Research priorities for improving infant and young child feeding in humanitarian emergencies

Educational models of infant and young child feeding among prenatal and postnatal women during the COVID-19 pandemic (January 2020-January 2023): A scoping review

Infant and young children feeding (IYCF) practices, particularly for infants and young children <2 y old, became increasingly challenging during the COVID-19 pandemic. Several studies have discussed various educational models in the pre-pandemic period, most of which were conducted in person. The last reviews on IYCF interventions were conducted in 2020 and were relevant to pre-pandemic contexts. Thus, there is a need to review IYCF interventions to inform educational models adapted to the COVID-19 pandemic. This study aimed to describe the IYCF educational models proposed during the COVID-19 pandemic. For this relevant literature, we searched PubMed, SCOPUS, EBSCO, ProQuest, Sage Journals, and Wiley Online Library. Thirty-five literature sources were screened, and 7 data sources were included for data extraction and analysis. Many studies on the IYCF educational models focused on exclusive breastfeeding and early initiation of breastfeeding; there was only one study on complementary feeding, and no research was found on continued breastfeeding. Four studies found no significant differences in the intervention given. Three studies had a significant effect, one had in-person meetings, and two consisted of WhatsApp discussions. Most IYCF educational models from the pandemic context comprised online education, whereas WhatsApp was the most popular media used. Future researchers may develop these findings to design research on a larger scale and for a longer period, especially on complementary feeding and continued breastfeeding based on IYCF indicators.

First do no harm overlooked: Analysis of COVID-19 clinical guidance for maternal and newborn care from 101 countries shows breastfeeding widely undermined

Background

In March 2020, the World Health Organization (WHO) published clinical guidance for the care of newborns of mothers with COVID-19. Weighing the available evidence on SARS-CoV-2 infection against the well-established harms of maternal-infant separation, the WHO recommended maternal-infant proximity and breastfeeding even in the presence of maternal infection. Since then, the WHO's approach has been validated by further research. However, early in the pandemic there was poor global alignment with the WHO recommendations.

Methods

We assessed guidance documents collected in November and December 2020 from 101 countries and two regional agencies on the care of newborns of mothers with COVID-19 for alignment with the WHO recommendations. Recommendations considered were: (1) skin-to-skin contact; (2) early initiation of breastfeeding; (3) rooming-in; (4) direct breastfeeding; (5) provision of expressed breastmilk; (6) provision of donor human milk; (7) wet nursing; (8) provision of breastmilk substitutes; (9) relactation; (10) psychological support for separated mothers; and (11) psychological support for separated infants.

Results

In less than one-quarter of country guidance were the three key breastfeeding facilitation practices of skin-to-skin contact, rooming-in, and direct breastfeeding recommended. Donor human milk was recommended in under one-quarter of guidance. Psychological support for mothers separated from their infants was recommended in 38%. Few countries recommended relactation, wet nursing, or psychological support for infants separated from mothers. In three-quarters of country guidance, expressed breastmilk for infants unable to directly breastfeed was recommended. The WHO and the United Kingdom's Royal College of Obstetricians and Gynecologists were each cited by half of country guidance documents with the United States Centers for Disease Control and Prevention directly or indirectly cited by 40%.

Conclusion

Despite the WHO recommendations, many COVID-19 maternal and newborn care guidelines failed to recommend skin-to-skin contact, rooming-in, and breastfeeding as the standard of care. Irregular guidance updates and the discordant, but influential, guidance from the United States Centers for Disease Control may have been contributory. It appeared that once recommendations were made for separation or against breastfeeding they were difficult to reverse. In the absence of quality evidence on necessity, recommendations against breastfeeding should not be made in disease epidemics.

Interventions to support the re-establishment of breastfeeding and their application in humanitarian settings: A systematic review

In 1998, the World Health Organisation (WHO) published general guidelines proposing essential measures to achieve relactation. Yet, increased knowledge about the practical set-up of relactation support interventions in different contexts is needed, especially in humanitarian settings, where nonbreastfed infants are particularly at risk. This study aimed to compile and assess the characteristics, outcomes and factors influencing the implementation of relactation support interventions reported since the latest WHO recommendations. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, undertaking a search from Medline, Embase, PubMed Central, Web of Science, Global Health and CINAHL electronic databases. Studies published in English and Spanish, reporting characteristics and outcomes of relactation support provided to non-(breastfeeding) BF mothers with infants aged less than 6 months were included. Data were analysed by narrative synthesis and the Johanna Briggs Institute Critical Appraisal Tools were used for quality assessment. Overall, 16 studies met the inclusion criteria. Most were observational and conducted in middle-income countries, only one focused on humanitarian settings. Studies reported inpatient and community-based interventions, which generally followed WHO recommendations for relactation. In 13 out of 16 studies, over 80% of mothers restarted BF after receiving relactation support. Enabling factors included younger infant age, shorter lactation gap, mother's strong motivation, family support, and continuous skilled support. Although current literature suggests that intensive relactation support can contribute to re-establish BF, its application and effectiveness in humanitarian settings remain uncertain. Further research is needed to explore the effectiveness, feasibility and acceptability of different approaches to relactation support, especially in humanitarian settings.

'We make a mistake with shoes [that's no problem] but… not with baby milk': Facilitators of good and poor practice in distribution of infant formula in the 2014-2016 refugee crisis in Europe

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.

Setting global research priorities for child protection in humanitarian action: Results from an adapted CHNRI exercise

BACKGROUND

Armed conflict, natural disaster, and forced displacement affect millions of children each year. Such humanitarian crises increase the risk of family separation, erode existing support networks, and often result in economic loss, increasing children's vulnerability to violence, exploitation, neglect, and abuse. Research is needed to understand these risks and vulnerabilities and guide donor investment towards the most effective interventions for improving the well-being of children in humanitarian contexts.

METHODS

The Assessment, Measurement & Evidence (AME) Working Group of the Alliance for Child Protection in Humanitarian Action (ACPHA) identified experts to participate in a research priority setting exercise adapted from the Child Health and Nutrition Research Initiative (CHNRI). Experts individually identified key areas for research investment which were subsequently ranked by participants using a Likert scale. Research Priority Scores (RPS) and Average Expert Agreement (AEA) were calculated for each identified research topic, the top fifteen of which are presented within this paper.

RESULTS

Intervention research, which aims to rigorously evaluate the effectiveness of standard child protection activities in humanitarian settings, ranked highly. Child labor was a key area of sector research with two of the top ten priorities examining the practice. Respondents also prioritized research efforts to understand how best to bridge humanitarian and development efforts for child protection as well as identifying most effective way to build the capacity of local systems in order to sustain child protection gains after a crisis.

CONCLUSIONS

Rigorous, scientific research that assesses the scope of child protection risks, examines the effectiveness of interventions to improve child well-being, and translates evidence to practice is critical. Findings from this research priority setting exercise offer guidance for a global research agenda on child protection in humanitarian settings, encouraging cooperation among donors, implementers, and academics to pursue a coordinated approach to evidence generation.

Maternal Perceptions of Infant Feeding and Health in the Context of the 2015 Nepal Earthquake

BACKGROUND

Displacement caused by the 2015 earthquake in Nepal exacerbated poor health and nutrition for thousands of women and children. Research aim: This study aimed to identify the perceptions of Nepalese mothers residing in earthquake relocation camps regarding barriers, facilitators, and situational factors influencing breastfeeding and family well-being.

METHODS

An exploratory, rapid ethnographic approach was used during two fieldwork phases. Phase 1 consisted of reconnaissance and observation, whereas Phase 2 consisted of observation and qualitative semistructured interviews with infant caretakers ( N = 14).

RESULTS

We found evidence of human milk substitutes donated by various groups after the earthquake, despite Nepal's media statement condemning these donations. Participants in this study expressed concerns about their milk supply. They also expressed concerns about the impending winter season combined with distress about the 2015 fuel crisis and the impact that this had on their infants and children. Furthermore, participants expressed choices about infant feeding that were influenced by traditional Nepalese practices. Specifically, homemade complementary foods and spices designed to boost lactation were identified as being used during daily infant feeding practices.

CONCLUSION

Infant caretakers need culturally specific support for breastfeeding after disasters. These findings can directly influence future interventions concerning Nepalese mothers' perceptions, infant care, and feeding practices in disaster scenarios.

Conserved and variable: Understanding mammary stem cells across species

Postnatal mammary gland development requires the presence of mammary stem and progenitor cells (MaSC), which give rise to functional milk-secreting cells and regenerate the mammary epithelium with each cycle of lactation. These long-lived, tissue-resident MaSC are also targets for malignant transformation and may be cancer cells-of-origin. Consequently, MaSC are extensively researched in relation to their role and function in development, tissue regeneration, lactation, and breast cancer. The basic structure and function of the mammary gland are conserved among all mammalian species, from the most primitive to the most evolved. However, species vary greatly in their lactation strategies and mammary cancer incidence, making MaSC an interesting focus for comparative research. MaSC have been characterized in mice, to a lesser degree in humans, and to an even lesser degree in few additional mammals. They remain uncharacterized in most mammalian species, including "ancient" monotremes, marsupials, wild, and rare species, as well as in common and domestic species such as cats. Identification and comparison of MaSC across a large variety of species, particularly those with extreme lactational adaptations or low mammary cancer incidence, is expected to deepen our understanding of development and malignancy in the mammary gland. Here, we review the current status of MaSC characterization across species, and underline species variations in lactation and mammary cancer through which we may learn about the role of MaSC in these processes. © 2017 International Society for Advancement of Cytometry.