Infant formula in Iraq: part of the problem and not a simple solution
Authors: Mija Ververs, Marie McGrath, Karleen Gribble, Christine Fernandes, Marko Kerac, Robert C Stewart
Journal: The Lancet Global Health (2018)

Mohamad Haidar and colleagues (December, 2017)1Haidar MK Farhat JB Saim K 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 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. International guidance advises that infant formula should be supplied where there is a demonstrated need, accompanied by a commitment to deliver or secure a package of care, including water, sanitation, feeding equipment, and fuel (for safe preparation of infant formula—ie, cleaning, sterilisation, and reconstitution), as well as access to health care and growth monitoring.2ENNInfant and young child feeding in emergencies.in: Operational guidance for emergeny relief staff and programme managers. Version 3.0, October 2017. Emergency Nutrition Network, Oxford2017: 14Google Scholar Only where supply is tightly targeted and supported in this way are distributions of benefit, given that indiscriminate distributions of infant formula increase rates of formula feeding, infectious disease, and malnutrition.3Hipgrave DB Assefa F Winoto A Sukotjo S Donated breast milk substitutes and incidence of diarrhoea among infants and young children after the May 2006 earthquake in Yogyakarta and Central Java.Public Health Nutr. 2012; 15: 307-315Crossref PubMed Scopus (38) Google Scholar, 4Adhisivam B Srinivasan S Soudarssanane MB Deepak Amalnath S Nirmal Kumar A Feeding of infants and young children in tsunami affected villages in Pondicherry.Indian Pediatr. 2006; 43: 724-727PubMed Google Scholar Where women lack confidence in their ability to breastfeed or are malnourished, the provision of nutritional, psychosocial, and breastfeeding support benefits their wellbeing and can improve infant nutritional status. It is important that women who believe that their milk is insufficient receive proper assessment and support so that appropriate intervention can be provided. Although specialist infant feeding and mental health experts are often in short supply in conflict situations, lay health workers have been found to be able to provide effective psychological interventions in conflict-affected settings.5Rahman A Hamdani SU Awan NR et al.Effect of a multicomponent behavioral intervention in adults impaired by psychological distress in a conflict-affected area of Pakistan: a randomized clinical trial.JAMA. 2016; 316: 2609-2617Crossref PubMed Scopus (156) Google Scholar Where mixed feeding is common, as in Iraq, sensitive, context-specific feeding counselling is needed to enable a mother to take informed infant feeding decisions. Providing both breastfeeding and artificial feeding support is challenging and not easily reflected in a simple medical protocol. Regarding the use of infant formula in emergencies, it is crucial to deliver a minimum package of care and supplies for as long as is needed (at least until the infant reaches the age of 6 months); otherwise, at best we do a disservice to those most vulnerable, and at worst, we risk doing much harm as well as good. We declare no competing interests. Severe 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 AccessInfant formula in Iraq: part of the problem and not a simple solution – Authors' replyWe 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.1 Full-Text PDF Open Access