Infant formula in Iraq: part of the problem and not a simple solution – Authors' reply
Authors: Mohamad K Haidar, Amber Alayyan, Jihane Ben Farhat, Malika Saim, Isabelle Defourny
Journal: The Lancet Global Health (2018)

We appreciate the Correspondence from Mija Ververs and colleagues, in response to our initial letter describing a pattern of severe malnutrition among infants younger than 6 months who had been displaced from Mosul, Iraq.1Haidar MK Farhat J Ben Saim M Morton N Defourny I Severe malnutrition in infants displaced from Mosul, Iraq.Lancet Glob Health. 2017; 5: e1188Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although we agree with the international guidance described by Ververs and colleagues,2Operational Guidance on Infant Feeding in Emergencies (OG-IFE) version 3.0.http://www.ennonline.net/operationalguidance-v3-2017Date: 2017Google Scholar and the statement that the requirements for the support of infant formula feeding go beyond the supply, we must re-emphasise the emergency nature of this intervention and the specific context prioritising the prevention of deaths due to malnutrition. Although the technical aspects of Ververs and colleagues' Correspondence are not in contention, the displaced mothers from Mosul reported previous formula milk use,1Haidar MK Farhat J Ben Saim M Morton N Defourny I Severe malnutrition in infants displaced from Mosul, Iraq.Lancet Glob Health. 2017; 5: e1188Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar and its unavailability was the major challenge to adequate infant feeding. The use of formula milk in Iraq is not a new practice that was introduced during this crisis; rather it has been common practice among children younger than 6 months since the 1970s.3World Health Organization RO for the EMBreast-feeding patterns: a review of studies in the Eastern Mediterranean Region.http://www.who.int/iris/handle/10665/119499Date: 1993Google Scholar, 4Benyamen YS Hassan MK Feeding patterns in the first two years of life in Basra, Iraq.East Mediterr Heal J. 1998; 4: 448-451Google Scholar In this particular context, war had caused the scarcity of formula milk and displacement made it unaffordable when available. Indeed, we do not advocate the indiscriminate distribution of infant formula with no regard for other components of care; rather we encourage the adaptation of emergency interventions to reflect the feeding practices of the population, before trying to address the underlying behavioural practices. Many of the women took the decision not to breastfeed before the war; others had a reduction in breast milk production because of the effects of the war. Their reasons are varied and are their own; hence, the utmost responsibility is to respect their choices in our interventions. In acute emergencies, tackling severe acute malnutrition and its cause-specific mortality remain the key factors when intervening. Timeliness of the response is a crucial factor, particularly when the prevalence of severe malnutrition reaches a quarter of the infant population younger than 6 months. Emergency responses should be adapted to population practices to ensure the accessibility and safety of adequate infant feeding and thereby avert avoidable deaths. We declare no competing interests. Infant formula in Iraq: part of the problem and not a simple solutionMohamad Haidar and colleagues (December, 2017)1 describe challenges in the management of nutritionally vulnerable infants in Iraq. They highlight the consumption of infant formula and inappropriate alternatives by malnourished infants and note that mothers report breastfeeding difficulties. They suggest that infant formula be distributed more widely as part of the emergency response. We are concerned that it was not emphasised that infant formula distributions must be carefully targeted, that the requirements for supporting infant formula feeding go well beyond just the supply, and that the usefulness of providing support for breastfeeding was not discussed. Full-Text PDF Open AccessSevere malnutrition in infants displaced from Mosul, IraqMédecins Sans Frontières (MSF) provides emergency medical care, including mother and child care, in 10 governorates of Iraq. The military operation by the Iraqi government on Mosul, the second largest city in Iraq, began in late 2016 and ended with a siege of the city that lasted from February, 2017 until July, 2017. The siege led to food shortages, and subsequent mass displacements presented further challenges for food security. Full-Text PDF Open Access