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Subject:
From:
Karleen Gribble <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Mon, 9 Feb 2009 21:45:42 +1100
Content-Type:
text/plain
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The other day I was reading reports from one of the organisations that
accepts donations of formula in Haiti. It was quite horrifying. Formula was
being used because mothers were malnourished or sick instead of treating the
mother and enabling her to breastfed. They also described how they would run
out of formula and then have to make choices abotu which formula dependent
babies would receive formula and which would not. There did not appear to be
any realisation that they had unnecesarily created the dependency.
There are very good reasons why aid orgs are supposed to buy any infant
formula they need. They need to budget for providing all of the needs of all
of the infants they are supporting for the first 6 months at least.
Purchasing also ensures that they end up with what they need (not out of
date, of the wrong type or labelling in  the wrong language) AND that they
are very careful about dispensing it. I'll paste in below some more info on
the sort of support carers of artificially fed infants require from
organisations providing formula....If you acquaintance is serious about
helping artificially fed babies and insistent on providing donations she
should also raise the considerable funds necessary to achieve what is
required to aupport artificial feeding.
Karleen Gribble
Australia


1) A constant supply of breastmilk substitute
The carers of infants in need of artificial feeding support must be provided
with an assured, continuous and sufficient supply breastmilk substitutes
(meeting Codex Alimentarius standards) for as long as the infants require
them. That is, until breastmilk is available to the infant or the infant is
at least six months of age. After six months, some other sort of milk and or
animal food is required for non-breastfed children during the complementary
feeding period (6-24 months) (Operational Guidance 6.4.3). Continuity of
supply is vital because otherwise carers may use milk products which are
unsuitable for infants, give sugar water and/or fruit juice between feeds,
give fewer feeds per day or over-dilute breastmilk substitutes, to the
detriment of the infant [1], [2]. For an infant to be artificially fed
between birth and six months of age requires, approximately 20 kg of
powdered breastmilk substitute[3]. Breastmilk substitutes should be labelled
in the local language and preferably be unbranded (Operational Guidance
6.3.2). Distribution of breastmilk substitutes and supporting resources
should be carried out to caregivers of targeted infants regularly (every
week- two weeks).

2) Clean water and fuel to boil that water
Water is needed for hand washing, for cleaning feeding implements and for
reconstituting breastmilk substitutes. At least three litres of safe water a
day must be provided for artificially fed infants in addition to any family
water supplies. All water used in the preparation of breastmilk substitutes
and the cleaning of feeding implements must be boiled (bottled water is not
sterile[4]). It should be ensured that the carers of artificially fed
infants have the resources to boil water and if they do not they should be
provided. Such resources may be substantial, for example, a year’s worth of
fuel amounts to 73kg of wood to boil the water using a wood fire[5].

3) Containers and implements for storing water, preparing and feeding
breastmilk substitutes
Carers of infants needing breastmilk substitutes require sealable containers
for storing water, pots in which water may be boiled, containers in which
breastmilk substitutes may be reconstituted, measuring instruments and
feeding cups (not bottles). If carers do not have these resources they need
to be provided by the implementing agency.

4) A clean environment for preparing feeds and soap for cleaning
Soap is necessary for hand washing and to assist in cleaning preparation and
feeding containers. A clean feed preparation area is also necessary as is a
clean storage area for powdered breastmilk substitutes. A plastic box may
used to provide these environments, the lid acting as a preparation area
while clean equipment and breastmilk substitute is stored inside. Drying
cloths should not be provided because they are a breeding ground for
bacteria, however equipment may air dry, disposable paper napkins used or
equipment could be left in the water after boiling.

5) Education
Carers require education on how to safely prepare and dispense artificial
feeds. The aim of such education is to reduce the risk that artificial feeds
expose infants to pathogens. Such education needs to start with
a) how to store water, because it has been found that drinking water is
often stored improperly at household level, resulting in contamination with
E. Coli [6].
b) how to most safely reconstitute breastmilk substitutes, which is a
complicated process, not only because powder and water must be accurately
measured but because powdered breastmilk substitutes themselves can be
contaminated with pathogens (i.e. infant formula is NOT sterile when in
unopened sealed containers). Thus, in order to kill bacteria, powdered
breastmilk substitutes should be prepared with water no cooler than 70°C[7].
This requires bringing water to a rolling boil for at least two minute,
allowing it to cool to no less than 70°C (max 30 minutes after boiling)
before adding it to the breastmilk substitute. Immediately after preparation
the reconstituted breastmilk substitute should be quickly cooled to feeding
temperature by holding container under running tap, or placing in container
of cold water in order to minimise the risk of bacterial proliferation.
c) how to accurately measure the breastmilk substitute and water in
reconstitution and the dangers of over-diluting or over-concentrating
breastmilk substitutes is also needed.
d) how to clean preparation and feeding implements, including the need to
disinfect via boiling.
e) how to feed the baby via the use of a cup and the need to discard unused
milk after feeds (since milk is an excellent medium for bacterial growth).

Education should not be just in the form of providing verbal or written
instructions but also one-on-one demonstrations and practical training
(Operational Guidance 6 2.3, 6.2.4).  The difficulty of providing education
may be increased in environments where artificial feeding is uncommon and
where carers are unable to read instructions.

6) Support
The logistics of a caregiver making up fresh breastmilk substitutes using
hot water every 3-4 hours and especially during the night are massive.
Research supports the proposition that carers find following the recommended
practices difficult [8],[9]. The challenges in the preparation and storage
of artificial feeds, despite counseling and support, are illustrated in the
following research from rural Uganda where mothers failed to follow the
minimum guidelines for artificial feeding.

Case study: In research from rural Uganda among HIV infected mothers (2008),
excess mortality was found amongst infants of HIV positive mothers, who were
artificially fed. One of the actions taken was additional support, targeted
at mothers whose babies were established on artificial feeding. A household
hygiene survey was conducted of these mothers (n=29) that found:
-all mothers reported using soap and water to wash hands and utensils.
However 59% (n=17) reported reusing feeding utensils without washing
-despite a ban on using bottles to feed, 86.7% (n=25) of mothers were using
them
-17.2% (n=5) mothers stored left over feed
-31.1% (n=9) reported difficulties maintaining clean utensils
-65.5% (n=19) reported difficulty measuring formula
-31.1% (n=9) reported difficulty in keeping utensils clean for night feeds
-59% (n=17) delegated feeding to caretakers, 47.1% (n=7) to older children
and the remaining to the father or a relative
-79.3% (n=23) had a toilet but only 47.8% (n=11) had handwashing facilities
at the toilet


During emergencies the increased dangers of artificial feeding together with
the additional pressures on a caregiver mean that it is vitally important to
the safety of the infant that caregivers strictly follow the recommended
practice. Carers therefore need continued support from the implementation
agency to enable them to make artificial feeding as safe as possible. In
circumstances where it is impossible to support carers (both in terms of
physical and educational resources) to the extent that the risks of
artificial feeding are reduced to an acceptable level to enable, on-site
reconstitution and consumption of breastmilk substitutes (may be referred to
as “wet” feeding) may be considered (Operational Guidance 6.2.5). Care
should be taken that there is no stigma attached to the need to use
breastmilk substitutes.

7. Monitoring and health care
Artificially fed infants, especially in emergencies, are highly susceptible
to illness and supporting artificial feeding must include regular monitoring
of the growth and health of infants and access to health care. Their weight
and health should be monitored each time breastmilk substitutes are provided
to their carers (no less than twice a month) and they should receive any
necessary medical support.

8. Ensure that carers are not given products that could be mistaken for a
breastmilk substitute
Sometimes other milk products such as whole milk powder, skim milk powder or
condensed milk are distributed in emergency situations. Carers can easily
mistake these products for a breastmilk substitute and feed them to their
infants to the detriment of their health. All care should be taken to ensure
that other milk products are not a part of general distributions.


--------------------------------------------------------------------------------

----- Original Message ----- 
From: "Jamelle Lyons" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, February 09, 2009 11:18 AM
Subject: Formula Donations to Haiti


I need help, and I need to vent. A very nice woman on the 'Social Justice'
commitee at church is co-ordinating a food and clothing drive to send items
Haiti.
Among the items that she requested donations for are the following: powdered
milk, non-fat powdered milk, Similac with Iron.

I 

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