Hi Genevieve, A few comments to your post, for those exceptional (no need to stress this) cases of mothers not being able to breastfeeding: - Wet feeding is the best option, provided is culturally accepted and HIV risk is considered. - Hydration of mothers: not sure whether this could be the cause, apart from serious cases. If so I would address this issue before moving to other options. - When formula milk is available but the problem is water... well, the water problem should be sorted out, in any case water will be needed to feed the child. - When the problem is cost, availability or access, I think, and more competent people can correct me, that animal milk at an appropriate dilution (cow's milk are more rich in protein than human one) and enrichment with some specific micronutrients is a viable option. However, and this is a crucial point, this type of information should never be broadcasted or in any way spread to the general population. Public health interventions, which include IEC campaigns, should always be weighted against their negative consequences. And I am sure such campaign could be seriously dangerous. Clinical, personalised care and counselling by medical staff is the way to go in this case. Best, Best,

Tricky one for programming, but I think you will need both short term and long term interventions depending on your program goal and objectives. (1) Modified animal milk (whole milk- water ratio 1:1 + sugar) given with daily Iron and folic supplements will be a good alternative. Need about 0.5 litre of clean water per day for the preparation and about 5 litres soap for cleaning utensils. (2) Wet nursing where the wet nurse’s HIV status is known with subsequent proper risk assessment for possible HIV infection during the course of breastfeeding (if HIV negative). If HIV positive, wet nurse must be on ARVs but this option should be probably be considered for orphaned children without access to infant formula or animal milk (last option). These options however, cannot be broadcast over the radio so you need to empower health workers to provide these services to infants under difficult circumstances. To reach the general population, I suggest you: (1) Broadcast of key messages on breastfeeding, can have a few talk shows to address local challenges to breastfeeding, and messages targeting women with common breastfeeding difficulties in that area. (2) Capacity building through training and mentorship of health workers (if possible midwives) on IYCF. The midwives will be able to educate women on breastfeeding right from ANC and provide continued support postpartum. From my experience, capacity building yield results and is sustainable. (3) Community support groups as change agents: Empower peer mothers/community volunteers to educate and support women at community level and on ANC/Immunization days( if there are staffing shortages at the health centre). The community workers then refer complicated cases to trained health workers. Can also integrate this into immunisation outreaches (if available) Best wishes!

Dear Genevieve, It would be interesting to hear more about how cases of women not producing breastmilk have been confirmed. Like you share, reports of not being able to breastfed or inadequate breastmilk are common in many contexts. There are many reasons that may account for this that will require different supports, and that may not be easy to address. However, an absolute failure in breastmilk production is a physiological rarity. In Sudan, there are not safe viable alternatives to breastfeeding; it is a lifeline to infants in such a community, especially in the first 6 months of life. This includes where HIV is prevalent; the risks of not breastfeeding greatly outweigh the risks of HIV transmission through breastfeeding when it comes to child survival. If you are looking for a topic to support infant feeding using radio, especially of infants < 6 months, in rural communities, I'd suggest you look at how you might galvanise community peer to peer support and networks to help mothers who are having difficulties breastfeeding, to overcome them. Perhaps identify and then feature experiences of mothers who were helped by other mothers in the community. As you say, capacity amongst health workers may not be available. But there may well be an untapped great resource amongst the mothers themselves to help each other. Regarding the particular issue of HIV and breastfeeding raised in the responses to this question, please check out another recent exchange on a question regarding HIV and wet nursing posted on en-net, see: [url]http://www.en-net.org.uk/question/1218.aspx[/url]

Hi Genevieve I can't envisage any situation in which it would be appropriate to broadcast information about artificial feeding on local radio - unless to say it is dangerous and should not be attempted except in the most desperate circumstances. Babies who can't be breastfed (because wet nurses can't be found) need quite intensive and complex medical support which can't be condensed to simple public health messages. More appropriate messages would focus on encouraging communities to support breastfeeding mothers by releasing them from livelihood activities that might separate them from their babies, or on the dangers of giving babies anything other than breastmilk, or encouraging communities to feed mothers so that they can feed babies. In Burma we used very simple messages such as "Giving babies anything other than breastmilk before they are 6months old causes diarrhoea." "Giving babies anything other than breastmilk before they are 6months old causes puemonia" "Breastmilk is all babies need for the first six months of life" "Mothers need your help to keep their babies healthy" Bear in mind that even where ARVs are unavailable, wet nursing by a mother of unknown HIV status (and possibly HIV+ status in some situations) still gives infants who can't be breastfed the best chance of survival. All that said, it sounds like you find yourself between the rock and the hard place, making decisions about what might be the least dangerous option.

From Felicity Savage, en-net technical expert: First, in such cases, somebody needs to be out there to support the mothers to breastfeed and relactate, and to know about the milk drying up. But even if relactation is planned and the mother agrees to it, you need to give something to the baby while doing it, usually formula. Wet nurses fine if available, HIV tested if possible but if not, you just have to go ahead and do it so long as the woman is not clinically ill. Formula, if available, is the preferred artificial option, if it can be properly reconstituted, and distribution controlled. Use of diluted animal milks (usually 1 measure of water to 2 or 3 of milk, plus sugar plus vitamins) is only useful as a temporary last resort measure – not as an easy option for the first 6 months, the child is likely to become malnourished and ill. WHO has banned it. Many of these issues are highlighted in IFE Module 2, which can be found here [url]http://www.ennonline.net/resources/4[/url] See also the IYCF module of the Harmonised Training Package, here [url]http://www.ennonline.net/pool/files/ife/m17p2.pdf[/url]