At the height of the very recent Typhoon Maring, I posted about how the public can help protect babies during emergencies. The article was a summary of recommendations by agencies such as WHO, UNICEF, and ENN (Emergency Nutrition Network) and our own Philippine Department of Health – agencies who have experience in disaster management and in addressing health and nutrition needs during disasters. The article included links to official guides on Infant and Young Child Feeding in Emergencies (IFE). The guides are not new – the IFE Manual was first produced in 2001 and was updated in 2007. And yet every time there is a call for relief goods and another call to ‘please, do not include infant formula in your relief packets’ the reminder is met with passionate objections.
Comments I have heard are : “So how about formula-fed babies? We just let them starve and die?”, “sure we all know breastfeeding is best, but why force our personal views on other mothers? What about respecting a mother’s choice to formula feed?”, “isn’t being evacuated from your home stressful enough? We have to make a mother continue breastfeeding on top of that?”, “even if most mothers breastfed, not all of them do. We should support ALL mothers equally.”
I had hoped that my original post on this topic adequately addressed these concerns. And anyone who actually read the attached guide to the public would have understood that these guidelines were designed not only for breastfeeding babies, but also specifically for formula-fed ones as well. Adhering to these guidelines helps keep EVERY BABY safe.
If you still think I am making this up only to push my personal agenda of promoting breastfeeding at all costs (and that I take secret joy in the suffering of formula fed infants), let’s put ourselves in the shoes of the formula-feeding mother in an evacuation center.
The National Disaster Coordinating Council’s final report on Typhoon Ondoy in 2009 states that 15,798 families or 70,124 persons were evacuated into 244 centers. The number of persons per center varied greatly, with some holding just a few families, and others like ULTRA, holding thousands.
One of the centers I visited during Ondoy was home to 350 families with an average family size of 4-6 persons each, putting the total number of evacuees at around 2000. 72 mothers had infants younger than 1 year, with the youngest infant being 2 weeks old. Prior to their evacuation, 68 of the mothers were breastfeeding, 3 gave formula occasionally and 1 mother (the one with the 2 week old ) was giving her baby formula exclusively. There was no source of running water in this center. There were about 10 portable toilets to be shared among all the evacuees. Families gathered rain water in buckets to use for bathing, cooking and drinking. They would take drinking water from the toilets as well.
In my previous post, I said that safely feeding an infant with formula requires 1) access to a constant supply of formula 2) access to clean water 3) access to heating implements (proper preparation of formula requires heating of water to a certain temperature in order to kill bacteria/decrease contamination) 4) ability to clean feeding implements.
Let’s look at the mother who is formula feeding and figure out how much clean water she needs to safely formula feed her baby in this setting. Let’s say her baby takes 24 oz of formula a day – that means she needs 750 ml of clean water for mixing formula alone. Formula that has been prepared but is not going to be consumed immediately needs to be refrigerated. Since there is no refrigerator in the evacuation center, she needs to prepare a fresh batch at every feeding – that is 6 to 8 times a day on average. To prepare a fresh batch, she needs to wash her cup and spoon/mixing implement. She will need clean water for that. Let’s assume you can properly wash a cup and spoon with soap and water using only 8 oz of water. Multiply 8 times and she needs 64 oz or almost 2 liters. Now she needs to wash her hands before she prepares formula and feeds her baby. Let’s again assume a minimum of 8 oz to properly soap and wash your hands (I don’t know anyone who can properly wash their hands in 8 oz of water) – again multiply by 8 and that is another 2 Liters. We are not including the times she should wash her hands after changing her baby’s diaper or after she herself goes to the bathroom. So a very conservative estimate is to say that she would need at least 5 liters of clean water per day in order to safely feed her baby with formula. If we assume that she is to stay in an evacuation center for 5 days, then that is 25 liters of water for that period. These are informal computations using very rough estimates, but we can say this is the very least amount of water such a mother would need.
How much water does an exclusively breastfed infant need? None. Zero. That is at least 5 liters less per day than the formula-fed infant needs. Now if we feel it is only fair that we provide formula to every mother – even the ones who are successfully breastfeeding – just so that they are allowed the option to formula feed, and we want to do the ‘responsible’ thing and provide enough clean water as well, how much water do we then need to provide?
72 mothers x 25 liters = 1800 liters of clean water in order to support “safe” formula feeding for 5 days. But does providing sufficient water for making formula ensure that mothers are going to do it safely? Why would a mother choose to use clean water to wash a cup or spoon or her own hands, when she, her husband and her other children do not have enough clean water to drink? Why should a baby who needs 0 Liters of water suddenly deserve an allocation of 5 extra liters per day? The approach does not make sense at all. Imagine being a mother of a purely formula-fed child who now has to compete with breastfeeding mothers for a limited amount of clean water because suddenly the breastfeeding mom feels now is a good time to formula feed.
We know that breastfeeding mothers can continue to breastfeed in disaster situations. We know that if they were capable of making enough milk yesterday or this morning, before the typhoon struck, then they are capable of continuing to make milk now, even in an evacuation center. If you are an agency providing relief goods and have only an X amount of funds with which to purchase goods, would you spend the money on infant formula, clean water, feeding implements to be distributed to mothers who actually are able to feed their babies without any of these? Or would you rather spend that same money on food that can be made available to everyone in the center?
Keeping infant formula away from general distribution means breastfeeding mothers are not tempted to use it. It protects formula-fed babies from having to compete with breastfed ones for limited resources. Keeping formula away from general distribution DOES NOT mean that formula fed babies are not fed. Formula-fed babies should be identified by the evacuation center staff and appropriate feeding is provided. If you are concerned that these children are not being identified, then instead of putting a packet of formula in ever bag, why not speak to the person in charge of the evacuation center and find out how they are caring for the infants who are purely formula fed?
The threat of infectious diarrhea in a congested living space with no access to running water and no functioning sewage system is real. Imagine how fast this can happen in a facility so overcrowded that people knowingly and unknowingly step in excrement, sleep on the floor, do not have the luxury of bathing or washing hands. This general lack of hygiene easily contaminates the food and water supply. It shouldn’t then surprise us to hear of outbreaks of diarrheal disease following natural disasters. An article on “Epidemics After Natural Disasters’ by Watson, Gayer and Connolly that was published in 2007 cites several instances – such as as 17,000-case outbreak of diarrhea in 2004 after flooding in Bangladesh and over 16,000 cases of cholera in West Bengal in 1998. Breastfeeding babies exclusively in these situations protects them from diarrheal disease, so helping mothers who were previously mix-feeding to return to exclusive breastfeeding isn’t about bullying or disrespecting them – it is about helping them choose the safest course of action. In the same way, helping a mother who formula feeds to relactate if she so desires, isn’t about making her life harder.