Severe malnutrition in infants displaced from Mosul, Iraq
Authors: Mohamad K Haidar, Jihane Ben Farhat, Malika Saim, Nikola Morton, Isabelle Defourny
Journal: The Lancet Global Health (2017)

Médecins 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. Mass screening among children aged 6–59 months in displacement camps, done by implementing partners as part of their programme, showed a low prevalence of malnutrition. However, in Qayyarah, one of the major sites for displaced persons, hospital-based MSF teams reported high admissions of severely malnourished infants aged under 6 months, especially from western Mosul. Therefore in May, 2017, MSF did an exhaustive screening in Al-Jad'ah camp in Qayyarah to estimate the prevalence of malnutrition among infants aged 1–5 months, and to explore barriers to adequate infant feeding. Weight-for-length Z-score is the WHO standard for malnutrition assessment among children in this age group.1World Health OrganizationManagement of infants under 6 months of age with severe acute malnutrition.http://www.who.int/elena/titles/sam_infants/en/Date: August 24, 2016Google Scholar However, due to the complexity of this method and, following recommendations2Kerac M Mwangome M McGrath M Haider R Berkley JA Management of acute malnutrition in infants aged under 6 months (MAMI): current issues and future directions in policy and research.Food Nutr Bull. 2015; 36: S30-S34Crossref PubMed Scopus (36) Google Scholar in 2015 from the Management of Acute Malnutrition in Infants project, we defined severe malnutrition in infants aged 1–5 months as: (1) having a mid-upper arm circumference of less than 110 mm (with or without oedema); (2) having a weight-for-age Z-score of less than −3 (with or without oedema); or (3) presence of oedema. Evidence suggests a strong association between these criteria and mortality.3Mwangome M Ngari M Fegan G et al.Diagnostic criteria for severe acute malnutrition among infants aged under 6 mo.Am J Clin Nutr. 2017; 105: 1415-1423PubMed Scopus (40) Google Scholar We conducted semi-structured interviews with mothers of severely malnourished children who were admitted to inpatient facilities supported by MSF to determine barriers to feeding. The prevalence of severe malnourishment among infants aged 1–5 months was 26% using mid-upper arm circumference (with or without oedema), 25% using weight-for-age Z-score (with or without oedema), and 4% using oedema alone. Interviews with mothers indicated that the use of infant formula was common, consistent with evidence from other studies among Iraqi women before the war.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 Some women interviewed were not able to breastfeed or perceived an inability to breastfeed on the basis of their own poor access to good nutrition and several life stressors. Inadequate access to formula milk resulted in substitutions such as water and sugar. Although breastfeeding is recommended and should be encouraged, it is not an option for all women. In complex humanitarian emergencies, breastmilk substitutes and, particularly, the distribution of formula milk should be incorporated into the response. Promoting breastfeeding and ensuring the availability of breastmilk substitutes are not mutually exclusive. The situation in Iraq underlines the need to adapt the humanitarian response to each context. We declare no competing interests. Infant 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 AccessInfant 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 Access