Donated breast milk substitutes and incidence of diarrhoea among infants and young children after the May 2006 earthquake in Yogyakarta and Central Java

Abstract

Distribution of breast milk substitutes (BMS) after the 2006 Yogyakarta earthquake was uncontrolled and widespread. We assessed the magnitude of BMS distribution after the earthquake, its impact on feeding practices and the association between consumption of infant formula and diarrhoea among infants and young children.
One month after the earthquake, caregivers of 831 children aged 0-23 months were surveyed regarding receipt of unsolicited donations of BMS, and on recent child-feeding practices and diarrhoeal illness.
Community-level survey in an earthquake-affected district.
Primary caregivers of surveyed children.
In all, 75 % of households with an infant aged 0-5 months and 80 % of all households surveyed received donated infant formula; 76 % of all households received commercial porridge and 49 % received powdered milk. Only 32 % of 0-5-month-old infants had consumed formula before the earthquake, but 43 % had in the 24 h preceding the survey (P < 0·001). Consumption of all types of BMS was significantly higher among those who received donated commodities, regardless of age (P < 0·01). One-week diarrhoea incidence among those who received donated infant formula (25·4 %) was higher than among those who did not (11·5 %; relative risk = 2·12, 95 % CI = 1·34, 3·35). The rate of diarrhoea among those aged 12-23 months was around five times the pre-earthquake rate.
There were strong associations between receipt of BMS and changes in feeding practices, and between receipt of infant formula and diarrhoea. Uncontrolled distribution of infant formula exacerbates the risk of diarrhoea among infants and young children in emergencies.

Full text

Public Health Nutrition: page 1 of 9 doi:10.1017/S1368980010003423
Donated breast milk substitutes and incidence of diarrhoea
among infants and young children after the May 2006
earthquake in Yogyakarta and Central Java
David B Hipgrave
1,
*, Fitsum Assefa
2
, Anna Winoto
3
and Sri Sukotjo
3
1
United Nations Children’s Fund China Country Office, 12 Sanlitun Lu, Beijing 100600, People’s Republic of
China:
2
United Nations Children’s Fund Zimbabwe Country Office, 6 Fairbridge Avenue Belgravia, Harare,
Zimbabwe:
3
United Nations Children’s Fund Indonesia Country Office, Level 10, Wisma Metropolitan II,
Jalan Sudirman, Jakarta, Indonesia
Submitted 24 January 2010: Accepted 20 September 2010
Abstract
Objective: Distribution of breast milk substitutes (BMS) after the 2006 Yogyakarta
earthquake was uncontrolled and widespread. We assessed the magnitude of
BMS distribution after the earthquake, its impact on feeding practices and the
association between consumption of infant formula and diarrhoea among infants
and young children.
Design: One month after the earthquake, caregivers of 831 children aged 0–23
months were surveyed regarding receipt of unsolicited donations of BMS, and on
recent child-feeding practices and diarrhoeal illness.
Setting: Community-level survey in an earthquake-affected district.
Subjects: Primary caregivers of surveyed children.
Results: In all, 75 % of households with an infant aged 0–5 months and 80 % of all
households surveyed received donated infant formula; 76 % of all households
received commercial porridge and 49 % received powdered milk. Only 32 % of
0–5-month-old infants had consumed formula before the earthquake, but 43 %
had in the 24 h preceding the survey (P,0?001). Consumption of all types of BMS
was significantly higher among those who received donated commodities,
regardless of age (P,0?01). One-week diarrhoea incidence among those who
received donated infant formula (25?4 %) was higher than among those who did
not (11?5 %; relative risk 52?12, 95 % CI 51?34, 3?35). The rate of diarrhoea
among those aged 12–23 months was around five times the pre-earthquake rate.
Conclusions: There were strong associations between receipt of BMS and changes
in feeding practices, and between receipt of infant formula and diarrhoea.
Uncontrolled distribution of infant formula exacerbates the risk of diarrhoea
among infants and young children in emergencies.
Keywords
Breast-feeding
Emergency
Breast milk substitutes
Infant formula
Diarrhoea
It is estimated that 219 million people in Indonesia live in
an environment in which there is a high risk of natural
disasters
(1)
. On 27 May 2006, an earthquake measuring
6?2 on the Richter scale
(2)
devastated the provinces of
Yogyakarta and Central Java, killing about 6000 people,
injuring another 40 000–60 000 and robbing hundreds of
thousands of their homes and livelihood
(3)
.
The emergency response to the earthquake was rapid;
during the weeks immediately following, we observed
humanitarian actors providing large volumes of consum-
ables to affected families. Contrary to the relevant opera-
tional guidelines
(4)
that provide detailed instructions on
the procurement, handling and use of donated breast milk
substitutes (BMS) such as infant formula, powdered milk
and complementary foods, such commodities were widely
distributed to families with infants and young children.
Many of these products were supplied in bulk, with no
instructions to relief workers on targeting, their safe use
or screening of recipient families’ needs. The channels of
distribution included their inclusion in the general ration
given to affected households, and handouts at temporary
and fixed health facilities and temporary shelters. BMS was
portrayed by donors, distributors and the media as pro-
viding essential nutrition for infants, and mothers were
considered less likely to breast-feed because of stress,
injury, pre-occupation with damage to property and loss of
privacy
(3,5)
.
Infant and young child feeding (IYCF) practices in
Indonesia are far from optimal. Real practices diverge
markedly from global recommendations for exclusive
SPublic Health Nutrition
*Corresponding author: Email dhipgrave@unicef.org rThe Authors 2011

breast-feeding for the first 6 months of life, followed by
continued breast-feeding with appropriate complementary
food up to the age of 2 years
(6)
. According to the 2007
Indonesia Demographic and Health Survey (DHS), only
17?8 % of infants are still exclusively breast-fed at 4–5
months of age, and 50?7 % of children are given pre-lacteal
intake (such as water, infant formula, honey, dates, banana,
herbal drinks or other substances
(7)
) before commencing to
suckle
(8)
. In addition, diarrhoeal illness is common among
children aged ,2 years in Indonesia
(8)
.
Early cessation of exclusive breast-feeding and of
any breast-feeding increases under-5 mortality
(9)
and sus-
ceptibility to infections
(10–15)
, especially in emergency
situations
(16,17)
. Although anecdotal information suggests
that certain emergency responses have negatively affected
breast-feeding practices in various situations
(18)
,thereis
limited evidence showing the extent or direct impact of the
problem. In this context, we report the results of a survey
conducted to assess the extent of distribution of BMS
and complementary foods after the May 2006 Yogyakarta
earthquake, and its association with IYCF practices and
diarrhoea incidence among children aged 0–23 months.
Methods
Study setting
The survey was conducted in tandem with the registration
of pregnancies by local health authorities from 18 to 24
June 2006 in the seven sub-districts most affected by the
earthquake in Bantul district, Yogyakarta province. Bantul
and adjacent Klaten (in Central Java province) were the
districts most affected by the earthquake.
Recruitment of interviewees
Pregnant women were identified using pre-earthquake
registers held at sub-district health centres. Women were
sought by survey team members at their residential
address or at temporary shelters within their neighbour-
hood. Women who could not be found locally were not
sought elsewhere.
Assuming that pregnancy and the location of pregnant
women were chance events, the registration process was
also used to randomly identify infants and young children
in the surveyed areas. For every second pregnant woman
interviewed, the child aged ,2 years who slept nearest to
her was identified, irrespective of whether that child was
hers or of a friend, relative or neighbour. If there was
more than one child ,2 years of age in the house, tent or
shelter, interviewers were instructed to randomly assess
only one of them. Once identified, the child’s primary
caregiver (mother, grandmother, etc.) was interviewed.
Data collection and survey instrument
Interviewers for the survey were students from the University
of Gajah Mada in Yogyakarta and from non-government
organisations, trained by UNICEF and university staff, and
supervised by the university’s Public Health and Nutrition
Department.
The questionnaire was prepared and tested locally,
and comprised fifteen simple questions, including eight
on IYCF and receipt of donations (see Box 1). If the
respondent was not the mother, surveyors were instruc-
ted to adapt the questions according to her relationship
to the child. Infant feeding status was assessed using
24 h recall
(19)
.
The other seven questions related to vitamin A sup-
plementation, measles vaccination and management of
injuries sustained.
Statistical analysis
The questionnaires were coded, entered, cleaned and
analysed using the Statistical Package for the Social Sciences
statistical software package version 11?0 (SPSS Inc., Chicago,
IL, USA) and OpenEpi freeware (available at www.
openepi.com). Data were verified by checking for con-
sistency and range.
The primary outcome variables were the type of BMS
donations received, BMS consumption before and
after the earthquake and prevalence of diarrhoea in the
previous week. Analysis was conducted by the number
of infants affected, not by number of episodes. Crude
analyses were used to test associations, expressed as two-
sided probability values.
Children were categorised by age (0–5, 6–11, 6–23 and
12–23 months), and BMS was categorised as infant for-
mula, commercial porridge, powdered milk and blended
fortified food. Receipt of baby bottles was also recorded.
Information on diarrhoeal disease rates among children
aged 12–23 months and living in Central Java before
the earthquake was drawn from a Nutrition and Health
Surveillance System maintained by the Indonesian gov-
ernment and Helen Keller International, which recorded
data quarterly during the years 1999–2003
(20)
.
Results
Sample characteristics
A total of 831 primary caregivers of children aged 0–23
months (46 % of the children were girls) agreed to be inter-
viewed; 296 (36 %) children on whom information was
sought were aged 0–5 months and 535 (64 %) were aged
6–23 months. In each sub-district, the number of such chil-
dren identified was within 4 % of that expected according
to pre-earthquake population data, with one exception in
which there were 10 % more children than expected, possi-
bly because of movement of displaced persons into that area.
Receipt of breast milk substitutes
The receipt of different types of BMS by the household
of each child surveyed is depicted in Fig. 1, which
shows that 80 % received infant formula, 76 % received
SPublic Health Nutrition
2 DB Hipgrave et al.

commercial porridge, 49 % received powdered milk and
31 % received blended food. A total of 89 % received
either infant formula or powdered milk. In addition, 14 %
received baby bottles. Although households with infants
aged ,6 months were around 10 % less likely to have
received infant formula than households with older chil-
dren, 75 % were supplied with it.
Impact of donations on the use of breast milk
substitutes
During the weeks immediately following the earthquake,
we observed that infant formula, powdered milk and
other BMS were distributed widely and free of charge, in
some cases as part of a general ration provided to dis-
placed or affected families (Fig. 1). The rate of exclusive
SPublic Health Nutrition
Box 1
Eight survey questions on infant and young child feeding and receipt of donations
1. At this moment, do you breast-feed your child? 1. Yes, exclusively-no. 5
2. Yes, with other drink/food -no. 5
3. No
2. Have you ever breast-fed your child? 1. Yes 2. No -no.5
3. Did you stop breast-feeding because of the earthquake? 1. Yes 2. No -no. 5
4. Why did you stop breast-feeding after the earthquake?
1. Breast milk not enough/would not come out 1. Yes 2. No
2. Could not breast-feed because of injury 1. Yes 2. No
3. Availability of BMS (baby’s milk, formula) from donations 1. Yes 2. No
4. No private place to breast-feed 1. Yes 2. No
5. Others, specify _____________________ 1. Yes 2. No
5. Please list the types of food and drink given to the child in the last
24 h (initially do not prompt; record all responses given; prompt if item
is not mentioned; record frequency of consumption for each)
1. Breast milk Times y9. Rice Times y
2. Infant formula Times y10. Vegetables Times y
3. Powdered milk Times y11. Fruit Times y
4. Commercial porridge Times y12. Tempe/tofu Times y
5. MP-ASI Times y13. Egg Times y
6. Mung bean porridge Times y14. Fish Times y
7. Biscuit Times y15. Meat Times y
8. Instant noodles Times y16. Others (list) Times y
6. Did you receive donations of any of the following after the earthquake?
(initially do not prompt; record all responses given; prompt if item is
not mentioned, and again after quickly looking for any obviously
donated items)
1. Commercial porridge 1. Yes 2. No 3. Don’t know
2. MP-ASI 1. Yes 2. No 3. Don’t know
3. Infant formula 1. Yes 2. No 3. Don’t know
4. Powdered milk 1. Yes 2. No 3. Don’t know
5. Baby bottle 1. Yes 2. No 3. Don’t know
6. Instant noodles 1. Yes 2. No 3. Don’t know
7. Biscuit 1. Yes 2. No 3. Don’t Know
8. Vegetables 1. Yes 2. No 3. Don’t know
9. Fruit 1. Yes 2. No 3. Don’t know
10. Cooking oil 1. Yes 2. No 3. Don’t Know
11. Drinking water 1. Yes 2. No 3. Don’t know
12. Stove 1. Yes 2. No 3. Don’t know
13. Othersy. specify 1. Yes 2. No 3. Don’t know
7. Before the earthquake did your child ever consume the following?
1. Commercial porridge 1. Yes 2. No 3. Don’t know
2. MP-ASI 1. Yes 2. No 3. Don’t know
3. Infant formula 1. Yes 2. No 3. Don’t know
4. Powdered milk 1. Yes 2. No 3. Don’t know
8. In the last 7 d did your child have diarrhoea? (loose stools more than
three times in 24 h)
1. Yes 2. No 3. Don’t know
MP-ASI, Makanan Pendamping ASI (a complementary food of blended fortified porridge, available from health centre).
BMS and diarrhoea among infants and young children in emergencies 3

breast-feeding in the 24 h before the survey among infants
,6 months of age was only 33 %, but breast-feeding into
the second year of life continued among the majority of
infants and young children surveyed (Table 1). However,
regarding infant formula intake among infants aged 0–5
months, there was an increase from 32 % having ever
consumed it before the earthquake (indicating that pre-
crisis infant feeding in the affected areas was not optimal)
to 43 % having done so in the 24 h before the survey.
Increases in previous and recent formula consumption
were observed among such infants in both recipient
(37–48 %, P,0?001) and non-recipient (18–30 %, P,0?001)
households.
The mass distribution of unsolicited BMS clearly changed
IYCF practices and increased formula feeding in the affec-
ted areas. For each of the four commodities assessed, sig-
nificantly more infants had consumed it in the previous 24 h
if the household had received it than if the household had
not (P,0?01 for each commodity). Most alarmingly, this
also applied to young infants aged 0–5 months (Fig. 2).
Among older infants and young children (aged 6–23
months), 67 % of infants in households receiving donated
formula had consumed it in the previous 24 h, compared
with 37 % in non-recipient households.
Incidence of diarrhoea
The 1-week incidence of diarrhoea among those who
received donations of infant formula (25?4 %) was more
than double that of those who did not (11?5 %; relative
risk (RR) 52?12, 95 % CI 1?34, 3?35; Table 1). Incidence of
diarrhoea among infant formula recipients increased with
age, and was greater than the incidence of diarrhoea in
non-recipients for each age group. This difference was
significant for the oldest age group. For each age group,
SPublic Health Nutrition
90
80
70
75
82 80
72
78 76
46 50 49
28
32 31
15 14 14
60
40
30
20
10
0
Infant formula Commercial porridge Powdered milk Blended/fortified food Baby bottles
50
%
Fig. 1 Household receipt of four varieties of donated breast milk substitutes and baby bottles by age ( , 0–5 months (n269);
, 6–23 months (n535); , total (0–23 months) (n831)
Table 1 Rates of breast-feeding and of diarrhoea according to receipt and consumption of donated infant formula, with corresponding RR
and 95 % CI, by age
Age (months)
0–5 (n296)* 6–11 (n258) 12–23 (n277) Total (n831)
%%%%
Breast-feeding during the 24 h before the survey
Exclusive 33 3?0314
Mixed 60 84?577 73
None 7 12?520 13
n%n%n%n%
Diarrhoea during the 7 d before the survey
Received infant formula
Yes 30 14 60 29 72 33 162 25
No 5 7 8 20 6 12 19 12
Adjusted RR 2?10 1?32 2?63 2.12
95 % CI 0?81, 5?40 0?66, 2?65 1?20, 5?78 1.34, 3.35
Consumed infant formula
Yes 19 15 40 28 49 30 108 25
No 18 11 30 27 32 28 80 20
Adjusted RR 1.39 1.07 1.02 1.23
95 % CI 0.74, 2.61 0.70, 1.63 0.69, 1.48 0.95, 1.60
RR, relative risk.
*For calculation of percentages, denominators were adjusted for missing data.
4 DB Hipgrave et al.

diarrhoea was also more common among those who had
consumed infant formula in the preceding 24 h, but the
differences were not significant. For the entire sample, the
RR for diarrhoea among children who had consumed
infant formula in the 24 h before the survey was 1?23
(95 % CI 0?95, 1?60).
Data collected before the earthquake enabled a compar-
ison of the overall surveyed incidence of diarrhoea among
those aged 12–23 months (29 %) with what was normal in
children of the same age in Central Java beforehand (1–7 %).
There was a large increase in the incidence of diarrhoea
among those affected by the crisis (Fig. 3)
(20)
.
Distribution of key outcomes by location surveyed
To enable a comparison of the key survey findings by
geographical location, and thus rule out local influences,
Table 2 provides the percentages of three key variables
assessed in each of the seven surveyed sub-districts.
There were no interactions between differences in
household receipt or consumption of infant formula and
SPublic Health Nutrition
60
50
40
30
20
10
0
Yes No Yes No Yes No
6
8
20
36
30
48
% Consumption
2
14
Yes
Infant formula Commercial porridge
Donations (0–5 months)
Powdered milk Blended/fortified food
No
Fig. 2 Consumption of four types of breast milk substitutes by infants aged 0–5 months according to household receipt of donated
supplies
30
25
20
15
10
5
0
323113
5
3
5
7
5
4
29
December 1999–
February 2000
December 2000–
February 2001
December 2001–
February 2002
December 2002–
March 2003
March–
June 2003
March–
May 2002
June 2000–
August 2001
June–
August 2002
June–
September 2003
June 2006
April–
June 2000
September–
November 2000
September–
November 2001
September–
November 2002
July–
September 2000
4
2
% Children
Fig. 3 Seven-day incidence of diarrhoea among children aged 12–23 months in Central Java, December 1999–September 2003,
and in Bantul, June 2009 (Source: Data for 1999–2003 are from Central Java. Data were not collected between February and June
2001. The June 2006 observation is from adjacent Bantul)
BMS and diarrhoea among infants and young children in emergencies 5

risk of diarrhoea among any of the infants and young
children across the seven sub-districts surveyed.
Discussion
We surveyed the receipt of donated BMS by earthquake-
affected families, as well as IYCF practices and the 1-week
incidence of diarrhoea, among infants and young chil-
dren in Yogyakarta in June 2006, 1 month after it was
devastated by an earthquake. We identified a general
disregard for recommended practices on IYCF in emer-
gencies
(4)
, with distribution of commodities to affected
families being both widespread and unscreened. There
appears to have been no attempt to limit the distribution of
BMS according to the pre-existing feeding practices of the
caregivers surveyed, or to households with older infants, or
to those in which infants were no longer being breast-fed
but with extra attention given to hygiene in such house-
holds. These findings confirm our observation and com-
munications that many agencies active in the relief effort
prioritised BMS distribution
(21–23)
, usually without regard to
these and other recommended practices.
IYCF practices changed as a result, with consumption
of infant formula among all infants aged ,6 months
increasing proportionally by more than a third, including
a significant increase in recipient households. These
increases may even be underestimates, as 24 h recall is
known to grossly underestimate longer-term consump-
tion of foods other than breast milk
(24)
. We note that the
increase was also significant among such infants in non-
recipient households, although numbers were small.
Clearly, BMS was easily available to all households and
breast-feeding was not being protected in the affected
areas. Young infants were also far more likely to consume
other commodities if the household had received them.
These findings underscore the fragility of good IYCF
practices, which, even when it is most important for them
to be safe, can easily tip from bad to worse without
support from the local health sector and under external
influences.
Moreover, we identified increased rates of diarrhoea
among children in households receiving infant formula
compared with those who did not, and, for those aged
12–23 months, compared with multi-year average rates
among same-aged peers in almost the same locality
(20)
.
We also found a strong trend towards an association
between diarrhoea and consumption of infant formula,
despite surveying formula intake only over the preceding
24 h. This association may have been significant if we had
surveyed consumption of infant formula during a longer
period of time.
Emergency workers and organisations frequently voice
concern that indiscriminate distribution of infant formula
in emergencies increases rates of formula feeding and
diarrhoea. However, we have not identified any similarly
documented risks of such distribution in disaster-affected
locations, most likely because of the difficulties involved
in conducting field surveys during emergency operations.
Although our survey can at best be described as a ‘quick
and dirty’ assessment, and causality has not been estab-
lished, the association between receipt of infant formula
and diarrhoeal disease was strong. The receipt of donated
commodities and IYCF practices that we observed were
not specific to certain sub-districts; there were no out-
breaks of diarrhoeal disease in earthquake-affected areas
during the weeks preceding the survey and the reports of
diarrhoea were not concentrated in certain locations. The
high overall 1-week incidence of diarrhoea identified also
suggests that all children in surveyed areas were at risk,
probably because of lack of clean water and/or poor
sanitation. In the 2007 Indonesia DHS, 2-week incidence
of diarrhoea among ,5-year-olds in Yogyakarta was only
5?4 % and in Central Java 9?3%
(9)
. The receipt of infant
formula after the Yogyakarta earthquake was associated
with more than double the risk of diarrhoeal illness in
young children, thus exacerbating the plight of affected
families.
Diarrhoeal disease is, after pneumonia, the second
most common cause of death due to infectious disease in
young children, accounting for 17 % of deaths among
children aged ,5 years
(25)
. Children in this age group are
at particularly high risk of malnutrition, morbidity and
mortality in disaster-affected areas
(26,27)
, and it is likely
that the risks are maximal in the first 2 years of life. Breast-
feeding was highly protective against severe morbidity
and mortality during a diarrhoea outbreak predominantly
affecting ,2-year-olds in Botswana
(28)
;upto90%of
deaths in emergency situations are due to diarrhoea
(16)
.
It is incumbent on agencies and individuals caring for
SPublic Health Nutrition
Table 2 Incidence of key outcome variables by sub-district
Sub-district name (and number sampled in each)
Bambang
Lipuro (n87)
Dlingo
(n73)
Imogiri
(n123)
Jetis
(n130)
Piyungan
(n149)
Pleret
(n195)
Pundong
(n74)
All
sub-districts
% %%%%%% %
Household receipt of infant formula 85 57 79 74 89 78 91 80
Consumption of infant formula (all ages) 59 36 43 62 61 50 44 52
One-week diarrhoea incidence (all ages) 24 16 20 22 24 22 35 23
6 DB Hipgrave et al.

infants and young children to provide for their health and
nutrition, to protect their safety and avoid causing harm.
Clearly, although this includes ensuring their adequate
nutrition (and for older infants and young children this
includes appropriate food), relief workers also have a
responsibility to protect breast-feeding and prevent the
risk of diarrhoeal illness due to consumption of un-
hygienically prepared food and drink, including in non-
breast-fed infants. However, this is not only a water,
sanitation and hygiene (WASH) issue. Use of infant for-
mula (even if partial breast-feeding continues) increases
the risk of respiratory and gastrointestinal infections, even
when WASH standards are not in question
(29–31)
.As
shown here, unsolicited donations of BMS change IYCF
practices and thus increase the risks of such infections.
Formula milk is also nutritionally inferior to breast milk in
a variety of ways
(31)
and emerging data suggest important
long-term negative impacts of formula feeding on adult
health and nutrition status
(32)
. Thus, from an infectious
disease and overall health and nutrition perspective, for-
mula feeding of infants and young children affected by
emergencies is risky, regardless of how it is prepared.
Children .6 months of age should also consume carefully
prepared, appropriate food to supplement breast milk
(or for non-breast-feeding infants, other milk) according
to the relevant guidelines
(4,33)
.
In any emergency, the procurement, management and
distribution of BMS, including milk products, bottles and
teats, should be strictly based on technical advice that
takes into account the attendant risks and impact on long-
term practices of recipient mothers, and on the needs of
the affected population. It should also comply with the
International Code on Marketing of BMS
(34)
, which was
adopted by WHO in 1981. Adherence to this code pro-
tects infants and young children from blatant or stealthy
attempts to influence their mothers’ behaviour, and in
emergency situations is especially important for control-
ling unsolicited donation and distribution of unsuitable
products (a form of advertising and, as shown here,
behaviour change communication by default).
During the response to the Yogyakarta earthquake, the
code and the related Operational Guidance
(4)
(including
a version in Bahasa Indonesia) were ignored. We saw no
centralised system to manage and control BMS distribu-
tion, and the widely held perspective was that most
women in Indonesia use infant formula already, hence its
distribution should be harmless. Many varieties of com-
mercial infant formula were distributed by a variety of
agencies, often with foreign labelling and no instruction
or counselling on usage. Similar widespread distribution
of BMS has been observed after many recent natural
disasters including the Indian Ocean tsunami in 2004
(35)
,
Pakistan earthquake in 2005
(36)
, Bangladesh cyclone in
2007
(37)
, Philippines typhoon in 2007
(38)
and China
earthquake in 2008
(39,40)
. A rapid search on the Internet in
late January 2010 again revealed calls for donations of
infant formula for the victims of the earthquake in Haiti.
Clearly, health authorities in Indonesia and elsewhere,
supported by local and international technical and pro-
fessional agencies, must raise awareness among relief and
philanthropic agencies on this issue.
On the basis of similar observations in Aceh after the
2004 tsunami, in 2005 UNICEF, WHO and the Indonesian
Paediatric Association released a joint statement on Infant
Feeding in Emergencies, followed by a related policy
note from the Ministry of Health. Both were distributed to
all province health offices. Although this was apparently
ignored in the immediate aftermath of this disaster,
the findings of this survey had an impact. The data were
used to facilitate advocacy and promotion of appropriate
IYCF in Yogyakarta and Central Java. However, it became
clear that this was insufficient. Accordingly, UNICEF and
the Indonesia Ministry of Health initiated a ‘cascade’
programme to train local breast-feeding counsellors.
Involvement of the government and a local women’s
empowerment group elevated IYCF to the highest level
of the humanitarian agenda, and since 2006 a stronger
national commitment to good IYCF practices has been
shown. The related initiatives
(41)
are relevant to both
routine infant care and to future natural disasters. During
the September 2009 West Java and West Sumatera earth-
quakes, IYCF responses had improved. Humanitarian
actors had apparently started to consider the principles
in the Operational Guidance in their responses, and
the government removed infant formula from the ration
distributed to affected families
(42)
. Informal reports also
indicated a strong local government commitment to
containing and managing the BMS donations received.
Uncontrolled distribution of infant formula and other
BMS can be extremely efficient during humanitarian
emergencies, but, as documented clearly here, is bad for
the health of children. It is encouraging that so many
actors want to help, and particularly that they are con-
cerned to help the most vulnerable – infants and young
children. However, relief agencies are often inexper-
ienced and poorly supervised in what is often a chaotic
situation. The unregulated relief, donor and philanthropic
environment that prevails in most humanitarian emer-
gencies has the potential to cause great harm; the assis-
tance provided, including BMS, should be regulated
appropriately. This is beginning to happen in Indonesia.
Further research is needed to determine why and by
whom BMS continues to be distributed during emergen-
cies elsewhere, and how this can be discouraged.
Acknowledgements
The fieldwork described in this paper was funded by UNI-
CEF Indonesia. Follow-up analysis and writing were under-
taken independently by the authors. The authors declare no
conflict of interest, and they have all seen and approved the
SPublic Health Nutrition
BMS and diarrhoea among infants and young children in emergencies 7

content of the paper. The views expressed in this paper are
solely attributable to the authors, and not to UNICEF globally
or to any of the UNICEF Country Offices where they work.
The present paper presents original work and analysis
undertaken by the authors. Approval from the Institutional
Review Board was not required by the implementing
agencies as identifying data were not maintained and the
research was a passive assessment of the situation with no
intervention by the survey team. Some of the basic results
were presented in a non peer-reviewed online bulletin cited
as reference 41. The focus of this earlier description of the
work was mostly on the follow-up to the survey and only
descriptive analysis was documented in that report. D.B.H.
managed the team undertaking the survey, further designed
and assisted with the data analysis and wrote the paper; F.A.,
A.W. and S.S. conceived and facilitated implementation of
the survey; F.A. contributed to writing the original survey
report; S.S. analysed the survey data, drafted the manuscript
and assisted with its finalisation. The authors recognise and
thank Ms Dorothy Foote and Mr Agus Riyanto, consultants to
UNICEF Indonesia in June 2006, for their contribution to
the design and conduct of the survey described in the pre-
sent paper, and also the staff and students at the University
of Gajah Mada School of Public Health for their work in
the field. The authors also thank Professor Damien Jolley of
Monash University, Australia, and Drs France Begin and
William Hawley and Ms Lilian Selenje of UNICEF for their
helpful comments on the analysis and manuscript.
References
1. Anonymous (2006) Walhi: 83 Persen Wilayah Indonesia
Rawan Bencana. http://www.antara.co.id/arc/2006/12/27/
walhi-83-persen-wilayah-indonesia-rawan-bencana/ (accessed
September 2010).
2. World Health Organization (2006) Earthquake, Yogyakarta
and Central Java. Emergency Situation Report no. 1.
Geneva: WHO; available at http://www.who.or.id/eng/
php/content/jogja-centraljava/Sitrep%20Indonesia%20Jogja-
Central%20Java%2029-05-06%20(1).pdf
3. World Health Organization (2006) Yogyakarta and Central
Java Earthquake. Situation Report no. 7. Geneva: WHO;
available at http://www.who.or.id/eng/php/content/jogja-
centraljava/Sitrep%20Indonesia%20Jogja-Central%20Java%
2004-06-06%20(7).pdf
4. IFE Core Group (2007) Infant and Young Child Feeding in
Emergencies. Operational Guidance for Emergency Relief
Staff and Programme Managers. Oxford: IFE Core Group c/o
Emergency Nutrition Network; available at http://www.
ennonline.net/pool/files/ife/ops-guidance-2-1-english-010307-
with-addendum.pdf
5. Herman A, Kusumastuti E, Bayu et al. (2006) Muba Kirim
Langsung: Bantuan ke Bantul. http://www.suarakarya-
online.com/news.html?id5145232 (accessed September 2010).
6. UNICEF (2009) Tracking Progress on Child and Maternal
Nutrition. New York: UNICEF.
7. World Health Organization, UNICEF & Wellstart International
(2009) Baby-friendly Hospital Initiative: Revised, Updated
and Expanded for Integrated Care. Section 3: Breastfeeding
Promotion and Support in a Baby-friendly Hospital. A
20-Hour Course for Maternity Staff.Geneva:WHO.
8. Statistics Indonesia (Badan Pusat Statistik – BPS) &
Macro International (2008) Indonesia Demographic and
Health Survey 2007. Calverton, MD: BPS and Macro
International.
9. Jones G, Steketee RW, Black RE et al. (2003) How many
child deaths can we prevent this year? Lancet 362, 65–71.
10. Kovar MG, Serdula MK, Marks JS et al. (1984) Review of the
epidemiologic evidence for an association between infant
feeding and infant health. Pediatrics 74, Pt 2, 615–638.
11. Jason JM, Nieburg P & Marks JS (1984) Mortality and
infectious disease associated with infant-feeding practices
in developing countries. Pediatrics 74, Pt 2, 702–727.
12. Victora CG, Smith PG, Vaughan JP et al. (1987) Evidence
for protection by breast-feeding against infant deaths from
infectious diseases in Brazil. Lancet 2, 319–322.
13. Rubin DH, Leventhal JM, Krasilnikoff PA et al. (1990)
Relationship between infant feeding and infectious illness:
a prospective study of infants during the first year of life.
Pediatrics 85, 464–471.
14. Howie PW, Forsyth JS, Ogston SA et al. (1990) Protective
effect of breast feeding against infection. BMJ 300, 11–16.
15. Beaudry M, Dufour R & Marcoux S (1995) Relation
between infant feeding and infections during the first six
months of life. J Pediatr 126, 191–197.
16. Toole MJ & Waldman RJ (1997) The public health aspects of
complex emergencies and refugee situations. Annu Rev
Public Health 18, 283–312.
17. Anonymous (2006) Diarrhoea Risk Associated with Not
Breastfeeding in Botswana. Report no. 29. Oxford:
Emergency Nutrition Network; available at http://fex.
ennonline.net/29/diarrhoearisk.aspx
18. Gribble K (2005) Infant feeding in the post Indian Ocean
tsunami context: reports, theory and action. Birth Issues 14,
121–127.
19. World Health Organization (1991) Indicators for Assessing
Breastfeeding Practices. Geneva: WHO.
20. Nutrition and Health Surveillance System Indonesia (2004)
Indonesia Crisis Bulletin: Nutrition and Health Surveillance
in Rural Central Java – Key Results for the Period: December
1999–September 2003. Jakarta Pusat: Helen Keller Interna-
tional, Indonesia Country Office; available at http://www.
hki.org/research/Ind%20Cris%20Bul%20y5%20iss%2010.pdf
21. Anonymous (2006) Aid for Java earthquake underway:
relief organizations and Swiss solidarity provide CHF 1
million. https://www.swiss-solidarity.org/Java.290.0.html?
&L53&tx_ttnews%5Btt_news%5D52269&tx_ttnews%5Bback
Pid%5D5288&cHash554600260a5 (accessed September 2010).
22. Wiebe G (2006) Yogyakarta earthquake response update.
http://ocha-gwapps1.unog.ch/rw/rwb.nsf/db900SID/SODA-
6SF8V7?OpenDocument (accessed September 2010).
23. Coolen E (2006) Yogyakarta earthquake. Jesuit Refugee
Service Indonesia. http://www.jrs.or.id/index.php?option5
com_content&task5view&id546&Itemid5117 (accessed
September 2010).
24. Aarts C, Kylberg E, Hornell A et al. (2000) How exclusive is
exclusive breastfeeding? A comparison of data since birth
with current status data. Int J Epidemiol 29, 1041–1046.
25. UNICEF (2008) The State of the World’s Children 2008.
New York: UNICEF.
26. Assefa F, Jabarkhil MZ, Salama P et al. (2001) Malnutrition
and mortality in Kohistan district, Afghanistan, April 2001.
JAMA 286, 2723–2728.
27. Salama P, Assefa F, Talley L et al. (2001) Malnutrition,
measles, mortality, and the humanitarian response during a
famine in Ethiopia. JAMA 286, 563–571.
28. Creek T, Arvelo W, Kim L et al. (2007) Role of infant feeding
and HIV in a severe outbreak of diarrhea and malnutrition
among young children, Botswana, 2006. Presented at CROI
2007, 14th Conference of Retroviruses and Opportunistic
Infections, Los Angeles, CA, 25–28 February 2007 [abstract 770].
SPublic Health Nutrition
8 DB Hipgrave et al.

29. Leon-Cava N, Lutta C, Ross J et al. (2002) Quantifying the
Benefits of Breastfeeding: A Summary of the Evidence.
Washington, DC: PAHO.
30. Paricio Talayero JM, Lizan-Garcia M, Otero PA et al. (2006)
Full breastfeeding and hospitalization as a result of
infections in the first year of life. Pediatrics 118, e92–e99.
31. Dewey KG, Heinig MJ & Nommsen-Rivers LA (1995)
Differences in morbidity between breast-fed and formula-
fed infants. J Pediatr 126, Pt 1, 696–702.
32. Horta B, Bahl R, Martines J et al. (2007) Evidence on the
Long-term Effects of Breastfeeding: Systematic Reviews and
Meta-analyses. Geneva: WHO.
33. World Health Organization (2005) Guiding Principles for Feed-
ing Non-breastfed Children Aged 6–24 months. Geneva: WHO.
34. World Health Organization (1981) The International Code of
Marketing of Breast-milk Substitutes.Geneva:WHO.
35. Anonymous (2005) Bright Beginnings(TM), the infant
formula endorsed by Brooke Shields, donates infant
formula and pediatric nutritional drinks to victims of the
Indian Ocean tsunami. http://www2.prnewswire.com/cgi-
bin/stories.pl?ACCT5105&STORY5/www/story/01-25-2005/
0002902203 (accessed September 2010).
36. Arts M (2006) Infant feeding in the South Asia earthquake
aftermath. http://fex.ennonline.net/pdf/27.pdf (accessed
September 2010).
37. Maclaine A (2008) Infant and young child feeding in
emergencies in selected unions affected by Cyclone Sidr.
http://fex.ennonline.net/29/infantfeeding.aspx (accessed
September 2010).
38. Anonymous (2007) Philippines: Nestle
´donates nutritional
formula to Red Cross for victims of recent typhoons.
http://ocha-gwapps1.unog.ch/rw/rwb.nsf/db900SID/JBRN-
6Y2F7E?OpenDocument (accessed September 2010).
39. Pang Li (2008) Donations: milk powder and diapers
greatly needed in quake-hit areas (China). http://www.
ennonline.net/resources/view.aspx?resid5635 (accessed
September 2010).
40. Anonymous (2008) Hongkong earthquake aid tied up in
red tape. http://www.earthtimes.org/articles/show/220791,
hong-kong-earthquake-aid-tied-up-in-red-tape.html (accessed
May 2010).
41. Assefa F, Sukotjo S, Winoto A et al. (2008) Increased
Diarrhoea Following Infant Formula Distribution in 2006
Earthquake Response in Indonesia: Evidence and Actions.
Report no. 34. Oxford, UK: Emergency Nutrition Network;
available at http://fex.ennonline.net/34/special.aspx
42. Departemen Sosial RI (2009) Laporan Penanggulangan
Bencana Gempa Bumi di Provinsi Sumatera Barat.
Indonesia: Departemen Sosial Republik Indonesia.
SPublic Health Nutrition
BMS and diarrhoea among infants and young children in emergencies 9