Save the Children (2020). IYCF-E Individual Capacity Assessment Tool for Health and Nutrition Service
Providers. https://www.nutritioncluster.net/IYCF-E_Ind_Cap_Assessment

97 

Note: For example, skilled midwives who are refugees and do not have permission to work as midwives in their host country
can be trained to become counsellors. Note that having a professional background or formal education is not required to be aneffective counsellor.

98 

Tool: Save the Children and Tech RRT (2020). IYCF-E Individual Capacity Assessment Tool for Health and Nutrition Service
Providers https://www.nutritioncluster.net/IYCF-E_Ind_Cap_Assessment

99 

Note: How they are administered can be adapted to the cadre e.g., a verbal multiple choice quiz can be conducted if peer
counsellor’s literacy levels are low (in a circle, facing outwards).

100 

Tool: Save the Children and Tech RRT (2020). IYCF-E Capacity Assessment / Mapping Report Template.

101 

Tool: Global Nutrition Cluster (2020). IYCF-E Checklist.

102 

Tool: Save the Children and Tech RRT (2020). IYCF-E Standard Operating Procedures for Emergency Response Teams.

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BOX 10 Key considerations for training in emergencies• U
 se methodologies that support adult learning including practical-skills building. True active listening andsupportive two-way discussions may be a new experience for trainees, particularly in settings with a didactic
healthcare culture of “telling women what to do”. Given the increased difficulties in effectively communicating intimes of high stress or when noisy transmission and distraction are present, adequate attention and time should be
dedicated to strengthening “listening and learning” and “building confidence and giving support” skills, including
through role-play simulation of potentially challenging situations (e.g., counselling a mother who is malnourished,distressed or disinterested in breastfeeding). Trainees should also practice using job aids and reporting tools.
On-the-job practice during which trainees apply each core competency a set number of times under supervision
may help to compensate for insufficient practice during training. See the IG-BFC for further guidance.
• Identify the right trainers with the right expertise. While national trainers (e.g., from the Ministry of Health ornational expertise and breastfeeding support networks) should ideally deliver training, their availability may beaffected by the emergency. If preparedness has been inadequate, they may also lack emergency-specific counsellingcompetencies themselves. Therefore, deployment of external trainers for training, mentoring and supportive
supervision may be warranted. In settings where it is not considered culturally appropriate for men to train female
staff, to counsel women or to observe counselling, women should be selected to become master trainers.
• A ddress existing beliefs and assumptions: Those recruited as counsellors may have beliefs, assumptions or feelings
about infant feeding that are not supportive of successful breastfeeding. It can sometimes be difficult for individuals
who have practiced inadvisable behaviours (e.g., prelacteal feeding) to counsel others against doing the same. Sufficient
time must be allocated to process provider beliefs and reflect on past feeding practices in light of new knowledge toensure that counsellors do not reinforce culturally based myths and misconceptions about infant feeding and care.
• C onsider a modular approach: During emergencies, competing capacity building activities and local emergency
recovery efforts often involve the same set of (limited) local human resources (Castillo et al; Garg et al 2016) . It
may be more efficient and effective to spread out training with opportunities to apply skills in practice in between
modules and to focus efforts on on-the-job training and mentoring. Standardised counselling modules can be added
to planned training curricula on maternal newborn and child health (MNCH) in emergencies. Advanced or more
specialised counselling competencies can be added gradually.

CASE STUDY 16 Cascade training
At the start of the 2006 Yogyakarta Earthquake
Response in Indonesia, there were few trainedbreastfeeding counsellors able to provide skilled
breastfeeding counselling. The number was not enoughto address the counselling needs of thousands ofmothers and to counteract inappropriate distributionsof donated BMS that were occurring. To address gaps
in infant and young child feeding response and ensure
the highest possible coverage, quality and sustainability,a ‘cascade’ system of training and breastfeedingcounselling was activated. The 40-hour WHO/UNICEF
training course was delivered to community workers/
volunteers and village midwives. Training was deliveredfor 3–4 hours twice a week over a period of six weeks.
Facilitators met regularly to evaluate the training process.
Twelve frontline counsellors/trainers were placed in
the community, each covering six areas. Each frontline
counsellor recruited six local lactation counsellors (LLCs)
from each of the areas and was responsible for training

36 LLCs over a six week period. Each LLC was required toprovide direct support to five mothers before graduating.
Mothers provided with support were recruited as peer
educators and required to refer at least two othermothers to LLCs for counselling. The cascade approachled to a ‘trickle’ effect with each frontline trainer
indirectly reaching up to 360 families (total programmereach: around 4,260 families). A monitoring exercise
showed that more mothers initiated breastfeeding in
the first hour after birth and that 63% of 54 mothers
interviewed were exclusively breastfeeding regardlessof access to free BMS, attributed to counselling andsupport received from LLCs. Considerations for cascade
training included the varied level of education of LLCs,
the cost of the training (approximately USD225 per LLC
due to the need to bring trainers from the central level)
and the relatively longer time needed to administer the
training taking into consideration the extension of the
trainings over a six week period.

Source: Assefa, F., Sukotjo, S., Winoto, A., & Hipgrave, D. (2008). Increased diarrhoea following infant formula
distribution in 2006 earthquake response in Indonesia: evidence and actions. Field Exchange 34, 29.

One frontline counsellor

52 

Responsible
for six areas(six LLCs per area)

36 LLCs are trainedby frontline counsellor
and provide support toat least five mothers(peer educators)

180 peer educators
trained/supported
by LLCs refer at least
two mothers forcounselling

360 families receive
supportOPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESSupportive supervision
Regular103 supportive supervision, as described in the IG-BFC, is particularly important during emergency
responses as new counsellors may quickly be given significant responsibility following rapid training.
Supervisors play a vital role in supporting and monitoring the quality of counselling service provision andevaluating the effectiveness of in-service training and other capacity building activities. Supervisors may
be the trainers of the counsellors as well as lactation consultants or other experienced breastfeedingcounsellors. Where services are integrated with other disciplines, ensure interdisciplinary collaborationand supervision (e.g., PSS supervisors can supervise counsellors and jointly review client records withcounselling supervisors). New local trainers and supervisors should themselves be adequately supported,
including through training on how to conduct supportive supervision104 , the provision of tools (e.g.,supervision checklists105 and learning materials) and access to technical support as needed (See Case
Study 17).

CASE STUDY 17 Supportive supervisionDuring the Rohingya Crisis, Save the Children (SC) set up
a nutrition programme providing basic and skilled IYCF
support in 12 Mother-Baby-Areas (MBAs) and othernutrition facilities (IYCF corners) within refugee camps in
Cox’s Bazaar, Bangladesh. A main challenge voiced within
the nutrition cluster was the lack of skilled staff available
to provide IYCF counselling and serve a population ofalmost one million. SC conducted a two-day IYCF-E
training based on the national IYCF training package
for over 140 newly recruited health and nutrition staff.
In addition, a supportive supervision system was put inplace to ensure ongoing support for the newly trained
counsellors as follows:
1. On-site support: At each nutrition facility, anutrition supervisor was available onsite to provide
daily routine support for the different nutrition
services, including IYCF counselling.
	

2. Rotational supervision and support: A core groupof five trained senior IYCF specialists were further
trained on supportive supervision and tasked toprovide onsite support to IYCF counsellors on arotational basis. Each member of the core group
was assigned to a number of MBAs/IYCF corners
to visit to:		1. Observe and provide feedback and guidanceon individual and group counselling sessions
conducted by the IYCF counsellor		2. Review data recording tools and forms		3. Meet with the IYCF counsellors to discusschallenges and recommendations.
The continuous and systematic supervision helped
to improve the consistency and quality of counselling
services provided and to ensure effective monitoring andtracking of counselling services.
Source: Save the Children, Bangladesh. Key informant interviews, 2020.

Where access is limited or specialist support is required for complex cases, remote supervision andmentoring can be considered to ensure counsellors are adequately supported. Technology can be particularly
useful for monitoring in insecure and inaccessible areas of operation (See Case Study 18) However, realtime support can be challenging due to connectivity issues and time zone differences. It is also important
for remote mentors to be familiar with the cultural and emergency context and response. Ongoing learningand support for counsellors can be facilitated through supervised peer to peer support, such as online
group chats (e.g. WhatsApp groupsclxxi) and regular reviews of difficult cases with team members.

103

 ote: More frequent supervisory contacts are likely to be needed where training of new counsellors has been shortened dueNto the emergency. Criteria used for selecting priority areas for supportive supervision visits can include poor breastfeedingpractices, low counselling coverage rates, poor reports from previous supervision visits, low post-training test results, areas withrecent reports of disease outbreaks, uncontrolled BMS distributions or other threats to breastfeeding.

104

 ool: UNICEF (2013). Supportive Supervision/Mentoring and Monitoring for Community IYCF. https://sites.unicef.org/nutrition/Tfiles/Supervision_mentoring_monitoring_module_Oct_2013(1).pdf

105

Tools: Save the Children’s IYCF-E Toolkit – Section H (examples of supervision and observation checklists).

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53

CASE STUDY 18 Remote monitoring and supportive supervision
From 2017 to 2018, Save the Children (SC) piloted an
integrated, remotely managed IYCF-E and PSS programmein Southern Syria. The programme was implemented by alocal partner. SC staff did not have access to the projectsites to directly supervise and support activities andtherefore needed to rely heavily on data. For security
reasons, it was not possible to video or record one-to-one
counselling sessions. To mitigate the impact of the lack ofon-the-ground presence on counselling quality, SC
invested significantly in MEAL capacity (training,
mentoring and coaching of dedicated MEAL staff,
electronic tablets) and developed an innovative MEAL
system using KOBO. As SC’s implementing partner was
new to IYCF-E, SC opted to closely follow activities
through day-to-day monitoring and supervision. The
partner’s relatively inexperienced IYCF supervisors were
provided with an IYCF-E counselling supervision checklist
and were remotely supported by experienced technicalstaff. The quality of one-to-one IYCF-E counsellingsessions was indirectly supervised by SC’s programmemanager (PM) through spot-checking Full Assessment
forms (scanned and uploaded via KOBO each day) toverify whether issues had been picked up on, correctly

noted and appropriately handled by the counsellors.
Counsellors also extracted key information (date, child’sage, feeding practices, support provided) into a behaviourchange tracking tool to allow tracking of changes in
feeding practices over time (programme impact). At theend of each day, counsellors summarised their activities inan electronic form sent to SC. Once a week, SC’s PM
discussed the received data with their partner staff andprovided feedback. While the day-to-day monitoring
system was found to be a time-, training and staffintensive investment that took time to set up, it did
facilitate communication between SC and partner staff. It
also allowed for increased control, transparency and acontinuous model of improvement whereby SC had
oversight of daily IYCF-E activities at each centre andcould provide regular feedback. For example, the PM
received valuable information on the type and number ofactivities carried out by each counsellor, the operating
hours of each centre and the working hours of eachcounsellor. The PM could ask questions (e.g., why a certain
counsellor was doing less follow-ups than their colleagues
or why attendance was higher in some centres thanothers) and provide support in response.

Source: Save the Children (2018). Review: IYCF-E and PSS Programme in South Syria.

5.5 JOB AIDS
Job aids supplement counselling by reinforcing the discussion and grasping of concepts by the caregiver(e.g., educational tools), as well as guiding and documenting the counselling process for the counsellor(e.g., checklists and forms). They are particularly important during the early phase of an emergency whencounsellors may not have much experience to build confidence and improve quality support. It is essentialthat job aids used during an emergency response are adapted to the emergency context (e.g., culture,
available food, public health recommendations), the counsellors who will use them and the population
they are intended for (Case Study 19). For example, different job aids may be needed when counselling
caregivers from refugee and host communities. In low-literacy settings, pictorial job aids can serve toremind breastfeeding counsellors of key knowledge and skills (Case Study 20). Refer to the IG-BFC for an
overview of job aids.
Although visual tools are important, where possible, practice with the mother in order for her to see, listen
to and feel her own body. The counsellor can also use her own body or ask the help of other mothers to act
as ‘model mother’ (e.g., to demonstrate hand expression).
Job aids that counsellors may use in emergencies to support and document the counselling process can
include Full Assessment forms (Annex B), breastfeeding observation checklists106 and postpartum visit
checklists107 among others. Counsellors can also maintain client case files to which information is added
during each counselling visit to track progress, monitor behaviour change and ensure continuity of care.

106

 ool: https://resourcecentre.savethechildren.net/sites/default/files/documents/4.11._template_of_breastfeed_observation_Tform.docx

107

 ool: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/breastfeedingTassessment-tools/

54 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESCASE STUDY 19 Adapting counselling cards
In response to the COVID-19 pandemic, UNICEF and
USAID Advancing Nutrition, with the support of the
Infant IFE Core Group represented by Save the Children
and Safely Fed Canada, have developed a counselling
package, Infant and Young Child Feeding Recommendations
when COVID-19 is Suspected or Confirmed. The set isbased on the original set of counselling cards which havebeen adapted to reflect the global recommendations from
WHO and UNICEF (March 2020) on IYCF in the context
of COVID-19. The cards were developed in a way that they
can be adapted and updated to reflect new or emerging
evidence as well as different emergency contexts.

CASE STUDY 20 Home-based counselling for low-literacy refugee mothers
Hashmi et al. (2019) report on a small-scale study whichpiloted educational materials for home-based counsellingof refugee mothers along the Thai-Myanmar border.
Educational materials (a “health-baby flipbook”) were
designed to feature a basic script for health workers andphotos of locally available, appropriate foods for largely
illiterate mothers. Important elements of the script wereadapted and updated based on findings from focus group
discussions that provided common rationale among
refugee mothers for inappropriate behaviours.

Source: Hashmi et al. (2019). The Healthy Baby Flipbook: piloting home-based counselling for refugee mothers
to improve infant feeding and Water, sanitation and hygiene (WASH) practices.

5.6 WHAT TO DO WHEN THERE IS NO BREASTFEEDING COUNSELLING CAPACITY
Breastfeeding counselling should be considered as a lifesaving activity in the first phase of an emergency108, 109.
However, where counselling capacity has not been adequately established in preparedness or where
counsellors are not immediately available, the following steps can be taken to protect and support
breastfeeding110 while action is taken to establish counselling capacity:
1. P revent harm: Sensitise humanitarian actors on the Code and emergency-specific infant feeding
recommendations. To prevent breastfeeding from being undermined, health workers in contact withpregnant women and mothers – including those working in the informal health sector – are usuallya priority group to sensitise. Take proactive steps to prevent separation of children from mothers/
caregivers. Prevent donations and uncontrolled distributions of BMS and feeding bottles111 including
through engaging different sectors in preventing, monitoring and reporting on Code violations.
To protect caregiver wellbeing and prevent re-traumatisation, orient responders working with the
caregivers of infants and young children on universal trauma-informed care.
2. A
 dvocate and plan for basic multi-sector breastfeeding support and protection112 . Enable priority
access for pregnant and breastfeeding women to essential services, facilitate non-separation ofchildren from their caregivers (e.g., provide baby carriers), register households with pregnant women,children under two years of age and at risk groups and provide supportive spaces to breastfeed113 . For
further guidance on how all sectors can contribute to the establishment of a breastfeeding-friendly
environment see UNHCR and Save the Children (2018) A Multisectoral Framework for Action
3. C ommunicate effectively about IYCF-E. The right message at the right time from the right person cansave lives. To be effective it is important to be first, be right, be credible, express empathy, promoteaction and show respect114 . Among others, audiences include emergency-affected communities andtheir leaders, emergency responders and public health officials115 and the media116 .
108

 igh quality counselling does save lives; however, it can be difficult to achieve in situations where caregivers are highly stressed,H
exhausted or distracted. The feasibility, acceptability and potential impact of counselling needs to be carefully considered duringhigh-stress, mass displacement situations and a minimum package of essential breastfeeding support activities defined.

109

IFE Core Group (2021). Brief: Breastfeeding Counselling in Emergencies.

110All counselling can be considered support but not all support interventions involve counselling (Mac Fadden et al., 2019).

111

IFE Core Group (2021). Infographic on Preventing and Managing Donations of BMS.

112

 s stated in the Global Strategy for Infant and Young Child Feeding (WHO, 2003), especially in exceptionally difficult
A
circumstances, it is necessary to develop an environment that protects, promotes, and supports breastfeeding.

113

GNC Technical Alliance (2020). Supportive Spaces for IYCF-E.

114

CDC (2018). Crisis and Emergency Risk Communication Manual. https://emergency.cdc.gov/cerc/manual/index.asp

115

IFE Core Group (2018). Model Joint Statement on IYCF-E. https://www.ennonline.net/modelifejointstatement

116IFE Core Group (2018). Media Guides on IYCF-E. https://www.ennonline.net/iycfmediaguide

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

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6. KEY RESOURCESGUIDELINES
WHO and UNICEF (2017) Protecting, promoting and supporting breastfeeding in facilities providing
maternity and newborn services. English.
WHO (2018) Guideline: Counselling of Women to Improve Breastfeeding Practices. English.
WHO (2020) Guideline: Improving Early Childhood Development. English.

GUIDANCE
Academy of Breastfeeding Medicine. Protocols. English, Spanish and more. Guidelines for the care ofbreastfeeding mothers and infants, covering various breastfeeding problems and clinical situations.
WHO and UNICEF UK. The International Code of Marketing of Breastmilk Substitutes. English. Includes
guidance for health professionals on working within the WHO International Code.
WHO (2011) Psychological First Aid: Guide for Field Workers. English, Arabic, French, Spanish and more.
WHO and UNICEF (2018) Implementation guidance: protecting, promoting, and supporting breastfeedingin facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018
WHO and UNICEF (2018) Operational Guidance: HIV and Infant Feeding in Emergencies. English, French,
Spanish, Arabic and Russian.

COUNSELLING CAPACITY
Capacity Assessment and Mapping
Tech RRT and Save the Children (2020) IYCF-E Individual Capacity Assessment Tool
Tech RRT and Save the Children (2020) IYCF-E Capacity Assessment / Mapping – Report Template
Online Learning
Caroline Global Breastfeeding Institute Breastfeeding University. English. Short modules for staff working in
healthcare settings and childcare settings.
UNICEF Agora: Nutrition in Emergencies Learning Channel – IYCF-E Short Course
Training Packages
UNICEF Community Based IYCF Counselling Package. English and French. Includes planning guide, adaptation
guide, facilitator guide, training aids , participant materials and further resources. Also includes a module on
supportive supervision, mentoring and monitoring.
WHO and UNICEF (2006) IYCF Counselling: An Integrated Course. English, Spanish and Russian. Training
course for health professionals and lay counsellors. Includes trainer’s guide, participant’s guide, director’s guide,
training follow-up guidelines.

56 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESWHO and UNICEF (2020) BFHI Training Course for Maternity Staff. English. Includes trainer’s guide,
participant’s guide, director’s guide and customisation guide.
WHO and UNICEF BFHI Competency Verification Toolkit. English. Comprehensive toolkit to assess staff
competency in the knowledge, skills and attitudes needed to implement the Ten Steps.
Job/Training Aids
CDC (2019) Storage and Preparation of Breastmilk. English and Spanish. Poster.
Global Health Media Breastfeeding Videos. English, French, Spanish, Arabic and more. Videos for counsellors
and mothers describing how to support mothers with breastfeeding, how to breastfeed and how to overcome
common challenges.
IBFAN, Safely Fed Canada, Breastfeeding Advocacy Australia and La Leche League International Cup
Feeding. English, French, Spanish and More. Posters describing a simple three-step process for cup feeding.
IBFAN, Safely Fed Canada, Breastfeeding Advocacy Australia and La Leche League International Drip
Drop Feeding. English, Spanish and more. Posters and videos describing a simple three-step process on using the
drip-drop method to encourage infants to feed at the breast.
La Leche League Tear Sheet Toolkit. English. Tips and tools for breastfeeding mothers and their families.
UNICEF Community Based IYCF Counselling Package. English, French, plus examples of country-level
adaptations. Counselling cards for community workers.
UNICEF IYCF Image Bank. Images of recommended IYCF practices, which can be used for job aids andother tools.

REFERENCE WEBSITES FOR COUNSELLORS AND PARENTS
Breastfeeding Support
Kellymom
UNICEF UK – The Baby Friendly Initiative
Australian Breastfeeding Association

FURTHER RESOURCES ON IYCF-E
GNC Technical Alliance Nutrition for Infants and Young Children. English and more. Technical assistanceand resources.
IFE Core Group IFE Core Group Resources and Outputs. Guidance and tools for IYCF-E programming.
IFE Core Group (2017) Operational Guidance on Infant Feeding in Emergencies (v3.0). Key global guidanceon IYCF-E programming. English, Arabic, French, Spanish and more.
IFE Core Group EN-NET IYCF-E Forum. English and French. Free and open online platform to provide fieldpractitioners with prompt technical advice for operational challenges.
Save the Children IYCF-E Toolkit. English, with some documents in Arabic and French. Collection of informationand practical resources to guide the rapid startup of an IYCF-E response.

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57

Glossary
Best practice statement: Inclusive language does not deliberately or inadvertently exclude people.
Instead, it acknowledges diversity, conveys respect to all people, is sensitive to differences andpromotes equal opportunities. The phrase “mothers and other caregivers” has been used in thisdocument in acknowledgement that not all people who birth a child identify as a mother and,particularly in emergencies which are often characterised by high morbidity and mortality rates
and increased mother-child separation, not all primary caregivers of infants and young children aremothers. What terminology is appropriate to use is culture and caregiver dependent. In line with thebasic principles of counselling, counsellors should actively listen and reflect whatever language theperson they are counselling is using, including how they want to be referred to. When unsure, it isbetter to ask than to make assumptions.
Antenatal: The time from conception until birth.
Artificial feeding: The feeding of infants with a breastmilk substitute.
Breastmilk substitute (BMS): Any food (solid or liquid) being marketed, otherwise represented or used
as a partial or total replacement for breastmilk, whether or not suitable for that purpose. In terms of milk
products, recent WHO guidance has clarified that a BMS includes any milks that are specifically marketed
for feeding infants and young children up to the age of three years. See the Code definition for moredetails (OG-IFE, 2017).
Breastfeeding: The provision of breastmilk, either directly from the breast or indirectly through expression.
Note that the feeding of expressed breastmilk can also be referred to as “breastmilk feeding” to moreaccurately describe how an infant is fed, in addition to what they are fed.
Breastfeeding counsellor: Health professional or paraprofessional who has appropriate training to provide
breastfeeding counselling.
Client-led counselling: Caregiver initiates counselling when needed/wanted.
Competency: The capability to use a set of related knowledge and skills to successfully perform identified
jobs, roles or responsibilities. Breastfeeding counselling competencies can be either basic or advanced
competencies.
Complementary feeding: The use of age-appropriate, adequate and safe solid or semi-solid food in
addition to breastmilk or a breastmilk substitute in children aged 6-23 months (OG-IFE, 2017).
Continued breastfeeding: The provision of breastmilk beyond the first six months of life (OG-IFE, 2017).
Early initiation of breastfeeding: Provision of mother’s breastmilk to infants within one hour of birth.
Exclusive breastfeeding: An infant receives only breastmilk without any other liquids or solids, not evenwater, except for oral rehydration solution or drops or syrups of vitamins, minerals or medicines (WHO, 2016).
Frontline workers: Emergency/humanitarian responders who interact directly with the emergency-affected
population. Examples include community health workers, midwives, child protection caseworkers, hygiene
promoters and distribution staff.
Full Assessment (FA): A systematic way for trained counsellors to gain an in-depth understanding of thefeeding practices of a child under two years of age in order to assess and analyse what type of support isneeded. The FA commonly follows on from the Simple Rapid Assessment (SRA).
Group counselling: Counselling of a group of pregnant women, mothers or other caregivers during theantenatal or postpartum period which allows them to share their breastfeeding experiences and support

58 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES

one other. Group counselling may have an educational component but is distinct from purely educational,
lecturing or classroom-style teaching. Group counselling is facilitated by a counsellor who may identify
individual mothers who require one-on-one breastfeeding counselling.
Individual level assessment: A process to evaluate a caregiver-baby pair, establish infant feeding practiceand needs and decide what type of support may be necessary. There are two levels of assessment: Simple
Rapid Assessment and Full Assessment (OG-IFE, 2017).
Infant: A child aged 0-11 completed months (may be referred to as 0-<12 m or 0-<1 year). An older
infant refers to a child from the age of six months up to 11 completed months of age (late infancy)(OG-IFE, 2017).
Lactation consultant (International Board Certified Lactation Consultation – IBCLC): Allied healthprofessional who has received a minimum of 90 hours of lactation specific education as well as
clinical experience. Lactation consultants have advanced competencies which enable them to provide
breastfeeding counselling and support for complex breastfeeding issues.
Lay counsellor: A type of paraprofessional (see definition). In the context of breastfeeding, an individual
who is not a certified healthcare professional who has been trained to provide breastfeeding counselling.
Low birth weight (LBW): Newborns with a weight of less than 2,500 grams, irrespective of gestational age(OG-IFE, 2017).
Nurturing care: Characterised by a caregiving environment that is sensitive to children’s health andnutritional needs, responsive, emotionally supportive and developmentally stimulating and appropriate
with opportunities for play and exploration and protection from adversities (WHO, 2020).
Paraprofessional: A type of breastfeeding counsellor trained to perform counselling without a formal
professional/graduate-level qualification. Paraprofessionals often work with and as an extensionof professional breastfeeding counselling services. They assist professionals but are not licensed orcredentialed as healthcare, nutrition or lactation consultant professionals. Paraprofessionals with extended
training and advanced competencies can support more complex breastfeeding problems. Examples include
peer counsellors and lay counsellors.
Peer counsellor: A type of paraprofessional. Breastfeeding peer counsellors are women or caregivers fromthe community to be served who usually have prior breastfeeding experience and are trained to provide
knowledge, experience, emotional and practical help to breastfeeding mothers. Peer counsellors may also
be known as “mother-to-mother counsellors”.
Peer support group: A group of mothers (or other caregivers) who meet regularly to share theirbreastfeeding experiences and knowledge to support each other in feeding and caring for their infants.
A peer support group may be moderated by a professional or paraprofessional who may provide
breastfeeding counselling to individual mothers. A peer support group may also be called a “mother support
group” or “mother-to-mother support group”. Peer support groups involving fathers are known as “father
support groups” or “father-to-father support groups”.
Postnatal period: The time immediately after birth until six weeks (42 days) thereafter. The postnatal
period consists of immediate (first 24 hours), early (day 2-7) and late (day 8-42) periods.
Prevention of mother-to-child transmission (PMTCT): Programmes and interventions designed to reduce
the risk of mother-to-child (vertical) transmission of HIV (OG-IFE, 2017).
Preparedness: The capacities and knowledge developed by governments, professional responseorganisations, communities and individuals to anticipate and respond effectively to the impact of likely,
imminent or current hazard events or conditions (OG-IFE, 2017).
Psychological first aid (PFA): First-line emotional and practical support for someone experiencing acute
distress following a recent (large scale or individual) crisis event. PFA key action principles are to look, listen
and link as part of a humane and supportive response.
OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

59

Relactation: The resumption of breastmilk production (lactation) in a woman who has stopped lactating,recently or in the past, in order to breastfeed her own or another infant, even without a further pregnancy.
Induced lactation is the stimulation of breastmilk production in a woman who has not previously lactated(OG-IFE, 2017).
Responsive feeding: Part of responsive caregiving and an approach to feeding which involves recognisinga child’s cues (e.g., hunger, fullness, need for comfort) and responding appropriately. Feeding responsively
recognises that feeds are not just for nutrition but also for love, comfort and reassurance between baby
and caregiver. Responsive breastfeeding also involves responding to a mother’s own need to breastfeed herbaby (e.g., to relieve engorgement, for connection).
Simple Rapid Assessment (SRA): A simple screening tool that does not require training in breastfeedingused to rapidly prioritise mothers or other caregivers for full assessment and further counselling (Module
2 IFE).
Supplementary feeding device: A lactation aid that allows for supplementary feeding (with expressedbreastmilk, donor breastmilk or infant formula) at the breast (OG-IFE, 2017).
Supportive space: An overarching term that describes the different kinds of safe spaces where pregnant
women and girls, mothers and other infants and young children can access support with feeding and caring
for their children and themselves during emergencies. Included in this term are Baby Friendly Spaces,
Mother Baby Areas, Baby Tents and IYCF Corners, among others (GNC Technical Alliance, 2020).
Supportive supervision: A process of helping counsellors to improve their work performance continuously
in a collaborative and positive way that promotes mentorship, joint problem-solving and two-way
communication.
The International Code of Marketing of Breast-milk Substitutes and subsequent resolutions (The Code):
The Code intends to ensure BMS will be used as safely as possible when they are necessary based on
impartial, accurate information. The Code does not restrict the availability of BMS, feeding bottles or teatsor prohibit the use of BMS during emergencies. In the context of the Code, BMS means any food being
marketed or otherwise represented as a partial or total replacement for breastmilk, whether suitable forthat purpose or not. The Code applies to the marketing and related practices, quality, availability andinformation on use, including but not limited to breastmilk substitutes (including infant formula, followon/follow-up milk, growing-up milk, other milk products, including bottle-fed complementary foods)
specifically marketed for feeding children up to three years of age, foods and beverages (baby teas, waters
and juices) when marketed for use as a partial or total replacement of breastmilk during the first six monthsof life, feeding bottles and teats. Note that the promotion of foods for infant and young children over six
months is covered by 69th WHA Provisional Agenda Item 21.1 A69/7 Add.1. stating that “products thatfunction as breast-milk substitutes should not be promoted” (OG-IFE 2017).
Trauma informed care (TIC): A framework that guides counsellors' support of caregivers that is sensitive
to a trauma's ongoing impact (e.g., on a person's perception of self, relationship to others and caregiving/breastfeeding experience) and seeks to avoid activating post-traumatic responses or causing trauma.
Principles of trauma-informed care include 1) the recognition that not all caregivers will disclose trauma
and so TIC should be applied universally, 2) respect for bodily autonomy, 3) facilitating a sense of control,4) compassionate listening, 5) clear communication, 6) unbiased and culturally competent support.
Wet nursing: Breastfeeding of a child by someone other than the child’s mother. (NB: This term should be
used with caution given its negative connotations in certain historical/cultural settings such as the USA).
When the child’s mother also continues to breastfeed the child, this practice can also be referred to as
co-nursing. When a lactating woman provides expressed breastmilk for feed a child that is not her own, thispractice can also be referred to as expressed breastmilk sharing (‘milk sharing’).
Young child: A person from the age of 12 months up to the age of 23 completed months (may also bereferred to as 12-<24m or 1-<2 years) (OG-IFE, 2017).

60 

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xci argest-Slade, A. C. and Gribble, K. D. (2015). ShakenHbut not broken: Supporting breastfeeding women after
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xcii

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xciii

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xcvi

Ceulemans et al. (2020)

xcvii

 irani, S. A. A., Richter, S., Salami, B. O., Vallianatos,H
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 ulaiman, Z., Mohamad, N., Ismail, T. A., Johari, N.,S
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c allaghan, W. M., Rasmussen, S. A., Jamieson, D. J. et al.
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cii

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D
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ciii

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cvi

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T
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D
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cxviii antella, L. (2011). Save the Children’s IYCF programmeP
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 irMohamadaliIe, M., Khani Jazani, R., Sohrabizadeh,M
S. and Nikbakht Nasrabadi, A. (2019). Barriers toBreastfeeding in Disasters in the Context of Iran.
Prehospital and Disaster Medicine, 34(1), 20-24.

cxix

 ull, N., Kam, R. L. and Gribble, K. D. (2020). ProvidingH
breastfeeding support during the COVID-19 pandemic:
Concerns of mothers who contacted the Australian
Breastfeeding Association

cxxxvi ribble, K. D., McGrath, M., MacLaine, A. and Lhotska,GL. (2011). Supporting breastfeeding in emergencies:
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 loem, C. M., Miller, A. C. (2013). Disasters and women'sBhealth: reflections from the 2010 earthquake in Haiti.
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 almquist, A. E. L., Gribble, K. D. (2018). Gender,P
Displacement, and Infant and Young Child Feeding in
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 merson, J. A., Tol, W., Caulfield, L. E. and Doocy, S.
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Randomized controlled trial investigating the effects
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Jorgensen et al. (2010).

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 lsamman, S. (2015). Managing infant and young childA
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Hays et al. (2015).

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clviii aclaine, A. and Corbett, M. (2006). ‘Infant feeding inMemergencies: experiences from Indonesia and Lebanon’.
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 hiri, J. E., Gunn, J. K., Center, K. E., Li, Y., Rouhani, M.,
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clxiii lsamman, S. (2015). Managing infant and young childA
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 merson, J. A., Tol, W., Caulfield, L. E. and Doocy, S.
E(2017). Maternal Psychological Distress and Perceived
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J orgensen, A. M., Mendoza, G. J., Henderson, J. L. (2010).
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Hargest-Slade, A. C. and Gribble, K. D. (2015).

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	Garg, A., Bucu, A. R. and Garela R. G. (2016). Philippines
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nigerianutpackagescaleup

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

65

Annex A

SIMPLE RAPID ASSESSMENT

1

Instructions:a) Use this assessment form for all mothers/caregivers with children 0-23 months (under 2)b) Once this assessment has been completed, decide whether the caregiver/mother needs counselling/full
assessment and/or other services.
• If yes, complete the referral form
• If no, refer for IYCF support services (e.g., education, peer support group)
SIMPLE RAPID ASSESSMENT
Staff name/ID

Date of assesment

Child's name

GenderChild's age
Caregiver's name

Caregiver relationship

Facility ID

Location

ASK
Age of baby

❑ 0-5.9 months❑ Newborn (<28 days)❑ 6-12 months❑ 12-24 months

Is the baby breastfed?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

(If yes) Are there any difficulties breastfeeding?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Is the baby drinking infant formula/milk powder?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Is the baby getting anything else to drink?

❑ Yes ❑ No

n/a

n/a

Is the baby getting anything else to eat?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Multiples (twins/triplets etc.)?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Caregiver requested infant formula?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Baby looks very thin/lethargic/ill?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Baby has sunken eyes/sagging skin?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Caregiver/child has an impairment?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Caregiver looks very thin/ill?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

Caregiver appears to be very anxious,
stressed, sad or distressed?

❑ Yes ❑ No

❑ Yes ❑ No

❑ Yes ❑ No

OBSERVE

Key:
Priority 1 – refer for full assessment
Priority 2 – refer for full assessment
No
need
for
IYCF
counselling–providepraise and encouragement❑1Adapted from Save the Children’s IYCF-E Toolkit

66 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESAnnex B

IYCF FULL ASSESSMENT FORM: 0-23 MONTHS

1This is a sample feeding assessment tool that has been adapted from Save the Children’s IYCF-E
Toolkit and should be contextualised before use. Always check for nationally and sub-nationallyapproved assessment guides and guidelines first.
1. COLLECT BASIC INFORMATION
Counsellor's ID

Location

Caregiver’s name

Relationship to child

Mother/Father/Grandmother/Sibling/Other: ____________

Child’s name

Sex

Male/Female

Child's ID No.

Child's age_______ months

Caregiver's age

Child’s D.O.B.

­//

Caregiver’s name

Relationship to child

Facility ID

Facility nameSource of referral

Date of assesment­//_______ years

District❑ Self-referral ❑ SRA – from____________ service ❑ No SRA – direct from____________ service

2. CHECK FOR DANGER SIGNS

2

Lethargic/unconscious?

Bilateral pitting oedemata? (+/++/+++ )

❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes

❑ No
❑ No
❑ No
❑ No
❑ No
❑ No

Caregiver appears out of touch with reality or infant appears to be
at risk from caregiver’s behaviour?

❑ Yes

❑ No

Vomits everything?
Unable to drink/breastfeed?
Difficulty breathing? (respiration rate, chest indrawing)
Low or high temperature? (< 35.5 or ≥ 38°C)

ACTION: IF ANY MARKED AS YES ➔ URGENT REFERRAL TO HEALTH SERVICES BEFORE CONTINUING IYCF ASSESSMENT

3. ASK ABOUT FEEDING PRACTICES
Please tell me about your experiencesof feeding your baby. What concerns orquestions would you like to discuss today?

What and how is the baby fed?
(Select all that apply)❑ Breastfeeding – at mother’s breast❑ Expressed breastmilk – mother’s own❑ Expressed breastmilk – informally shared❑ Donor human milk
❑ Breastfed by a woman who is not the child’s mother❑ Some artificial feeding (BMS)❑ Fully artificially fed (BMS)❑ Fully artificially fed (BMS)❑ Bottle ❑ Spoon ❑ Cup
Does the baby eat or drink anything other than breastmilk?
❑ Yes
❑ No
3

1

 dapted from Save the Children’s IYCF-E Toolkit: Rapid Start Up for Emergency Nutrition Personnel and the WHO B-R-E-A-S-TA
FEED Observation Form.

2

Adapted from IMCI Danger Signs. Please refer to national IMCI guidelines.

3Note: Counsellor should be trained to probe (e.g., “how about water – do you give baby any water?”).

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

67

(If yes) What else do you give the baby?

❑ Infant formula ❑ Other milks ❑ Water❑ Tea/coffee ❑ Sugary drinks/soda❑ Juice: ____________ ml/cups❑ Medicine ❑ Food ❑ Other : _______________________
4

No. of previous children:

No. of previous breastfed children:

ACTION: IF ARTIFICIALLY FED ➔ COMPLETE FULL ASSESSMENT – ARTIFICIAL FEEDING FORM

(If yes) What else
do you give thebaby?
Do you use a pacifier for the baby?

❑ Yes
❑ Yes

Is the baby currently sick?

❑ No
❑ No

(If sick) Since your baby has been sick, have there been any changes in the way you have been feeding?
Breastfeeding❑ More/no change❑ More/no change❑ Extra nutrious food(If 6-23 months) Complementary feeding
Extras❑ Less often❑ Less often❑ Infant formula❑ Stopped❑ Stopped

4. CHECK DIAPER OUTPUT
How many wet diapers does baby have in 24 hours?

____________ times

Does the baby’s urine have a strong smell or colour?

❑ Yes

How many soiled diapers does baby have in 24 hours?
Have there been any recent changes from usual?

❑ No____________ times5❑ Less frequentstooling❑ Diarrhoea❑ No changes

ACTION: IF DIAPER OUTPUT IS LOW/CONCERNING ➔ EXPLORE POSSIBLE LOW MILK SUPPLYACTION: IF CHILD HAS DIARRHOEA ➔ REFER TO HEALTH SERVICES

5. ASK ABOUT BREASTFEEDING/BREASTMILK FEEDING
How often do you breastfeed/feed your baby breastmilk?
How do you decide when to feed your baby?
(If breastfeeding) Do you experience any pain or
discomfort while breastfeeding?

_________ times total_________ times in the night❑ Responsive❑ Yes❑ Scheduled❑ Extreme ❑ Moderate ❑ Mild

❑ No

6. REQUEST PERMISSION TO OBSERVE THE MOTHER BREASTFEEDING (IF APPLICABLE)
Assess breast health:Colour: ❑ Normal ❑ Redness Condition: ❑ Normal ❑ Shiny ❑ Hard ❑ Warm

❑ Engorged ❑ Damaged nipple ❑ Suspected blocked duct
❑ Suspected mastitis ❑ Suspected thrush ❑ Suspected breast abscess

ACTION: IF THRUSH, BREAST ABSCESS OR MASTITIS ➔ REFER TO HEALTH SERVICES FOR TREATMENT

Signs breastfeeding is going wellSigns of possible difficulty

BODY POSITIONBODY POSITION❑ Mother relaxed and comfortable❑ Mother’s back and arms are well supported❑ Baby's body close, facing breast❑ Starts feed with baby’s nose opposite nipple❑ Baby’s head free
❑ Baby's head and body straight (in line)❑ Baby's chin touching breast❑ Shoulders tense/leaning over baby
❑ Baby’s body far away from mother’s body
❑ Starts feed with baby’s mouth opposite nipple❑ Baby’s head cannot move back freely❑ Baby’s neck twisted/not in line with shoulder and hip❑ Baby’s chin not touching breast

4

Note: Contextualise with most commonly given liquids.

5

 ote: Counsellors need to be provided with job aids or reference materials and trained on what is considered acceptable in termsNof stooling depending on the infant age and what they are fed.

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OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESSigns breastfeeding is going wellSigns of possible difficulty

RESPONSESRESPONSES❑ Baby reaches for breast if hungry❑ [Baby roots for breast]❑ Baby explores breast with tongue❑ Baby calm and alert❑ Baby stays attached to breast❑ [Signs of milk ejection] – leaking, afterpains❑ No response to breast❑ [No rooting observed]❑ Baby not interested in breast❑ Baby restless or crying❑ Baby slips off breast❑ [No signs of milk ejection]❑ Mother shows signs of pain/discomfort❑ Baby coughs/gags/chokes

EMOTIONAL STATE AND BONDINGEMOTIONAL STATE AND BONDING❑ Secure, confident hold
❑ Eye contact❑ Mirroring of facial expressions between parent
and child❑ Much touching by mother❑ Responsive to baby’s needs❑ Nervous/limp hold❑ No eye contact❑ Shaking or poking baby/breast❑ Little touching❑ Struggles to soothe baby when crying

SUCKLING/ATTACHMENTSUCKLING/ATTACHMENT❑ Mouth wide open
❑ Lower lip turned outwards❑ Tongue cupped around breast❑ Cheeks round❑ More areola above baby’s mouth❑ Slow deep sucks, bursts with pauses❑ Can see or hear swallowing❑ Mouth not wide open/points forward❑ Lower lip turned in❑ Baby’s tongue not seen
❑ Cheeks tense or pulled in❑ More areola below baby’s mouth❑ Rapid sucks only
❑ Can hear smacking or clicking

END OF FEEDEND OF FEED❑ Baby releases breast❑ Nipple looks normal/round/erect❑ Baby suckled for 5+ minutes❑ Mother keeps breast available/offers other breast❑ Baby’s hands are relaxed/open❑ Baby looks relaxed/satisfied/sleepy❑ Breasts feel softer❑ Mother takes baby off breast❑ Nipple looks creased/squashed/flattened❑ Baby suckled for <5 minutes❑ Mother does not keep breast available offer other❑ Baby’s hands are clenched/near face
❑ Baby fusses/cries/appears unsatisfied

Time spent breastfeeding _________ minutes
6

7. ASSESS MATERNAL/CAREGIVER WELLBEING
Over the last two weeks, have you experienced any of
the following feelings?
Feeling anxious or worrying uncontrollably(If yes) Frequency in the last 2 weeks?

❑ No
❑ No

❑ Sometimes❑ Often❑ Almost every day

Difficulties coping with daily chores

❑ Yes
❑ Yes

❑ Sometimes❑ Often❑ Almost every day

Little interest or pleasure in doing things
that you used to enjoy

❑ Yes

❑ No

❑ Sometimes❑ Often❑ Almost every day

Feeling down, depressed or hopeless

❑ Yes

❑ No

❑ Sometimes❑ Often❑ Almost every day

On a scale of 1 (very unsupported) to 5 (very supported), how supported to you feelby family and friends in caring for your baby?

1

2

3

4

5

Who do you mostly rely on for support, if anyone?
How does your family feel about you breastfeeding?
ACTION: IF ANSWERED YES – OFTEN / ALMOST EVERYDAY OR SCORE 1 – 3 ➔ CONDUCT MHPSS ASSESSMENT

6

Instead of questions, caregivers may also be shown drawings and asked which most accurately reflects their mood.

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69

Do you have any concerns about the baby’s growth and development or levelof alertness, compared to other babies of a similar age?

❑ Yes

❑ No

HOW MUCH?

TEXTURE?

ACTION: IF ANSWERED YES ➔ REFER TO HEALTH AND ECD SERVICES

How is your current health?

8. (IF 6-23 MONTHS) ASSESS COMPLEMENTARY FEEDING PRACTICES
Who helps/assists the child with eating?
How many times did (name) eat solid, semi-solid or soft
foods yesterday during the day or at night?
Yesterday, during the day and night what did you give
your child to eat?

_________ times
WHAT?

(cups/handfuls)(thick/thin/
chopped/whole)

❑ Yes
❑ Yes

❑ No
❑ No

Grains, roots, tubers
Legumes and nuts
Dairy products (e.g., milk, yoghurt, cheese)
Flesh foods (meat, fish, poultry, liver/organ meats)
Eggs
Vitamin A rich fruits and vegetables
Other fruits and vegetables
Check: ≥ 4 food groups?
Did you give your child micronutrient powder (MNP)?
What do you use to feed your child liquids?

❑ Open cup ❑ Cup with spout ❑ Bottle❑ Before preparing food
At what important times in the day do you wash your hands with water and soap?
❑ Before eating❑ Before feeding child
Do you wash the child’s hands with clean water and soap before they eat?
❑ Yes
❑ No
Have you noticed the child experiencing any difficulties when eating?
❑ Yes
❑ No
❑ Coughing/choking ❑ “Wet”/“gurgly” voice breathing ❑ Discomfort ❑ Watery eyes ❑ Changes in colour/breathing
ACTION: IF SIGNS OF POSSIBLE ASPIRATION ARE PRESENT ➔ REFER FOR PAEDIATRIC ASSESSMENT

9. NOTE DOWN ANY KNOWN RISK FACTORS (e.g., noted when referred)Child

Mother/caregiver❑ Premature ❑ Low birth weight ❑ Under 6m with growth failure❑ Sick ❑ Multiple ❑ Malnourished ❑ Disability impacting feeding❑ Signs of extreme distress ❑ Maternal orphan ❑ Separated/unaccompanied❑ Malnourished ❑ Severely ill ❑ Recovering from Caesarean birth/difficult birth❑ Disability impacting feeding
Voluntary disclosure only: ❑ MHPSS difficulties ❑ SGBV survivor ❑ HIV positive❑ First time mother ❑ Adolescent mother

ACTION: IF RISK FACTOR(S) ARE PRESENT ➔ ENROL FOR COUNSELLING + REFER TO REQUIRED SERVICES

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OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES

10. NOTE DOWN ANY OBSERVATIONS MADE DURING THE ASSESSMENT
Quality of mother’s/caregiver’s-child interaction(holding, touching, visual contact, verbal exchange, mirroring, playing)❑ Poor❑ Moderate❑ GoodChild’s reaction to the mother’s/caregiver’s stimulation❑ Poor❑ Moderate❑ GoodMother’s/caregiver’s reaction to the child’s calls forattention and need for comfort❑ Poor❑ Moderate❑ Good❑ Poor❑ Poor❑ Moderate❑ Moderate
❑ Yes
❑ Yes
❑ Yes

❑ Good❑ Good
❑ No
❑ No
❑ No

Mother’s/caregiver’s awareness of child’s movements
Mother’s/caregiver’s response to child needing correction
Child moves both arms and legs equally
Normal tone and posture
Mother/caregiver requested infant formula

11. COUNSELLING ACTIONS/DECIDE ON CARE PLAN
Possible problems:

Counselling actions taken:❑ Positioning and attachment: ______________________________________________________________❑ Stress management: _______________________________________________________________________❑ Information given on: ______________________________________________________________________❑ Supplies provided: _________________________________________________________________________❑ Referrals made: health/nutrition/MHPSS/ECD/FSL/WASH/other: _________________________________________________________________________________________________________________❑ Other: _______________________________________________________________________________________
Further counselling needed?
❑ Yes
❑ No
ACTION: IF NO ➔ REFER FOR OTHER IYCF SERVICES❑ Education ❑ Peer group support ❑ Other ____________________
Reason for further counselling(refer to triage tool)
Support to be provided
BASIC SUPPORT AND COUNSELLINGADVANCED SUPPORT AND COUNSELLING❑ Positioning and attachment❑ Maternal confidence❑ Milk expression❑ Cup/spoon feeding❑ Flat or inverted nipples❑ Sore or damaged nipples❑ Engorgement❑ Increase/decrease milk production❑ Restorative care/emotional support❑ Wet nursing❑ Breastfeeding in public/crowded spaces❑ Breastfeeding at night❑ Infection Prevention Control❑ Rejecting donations of BMS/feeding bottles/teats❑ Preparing for crisis/evacuation❑ Encourage age appropriate feeding❑ Complementary feeding❑ Maternal diet
❑ Other: ____________________________________________________❑ Manage mastitis/thrush❑ Manage tongue tie❑ Breastfeed LBW or preterm infant/KMC❑ Breastfeeding during maternal/child severe illness❑ Feeding with a disability impacting feeding❑ Feeding while experiencing mental health difficulties❑ Relactation❑ Suppress lactation (stillbirth/infant loss)❑ Maintaining lactation during separation❑ Breast refusal❑ Other: ____________________________________________________

Follow up date:
Time spent today:

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

71

Annex C

STRATEGIES FOR OVERCOMING1BARRIERS TO REMOTE
BREASTFEEDING COUNSELLING

Possible challenges

Possible solutionsI nability to see each other (telephone counselling)• Counsellor cannot gather information on caregiver’s
receptiveness, understanding or wellbeing throughnon-verbal cues (e.g., facial expression, bodylanguage)• Harder to build rapport (facial expressions, eyecontact)• Counsellor cannot reinforce with non-verbal
communication (e.g., gestures)• Counsellor cannot see signs of malnutrition orconditions of the infant, latch, anatomy or positioning• Counsellor cannot see signs of infection or otherphysiological conditions of the breast• Caregiver may feel that she is not being heard• Focus on strengthening counsellors’ verbal
communication skills e.g., active listening, reflective
techniques, descriptive language, tone of voice, use ofaffirmative sounds• Train counsellors to assess growth and how
breastfeeding is going without visuals• Allow for more time for caregivers to build trust anddisclose personal or sensitive issues• Consider making the connection via an outreachworker who is in the community to introduce
the counsellor and encourage trust between thecounsellor and the caregiver• Discuss the option and viability of using a technologythat allows visuals such as pictures• Use a comprehensive, structured approach to gather
information otherwise gathered visually. Follow up
with clarifying questions to reach required levels ofdetailNo physical presence• Counsellor cannot gather information from homeenvironment (e.g., hygiene)• Harder to build a trusted and warm relationship (e.g.,
no touch or physical greeting possible)• Cannot physically help caregiver (e.g., positioning or
conduct a physical assessment)• Cannot weigh the infant• Focus on strengthening counsellors’ rapport building
skills (e.g., active listening, verbal engagement, match
communication styles and language, appropriate tone
and texture of voice, breathing) to build a relationship• Train counsellors on a no-touch/hands off approach2(e.g., demonstrate positioning using a doll or giving
verbal cues)• Allow more time for caregivers to build trust anddisclose personal or sensitive issues• Train counsellors on how to assess newborn intake
remotely3

Technology availability and access• Poor quality or coverage of phone or internet
connection• Caregiver may not have access to telephone ortechnology due to cost (cost of device, cost ofcommunication or data streaming) or may share withothers• Use a community/community health worker phone• Cover caregiver’s mobile data/internet costs orprovide toll-free phone numbers• Share low resolution images• Agree on a day and time when the caregiver will beable to use the phone/device• Provide contact details for the caregiver to initiate
counselling (client-led counselling)• Let the caregiver know you will re-connect/call back if
the connection is disrupted

Cultural acceptance• Use of technologies not culturally accepted• Caregiver may not own phones/technology• Engage community leaders in discussions around bestmodality for remote counselling

1Adapted from: WHO and UNICEF (2021). Implementation Guidance on Counselling to Improve Breastfeeding Practices.

2

Note: this is a best practice that is also encouraged during face-to-face counselling.

3

Tool: https://abaprofessional.asn.au/assessing-newborn-intake-in-the-context-of-covid-19/

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OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESPossible challenges

Possible solutions

Lack of confidentiality/privacy• Caregiver cannot speak freely/lack of privacy at home
• Fears about overhearing personal/sensitive
information/spying/hacking• Start counselling sessions by verifying that the
caregiver is comfortable to be counselled. If not, agree
on a date and time during which they expect to haveprivacy and feel comfortable• Use a text rather than voice or video service whenappropriate• Use closed (yes/no) questions to verify a caregiver’s
safety and wellbeing (e.g., if violence against womenand girls is suspected)• Ensure confidentiality in online groups, e.g., notsharing information without consent• Use end-to-end encrypted communication services• Ensure remote counselling services abide by dataprotection policies, laws and regulations

Distractions and responsibilities at home
• Caregiver may need to attend to household orchildcare duties during counselling operating hours• Caregiver may be distracted by children and otherfamily members in the home

• Use text rather than voice or video so that the
caregiver can reply when it is convenient for her• Use flexible call schedules so calls can be returned atconvenient times• Thoroughly check caregiver’s understanding• Follow-up frequently and reinforce information
through following up with IEC materials

Caregiver’s ability to use technology• Caregiver may have little/no experience with using
technology• Caregiver may have low literacy level• Use voice/visuals instead of text
• Engage community health workers in the setting up of
remote counselling sessions

For further guidance on remote counselling, refer to: Save the Children, IFE Core Group, ENN, USAID,ACF USA, PATH, SafelyFed Canada (2021). Practical Guidelines for conducting and Supporting Infant andYoung Child Feeding – e-Counselling via telephone with considerations for planning and implementation.
www.iycfehub.org/document/practical-guidelines-for-conducting-and-supporting-infant-and-young-childfeeding-e-counselling-via-telephone-with-considerations-for-planning-and-implementation

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

73

Notes______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
74 

OPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIESOPERATIONAL GUIDANCE BREASTFEEDING COUNSELLING IN EMERGENCIES 

75

A community health worker counsels
a breastfeeding woman using apictorial job aid during a home visit
ACTION AGAINST HUNGER/KHAULA JAMIL

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