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

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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.
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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.
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SPublic Health Nutrition
BMS and diarrhoea among infants and young children in emergencies 9
... For the first six months after giving birth, infants should be exclusively breastfed and should continue to be breastfed up until the age of one or beyond (Centers for Disease Control and Prevention, 2019). Breastfeeding decreases the risk of infants contracting infections by strengthening their immune systems (Gribble et al., 2011;Hipgrave et al., 2012;DeYoung et al., 2018a;Gribble, 2018). Formula and breast milk substitutes increase a child's risk of illness and infections, especially in a disaster setting where clean water and supplies needed to sterilize bottles may not be easily accessible (Gribble et al., 2011;Hipgrave et al., 2012;DeYoung et al., 2018a;Gribble, 2018). ...
... Breastfeeding decreases the risk of infants contracting infections by strengthening their immune systems (Gribble et al., 2011;Hipgrave et al., 2012;DeYoung et al., 2018a;Gribble, 2018). Formula and breast milk substitutes increase a child's risk of illness and infections, especially in a disaster setting where clean water and supplies needed to sterilize bottles may not be easily accessible (Gribble et al., 2011;Hipgrave et al., 2012;DeYoung et al., 2018a;Gribble, 2018). Infant formula itself may contain bacteria or be expired (Barron and Forsythe, 2007;DeYoung et al., 2018a;Cho et al., 2019), which can lead to serious diarrheal illness that can result in an increase in infant mortality (Gribble et al., 2011;Gribble, 2018). ...
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Full-text available
The global impact of COVID-19 and SARS-CoV-2 on Maternity Care Practices and Childbearing, including newborn and maternal health outcomes.
... However, providing effective infant and young child feeding in emergencies (IYCF-E) interventions can be challenging and the aid provided can do more harm than good. In particular, inappropriate distributions of infant formula reduce breastfeeding, increasing rates of infectious disease and endangering breastfed infants (Borrel et al., 2001;Hipgrave et al., 2012;MirMohamadaliIe et al., 2019). Non-breastfed infants are also endangered by inappropriate distributions of infant formula as these distributions are characterised by discontinuity of supply and absence of necessary support (Gribble & Fernandes, 2018). ...
... ). Seeking to address this concern the WHA recently called on the Director General of the World Health Organisation (WHO) to make available, 'technical support to Member States in mobilizing resources, including financial resources, and monitoring and implementation of WHO recommendations to support infant and young child feeding, including in emergencies' and 'to develop tools for training, monitoring, advocacy and preparedness for the implementation of the operational guidance on infant and young child feeding in emergencies and support Member States to review experiences in its adaptation, implementation and monitoring' (Seventy-First World Health Assembly, 2018). This investment and support are clearly needed.Training programmes for humanitarians should include content on how breastfeeding protects infants and mothers in emergencies; the robustness of breastfeeding when mothers are stressed, traumatised or malnourished; and how breastfeeding counselling assists women to continue or resume exclusive breastfeedingGribble et al., 2011Gribble et al., , 2020Gribble & Fernandes, 2018).Training programmes should also include content on how formula feeding increases susceptibility to infection, food insecurity, malnutrition and maltreatment in emergencies; and how donations and inappropriate distributions of infant formula decrease exclusive breastfeeding(Gribble et al., 2020;Hipgrave et al., 2012). Humanitarians need to be trained to consider the long-term consequences of immediate decisions regarding infant formula provision.This research confirms that advocacy regarding how to support breastfed and non-breastfed infants in emergencies, including in the media, is needed. ...
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The Infant and Young Child Feeding in Emergencies Operational Guidance (OG‐IFE) gives direction on providing aid to meet infants' and young children's feeding needs in emergencies. Because of the risks associated with formula feeding, the OG‐IFE provides limited circumstances when infant formula should be provided in aid. However, distributions against this guidance are common, reducing breastfeeding so risking increased infant morbidity and mortality. This study sought to identify factors that contributed to following (‘good practice’) or not following (‘poor practice’) the OG‐IFE regarding infant formula distribution in the 2014–16 refugee crisis in Europe. Thirty‐three individuals who supported, coordinated, or implemented infant feeding support in the Crisis were interviewed regarding their experiences and views. Reflexive thematic analysis of transcribed interviews was undertaken. It was identified that presence of breastfeeding support, presence of properly implemented formula feeding programmes, understanding that maternal choice to formula feed should be considered within the risk context of the emergency, and positive personal experiences of breastfeeding contributed to good practice. Presence of infant formula donations, absence of properly managed formula feeding programmes, belief that maternal choice to formula feed is paramount and should be facilitated, and personal experience of insurmountable breastfeeding challenges and/or formula feeding contributed to poor practice. Governments, humanitarian organisations, and donors should ensure that infant and young child feeding in emergencies preparedness and programmes are adequately resourced. Emergency responders should be appropriately trained with training including infant feeding experience debriefing. Health and emergency organisations should provide maternity protections enabling employees to breastfeed as recommended.
... Resolution WHA63.23 (2010) calls on governments to adhere to the Operational Guidance on Infant and Young Child Feeding in Emergencies [28,73], which stipulates that donations of BMS, complementary foods and feeding equipment should not be sought or accepted, and supplies should be procured through official channels. However, as a way to widen existing markets and facilitate public relations, companies have long capitalized on public health emergencies caused by natural hazards, internal conflicts, epidemics, and wars to give donations [25,[74][75][76][77][78]. The harmful impact of BMS donations in emergency contexts has been well-documented [74][75][76][77][78]. ...
... However, as a way to widen existing markets and facilitate public relations, companies have long capitalized on public health emergencies caused by natural hazards, internal conflicts, epidemics, and wars to give donations [25,[74][75][76][77][78]. The harmful impact of BMS donations in emergency contexts has been well-documented [74][75][76][77][78]. The unsolicited BMS, and the indiscriminate distribution of them, can easily spillover to breastfeeding mothers, potentially resulting in mixed-feeding or cessation of breastfeeding. ...
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Breastfeeding is critical to maternal and child health and survival, and the benefits persist until later in life. Inappropriate marketing of breastmilk substitutes (BMS), feeding bottles, and teats threatens the enabling environment of breastfeeding, and exacerbates child mortality, morbidity, and malnutrition, especially in the context of COVID-19. These tactics also violate the International Code of Marketing of Breast-Milk Substitutes. This study identified marketing tactics of BMS companies since the start of the COVID-19 pandemic by reviewing promotional materials and activities from 9 companies in 14 countries, and the official Code reporting data from the Philippines. Eight qualitative themes emerged that indicate companies are capitalizing on fear related to COVID-19 by using health claims and misinformation about breastfeeding. Other promotional tactics such as donations and services were used to harness the public sentiment of hope and solidarity. Past studies show that these tactics are not new, but the pandemic has provided a new entry point, helped along by the unprecedented boom in digital marketing. There was a sharp increase of reported violations in the Philippines since the pandemic: 291 during the first months of the outbreak compared with 70 in all of 2019, corroborating the thematic findings. A lack of public awareness about the harm of donations and inadequate Code implementation and enforcement have exacerbated these problems. Proposed immediate action includes using monitoring findings to inform World Health Assembly (WHA) actions, targeted enforcement, and addressing misinformation about breastfeeding in the context of COVID-19. Longer-term action includes holding social media platforms accountable, raising public awareness on the Code, and mobilizing community monitoring.
... This finding is consistent with findings from studies in other regions during the same period, which show that BMS companies are capitalizing on fear of breastfeeding during the pandemic to market their products [59]. Such strategies to promote and distribute BMS during emergencies such as earthquakes [60,61] and tsunamis [62] have been documented internationally [63]. Together, this evidence highlights that governments and international organizations need to step in to regulate BMS donations and guard mothers and infants against unnecessary promotion and distribution of BMS, which often reaches the most vulnerable populations. ...
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Background Because breastfeeding offers short- and long- term health benefits to mothers and children, breastfeeding promotion and support is a public health priority. Evidence shows that SARS-CoV-2 is not likely to be transmitted via breastmilk. Moreover, antibodies against SARS-CoV-2 are thought to be contained in breastmilk of mothers with history of COVID-19 infection or vaccination. WHO recommends direct breastfeeding as the preferred infant feeding option during the COVID-19 pandemic, even among women with COVID-19; but conflicting practices have been adopted, which could widen existing inequities in breastfeeding. This study aims to describe how information about breastfeeding was communicated in Mexican media during the pandemic and assess Mexican adults’ beliefs regarding breastfeeding among mothers infected with COVID-19. Methods We conducted a retrospective content analysis of media coverage on breastfeeding in Mexico between March 1 and September 24, 2020, excluding advertisements. For the content analysis, we performed both a sentiment analysis and an analysis based on strengths, weaknesses, opportunities, and threats (SWOT) for breastfeeding promotion. Additionally, we conducted a descriptive analysis of nationally representative data on adults’ beliefs about breastfeeding from the July 2020 round of the ENCOVID-19 survey in Mexico and stratified the results by gender, age, and socioeconomic status. Results A total of 1014 publications on breastfeeding were identified on the internet and television and in newspapers and magazines. Most information was published during World Breastfeeding Week, celebrated in August. The sentiment analysis showed that 57.2% of all information was classified as positive. The SWOT analysis indicated that most information focused on current actions, messages, policies, or programs that enable breastfeeding (i.e., strengths) or those not currently in place but that may enable breastfeeding (i.e., opportunities) for breastfeeding promotion. However, ENCOVID-19 survey results showed that 67.3% of adults living in households with children under 3 years of age believe that mothers with COVID-19 should not breastfeed, and 19.8% do not know whether these mothers should breastfeed. These beliefs showed differences both by gender and by socioeconomic status. Conclusions While the Mexican government endorsed the recommendation on breastfeeding during the COVID-19 pandemic, communication was sporadic, inconstant and unequal across types of media. There was a widespread notion that mothers with COVID-19 should not breastfeed and due to differences on beliefs by socioeconomic status, health inequities could be exacerbated by increasing the risk of poorer breastfeeding practices and preventing vulnerable groups from reaping the short and long-term benefits of breastfeeding.
... One of the most potent barriers is the aggressive and inappropriate marketing of breastmilk substitutes (BMS) [8]. This marketing includes promotion to the general public, health workers and mothers directly and via media [9][10][11][12][13][14], donations of free and low-cost supplies of BMS and equipment to health services [8] and in emergency situations [15,16], gifts to health workers and to mothers [17][18][19][20], and unsubstantiated health claims [21][22][23][24], among other activities. The highly profitable marketing utilises highly effective strategies to influence the "first food system" to undermine breastfeeding, unduly influence the policy frameworks that protect breastfeeding from commercial influence, and ultimately influence the attitudes and practices of parents, caregivers, healthcare workers, even policymakers [25]. ...
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This is the protocol for a scoping review that aims to systematically explore and summarise the published evidence of violations of the International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent World Health Assembly Resolutions globally. The planned scoping review will seek to identify what research has been conducted on the topic, examine the geographic spread and nature of violations, and summarise knowledge gaps. The Code was adopted in 1981 by the World Health Assembly to protect infant health, in particular from aggressive and inappropriate marketing of breastmilk substitutes including formula and related products. Non-compliance with the Code or violations are described in reports, however, no existing systematic review of the global research appears to have been conducted that encompasses the varied disciplines including health, economics, and gender. The review will inform international and national decision-makers on the nature of violations and potentially highlight the need for new modalities to regulate this marketing. The proposed scoping review will use the six-step process of Arksey and O’Malley which includes defining the research question; identifying the relevant literature; selecting studies; charting the data; collating, summarising and reporting the findings; and will include a consultative group.
... diarrhea were 30 times more likely not to have been breastfed compared with infants without diarrhea [4]. After the 2006 earthquake in Indonesia, the use of donated infant formula doubled the rates of diarrhea in young children compared with those who had not received donated infant formula [5]. In the aftermath of the 2005 Hurricane Katrina that flooded the city of New Orleans in the United States, several infants died of dehydration when food and water supplies ran out due to a fractured coordination of disaster response [6]. ...
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... Furthermore, the global impact of breastfeeding on maternal health is significant, with a reduction in the risk of breast cancer and potential to prevent 20,000 deaths [1]. In environments where access to safe water is limited and food insecurity is a significant issue for families, exclusive breastfeeding for new-borns and infants is a lifesaving public health intervention [14][15][16][17][18][19][20][21]. It is important to ensure that additional studies are conducted in similar contexts, to ensure that findings are reflected in practical measures to protect the lives of the youngest and most vulnerable in humanitarian settings, whilst providing the needed support for pregnant women and mothers. ...
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Around the world, one in four children live in a country affected by conflict, political insecurity and disaster. Healthcare in humanitarian and fragile settings is challenging and complex to provide, particularly for children. Furthermore, there is a distinct lack of medical literature from humanitarian settings to guide best practice in such specific and resource-limited contexts. In light of these challenges, Médecins Sans Frontières (MSF), an international medical humanitarian organisation, created the MSF Paediatric Days with the aim of uniting field staff, policymakers and academia to exchange ideas, align efforts, inspire and share frontline research and experiences to advance humanitarian paediatric and neonatal care. This 2-day event takes place regularly since 2016. The fourth edition of the MSF Paediatric Days in April 2021 covered five main topics: essential newborn care, community-based models of care, paediatric tuberculosis, antimicrobial resistance in neonatal and paediatric care and the collateral damage of COVID-19 on child health. In addition, eight virtual stands from internal MSF initiatives and external MSF collaborating partners were available, and 49 poster communications and five inspiring short talks referred to as ‘PAEDTalks’ were presented. In conclusion, the MSF Paediatric Days serves as a unique forum to advance knowledge on humanitarian paediatrics and creates opportunities for individual and collective learning, as well as networking spaces for interaction and exchange of ideas.
Preprint
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Background: Breastfeeding offers short- and long- term health benefits to mothers and children and constitutes a priority for public health. Evidence shows that SARS-CoV-2 is not likely to be transmitted via breastmilk. Moreover, antibodies against SARS-CoV-2 are presumably contained in breastmilk of mothers with history of COVID-19 infection or vaccination. Direct breastfeeding is the preferred infant feeding option during the pandemic, but conflicting practices have been adopted, which could widen existing disparities in breastfeeding. This study aims to describe how was information about breastfeeding communicated in Mexican media during the pandemic and assess Mexican adults’ beliefs regarding breastfeeding among mothers infected with COVID-19. Methods: A retrospective content analysis of media coverage on breastfeeding in Mexico between March 1 and September 24, 2020, excluding advertisements, was done. For the content analysis, both a sentiment analysis and an analysis based on strengths, weaknesses, opportunities and threats for breastfeeding promotion were performed. Also, we incorporated a descriptive analysis from the July 2020 wave of the ENCOVID-19 survey, which included questions on beliefs about breastfeeding. This information was stratified by gender, age, and socioeconomic status. Results: 1014 publications on breastfeeding were identified in internet, newspapers, TV, and magazines. Most information was published during World Breastfeeding Week, celebrated in August. Based on the sentiment analysis, 57.2% of all information was classified as positive, and based on the SWOT analysis, most information was classified either as strengths or opportunities for breastfeeding promotion. However, the ENCOVID-19 data showed that 67.3% of people living in households with children under 3 years of age believe that mothers with COVID-19 should not breastfeed, and 19.8% stated that they simply didn’t know. These beliefs showed differences both by gender and by socioeconomic status. Conclusions: While the Mexican government endorsed the recommendations on breastfeeding during the COVID-19 pandemic, communication of those messages was sporadic, inconstant and unequal across types of media. Moreover, there were also negative messages for breastfeeding circulating on the media. There continues to be a widespread notion that mothers with COVID-19 should not breastfeed and, due to differences on beliefs by socioeconomic status, health inequities could be exacerbated.
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In a population-based case-control study of infant mortality in two urban areas of southern Brazil, the type of milk in an infant's diet was found to be an important risk factor for deaths from diarrhoeal and respiratory infections. Compared with infants who were breast-fed with no milk supplements, and after adjusting for confounding variables, those completely weaned had 14.2 and 3.6 times the risk of death from diarrhoea and respiratory infections, respectively. Part-weaning was associated with corresponding relative risks (RR) of 4.2 and 1.6. The risk of death from infections other than diarrhoea or respiratory infection was less clearly associated with breast-feeding (completely weaned, RR = 2.5; partly weaned, RR = 0.4). Cow's and formula milk seemed to be equally hazardous. For deaths due to diarrhoea the increased risk associated with not breast-feeding was greatest in the first two months of life (RR for completely weaned vs breast-fed without supplementary milk = 23.3). PIP In a population-based case-control study of infant mortality in 2 urban areas of southern Brazil, the type of milk in an infant's diet was found to be an important risk factor for deaths from diarrheal and respiratory infections. Compared with infants who were breastfed with no milk supplements, and after adjusting for confounding variables, those completely weaned had 14.2 and 3.6 times the risk of death from diarrhea and respiratory infections, respectively. Part-weaning was associated with corresponding relative risks (RR) of 4.2 and 1.6. The risk of death from infections other than diarrhea or respiratory infection was less clearly associated with breastfeeding (completely weaned, RR=2.5; partly weaned, RR=0.4). Cow's and formula milk seemed to be equally hazardous. For deaths due to diarrhea the increased risk associated with not breastfeeding was greatest in the 1st 2 months of life (RR for completely weaned vs. breastfed without supplementary milk =23.3). (author's modified).
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Context The World Food Programme estimated that 10 million people were at risk of starvation in Ethiopia in 2000 but later reported that a famine had been averted. However, no population-based data on mortality or nutrition existed for Gode district, at the epicenter of the famine in the Somali region of Ethiopia. Objectives To estimate mortality rates, determine the major causes of death, and estimate the prevalence of malnutrition among children and adults for the population of Gode district. Design and Setting Two-stage cluster survey conducted from July 27 through August 1, 2000, which included anthropometric measures and 8-month retrospective mortality data collection. Participants A total of 595 households comprising 4032 people living in Gode district of Ethiopia. Main Outcome Measures Crude mortality rates and mortality rates for children younger than 5 years, causes of death, weight for height of less than −2 z scores among children aged 6 months to 5 years, and body mass index of less than 18.5 kg/m2 among adults and older persons. Results Of the 595 households, 346 (58.2%) were displaced from their usual places of residence. From December 1999 through July 2000, a total of 293 deaths occurred in the sample population; 159 (54.3%) deaths were among children younger than 5 years and 72 (24.6%) were among children aged 5 to 14 years. The crude mortality rate was 3.2/10 000 per day (95% confidence interval [CI], 2.4-3.8/10 000 per day), which is 3 times the cutoff used to define an emergency. The mortality rate for children younger than 5 years was 6.8/10 000 per day (95% CI, 5.4-8.2/10 000 per day). Approximately 77% of deaths occurred before major relief interventions began in April/May 2000. Wasting contributed to 72.3% of all deaths among children younger than 5 years. Measles alone or in combination with wasting accounted for 35 (22.0%) of 159 deaths among children younger than 5 years and for 12 (16.7%) of 72 deaths among children aged 5 to 14 years. The prevalence rate for wasting (weight for height of <−2 z score) among children aged 6 months to 5 years was 29.1% (95% CI, 24.7%-33.4%). Using a method to adjust body mass index for body shape, the prevalence of undernutrition (body mass index <18.5 kg/m2) among adults aged 18 to 59 years was 22.7% (95% CI, 17.9%-27.5%). Conclusions To prevent unnecessary deaths, the humanitarian response to famine needs to be rapid, well coordinated, and based on sound epidemiological evidence. Public health interventions, such as mass measles vaccination campaigns with coverage extended to children aged 12 to 15 years should be implemented as the first priority. The prevalence of wasting and undernutrition among children and adults, respectively, should be assessed in all prolonged, severe famines.
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To assess the relations between breast feeding and infant illness in the first two years of life with particular reference to gastrointestinal disease. Prospective observational study of mothers and babies followed up for 24 months after birth. Community setting in Dundee. 750 pairs of mothers and infants, 76 of whom were excluded because the babies were preterm (less than 38 weeks), low birth weight (less than 2500 g), or treated in special care for more than 48 hours. Of the remaining cohort of 674, 618 were followed up for two years. Detailed observations of infant feeding and illness were made at two weeks, and one, two, three, four, five, six, nine, 12, 15, 18, 21, and 24 months by health visitors. The prevalence of gastrointestinal disease in infants during follow up. After confounding variables were corrected for babies who were breast fed for 13 weeks or more (227) had significantly less gastrointestinal illness than those who were bottle fed from birth (267) at ages 0-13 weeks (p less than 0.01; 95% confidence interval for reduction in incidence 6.6% to 16.8%), 14-26 weeks (p less than 0.01), 27-39 weeks (p less than 0.05), and 40-52 weeks (p less than 0.05). This reduction in illness was found whether or not supplements were introduced before 13 weeks, was maintained beyond the period of breast feeding itself, and was accompanied by a reduction in the rate of hospital admission. By contrast, babies who were breast fed for less than 13 weeks (180) had rates of gastrointestinal illness similar to those observed in bottle fed babies. Smaller reductions in the rates of respiratory illness were observed at ages 0-13 and 40-52 weeks (p less than 0.05) in babies who were breast fed for more than 13 weeks. There was no consistent protective effect of breast feeding against ear, eye, mouth, or skin infections, infantile colic, eczema, or nappy rash. Breast feeding during the first 13 weeks of life confers protection against gastrointestinal illness that persists beyond the period of breast feeding itself.
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Prior studies investigating the relationship between infant feeding and infectious illnesses in developed countries have provided conflicting data about whether breast-feeding protects against common infectious illnesses early in life. These conflicts may in part be due to the failure to consider the following methodologic issues: (1) collecting data prospectively at frequent intervals for active surveillance of the detection of infections and of feeding practices, (2) specifying what is meant by infectious illnesses and breast-feeding, (3) controlling for confounding variables such as social class or presence of siblings in the household, and (4) applying appropriate analytical strategies to a population in which both feeding and exposure to illness change over time. A total of 500 infants born consecutively in a university-affiliated community hospital in Copenhagen, Denmark, were studied prospectively for the first 12 months of life by means of a detailed, monthly, mailed questionnaire that focused on feeding practices and illnesses (overall response rate, 73%). The percentage of infants who were completely or mostly breast-fed decreased from 88% at 1 month to 20% at 12 months of age. After adjustment for major covariates, no statistically significant relationship was found between the type of infant feeding and the incidence of four categories of infectious illnesses: gastroenteritis, upper respiratory illness, otitis media, and lower respiratory illness. The adjusted incidence density ratio for gastroenteritis was 1.067 (95% confidence interval = 0.982, 1.226) and for upper respiratory illnesses 0.984 (95% confidence interval = 0.883, 1.096).(ABSTRACT TRUNCATED AT 250 WORDS)
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The approach in this paper is to investigate the health impact of feeding infants breast milk or its substitutes in the United States and other industrialized countries today. This report is limited to an evaluation of epidemiologic and clinical studies of human populations conducted in the United States and other industrialized countries and published since 1970. QUESTIONS ADDRESSED This review addresses five questions on breast-feeding: 1. Is breast-feeding associated with lower post-neonatal mortality than alternative forms of feeding? 2. Is breast-feeding associated with lower infectious disease-specific morbidity than alternative forms of feeding? 3. Is breast-feeding associated with lower rates of allergic disease-specific morbidity than alternative forms of feeding? 4. Is breast-feeding associated with malnutrition as indicated by either unusually rapid growth or faltering growth? 5. Is breast-feeding associated with bonding or with better psychological and intellectual development? QUESTIONS NOT ADDRESSED The decision to focus on specific questions meant that several issues could not be addressed. For example, the relationship between breast-feeding and fertility, the possible impact of breast-feeding on the mother's health, and the possible impact of a mother's health condition or her use of drugs on infant feeding are not discussed, nor are medical characteristics of the infant that might make breast-feeding difficult or inadvisable. Thus, several factors that should be taken into consideration in evaluating whether breast-feeding should be encouraged or discouraged in specific circumstances are not discussed in this section. Biochemical and immunologic laboratory studies and animal studies have also not been reviewed. Such studies are potentially valuable, and the decision to exclude them should in no way be interpreted as failure to recognize their importance.
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This review examines the available studies bearing on the relation between infant-feeding mode and infectious illness in the populations of less-developed countries. A companion critical review of studies of the relationship of infant-feeding methods and infection in industrialized countries has concluded that, although laboratory studies provide biologic plausibility for a lower infection rate in breast-fed infants, an effect, if present, is apparently modest.39 The strongest evidence for a protective effect of breast-feeding in industrialized countries is for gastrointestinal (diarrheal) illness. In this review of studies among populations in developing countries we found the evidence for an important protective effect of breast-feeding against infectious illness to be much stronger. This conclusion was reached despite serious problems in the design of many of the studies reviewed. One characteristic that distinguishes populations in less-developed countries from those of industrialized ones is the infant mortality. Even today, infant mortality for much of the world is up to ten times higher than infant mortality in the United States and Northern Europe.46 This undoubtedly reflects differences in sanitation, nutrition, housing, and other indicators of socioeconomic status. Much of the difference in rates of infant and child mortality and morbidity is attributable to high rates of infectious illness, especially gastrointestinal disease. Thus, in these populations, the positive effects of breast-feeding are of greater potential importance for the health of the infant population and should be easier to detect in clinical and epidemiologic studies. In this review we will address the following key questions: (1) whether the method of infant feeding (breast v other) is associated with differences in rates of mortality, both overall and infectious, and in rates of infectious morbidity in less-developed countries;
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To determine whether breast-feeding is protective against infection in relatively affluent populations, morbidity data were collected by weekly monitoring during the first 2 years of life from matched cohorts of infants who were either breast fed (BF) (N = 46) or formula fed (FF) (N = 41) until at least 12 months of age. Cohorts were matched for characteristics such as birth weight and parental socioeconomic status, and we controlled for use of day care in data analysis. Mean maternal educational level was high (16 years) in both groups. In the first year of life the incidence of diarrheal illness among BF infants was half that of FF infants; the percentage with any otitis media was 19% lower and with prolonged episodes (> 10 days) was 80% lower in BF compared with FF infants. There were no significant differences in rates of respiratory illness; nearly all cases were mild upper respiratory infections. Morbidity rates did not differ significantly between groups in the second year of life, but the mean duration of episodes of otitis media was longer in FF than BF infants (8.8 +/- 5.3 vs 5.9 +/- 3.5 days, respectively; p = 0.01). These results indicate that the reduction in morbidity associated with breast-feeding is of sufficient magnitude to be of public health significance.