Ebola virus is transmitted through breast milk (and saliva), even during convalescence. See: [url]http://jid.oxfordjournals.org/content/196/Supplement_2/S142.full.pdf[/url] Given the risks of Ebola, it would would be worth alternative feeding strategies in mothers who have symptoms. Jay

I am no expert on the infectious diseases but it is worth keeping in mind that the presence of a virus in breastmilk does not mean that the infection is transmitted via breastmilk. Viruses are found in breastmilk but no transmission occurs, eg Hep B and C. Or transmission occurs with difficulty under the influence of other factors such as the feeding of other foods ie HIV. In the absence of other evidence, it is not possible to assume that the presence of a virus in breastmilk means that infection will or will not be transmitted via breastmilk.

You may be right Jay but we know from past experience that drawing conclusions from very limited data (and the paper linked to had n=1) in relation to breastmilk and infection can lead to very poor outcomes. This was evident in relation to HIV and infant feeding recommendations. If a woman has ebola her infant has presumably already been exposed at a high level, withdrawing breastfeeding at this point may be very counterproductive. This is just to point out that the situation is way more complex than ebola is in breastmilk and therefore should be avoided.

I think stopping breastfeeding if women is found with Ebola might not be fruitful and may have negative effect to the baby especially in the current situation of west Africa countries where there is high spread of the disease and patient are diagnosed at a later stage due to the outbreak. However i belief is something which need more scientific proofs but as my colleagues put it may not be advisable to abruptly stop the breastfeeding once the virus is found with the mother.

Many people are asking this question. Current understanding is that the virus can be transmitted by breastfeeding, and in the case of confirmed maternal infection, breastfeeding is contraindicated (PAHO, WHO). However, as usual this is not the whole problem. Many infections start the same way, and there will be lots of suspected cases that turn out to be something else. There is a fear that mothers with these early symptoms will stop breastfeeding anxious "in case" it turns out to be Ebola. Breastfeeeding or not is only part of the baby's problems: transmission is likely if there is any close contact with the mother and probably both mother and baby should be put in strict isolation, including from each other. Strict barrier nursing would need to be enforced. The baby itself will be a possible source of infection. Who will feed and care for the baby while the situation unfolds? What if the mother dies? I have not seen these questions addressed.

Felicity raised very important questions (Who will feed and care for the baby while the situation unfolds? What if the mother dies? ), that must be addressed in this context. I am presently in Sierra Leone and have seen the ebola outbreak unfold and how cases are managed to date. The cases are isolated once they are suspected with ebola and their blood samples taken for test and confirmation. This process takes a minimum of 72 hours especially when the cases are not in the district or town where the laboratory is available. If a case is confirmed positive he/she is transferred to the treatment center. Whilst in isolation and treatment centers only doctors and nurses with personal protective equipment have direct contact with the case. Contacts of ebola cases are traced and also quarantined. The contacts are also monitored for a minimum 21 days. In a situation like this, a breastfeeding mother (who has suspected or confirmed ebola) may not have contact with her child. In fact the mother will be so weak to effectively breastfeed. Some mothers have died and the outbreak is still unfolding. So we need to agree on alternative infant feeding strategies that are acceptable at the country level to ensure optimum nutrition for infants and young children whose mothers are infected by ebola virus.

I have a question, how wide spread the situation is? Is there any breastfeeding child affected by Ebola virus? If yes, then how many of them? How it is detected that they have been transmitted through breastmilk? What are the recommended IYCF practices in Ebola Outbreak areas? What strategy Government and INGOs are taking to aware the community?

Well, I think we have clear that breastfeeding is a high risk practice talking in terms of Ebola. Not only for the risk of mother to child transmission through the breast milk, which is confirmed and direct guidelines have been given by WHO: "Breastfeeding: Because the virus is transmitted through breastfeeding it is recommended that women symptomatic for EVD pending confirmation and those who have been confirmed for EVD not breastfeed." The close contact of the mother with the child, including the sweat, saliva and excreta during nursing makes it one of the easiest ways of transmission, increasing the chances highly. I don't have much doubts about how to deal with a couple mother - child suspected or confirmed for Ebola in an isolation facility: Isolation in separated areas is mandatory. The next steps are clear too in any protocol related to Ebola and sorts: Individual care for the mother and child, infant formula fed to the child while in isolation by fully protected staff, and continued until the final resolution of the status (infected or not). But these are are just a few among the population involved in the epidemic, and they are the ones that are "under control". What worries me more and think that it is where most non-medical agencies can play a role, are the implications of this discouragement of breastfeeding, and how to present it to communities hoping it doesn't arrive first as a rumor. It is the question of the fear among the populations, mass panic, misunderstandings of the role of the actors and use of "extreme measures" to halt the suspicions of the problem. That will actually relate to the 99% of the people and communities affected by this crisis. Case management is important, but the other 2 aspects of this kind of response are vital to stop the epidemic: Sensitization and case tracing. While it is important for everyone to reach a common ground on the issue of factual transmission through the breast milk for practical case management, the biggest effort needs to be placed in what are the implications of it at community level. We may see at some point (or not even get to see, but will happen for sure) that hundred of children and/or their mothers will be abandoned and outcast from their communities (if not worst) by the appearance of any symptom similar to Ebola. Efforts need to be directed towards Sensitization of communities with easy and trustworthy messages and channels, and sensible case tracing.

Going by the messages being circulated, Ebola is spread by having direct contact with body fluids of an infected person i.e blood, urine, sweet, kaka, mucus, semen ..... etc from a none medical person (me), is breast milk not classified as body fluid therefore to be avoided? are breast feeding children not at risk given that some symptoms do not appear to be Ebola at the early stages i.e fever, headache, fatigue etc and mothers continue to breastfeed.

Dear en-net, Sparked by this exchange, a collective of UN agencies, NGOs and experts are working to produce a practical guidance on this issue and address these and other questions emerging around infant feeding in this situation. We are aiming for a quick 24 hour turnaround (stranger things have happened). Watch this space.......

Hi Marie, everyone, Marie, that's amazing. Have been following the discussion and really good to know. Many thanks, Genevieve

Dear all, The guidance document is taking a little longer than Marie had optimistically hoped, however, we'd like to assure you that people are working hard behind the scenes to try to pull together the best available advice. As you are all aware, these are difficult questions. In the meantime, there is a site that may be helpful for more general guidance, where a lot of documents on ebola have been posted: [url]http://www.medbox.org/ebola-toolbox/listing[/url] Best wishes, Tamsin

Dear all, Please find a link below to a guidance document on infant feeding in the context of this ebola outbreak. The document was developed in consultation with members of the Infant Feeding in Emergencies (IFE) Core Group, WHO's Departments of Nutrition for Health and Development, and Pandemic and Epidemic Diseases and UNICEF. Your feedback is welcome and can be posted on this forum, sent to post@en-net.org.uk or directly to the IFE Core Group members. [url]http://www.ennonline.net/infantfeedinginthecontextofebola2014[/url] (this link has now been updated to the latest guidance, see below). Best wishes, Tamsin

Some questions were submitted to the en-net postbag by Jessica Bourdaire at Save the Children. They are posted below with answers provided on consultation with UNICEF and WHO (thanks to their respective HQ, regional and country offices for their valuable and speedy inputs). From Jessica: Thanks for the document, I have few questions below related to the recommendations (quoted): 1. “Community at large The key messages are: 3) Only when a trained health worker has determined that a mother meets the criteria of probable, suspected or confirmed Ebola Virus Disease (EVD), breastfeeding should be stopped and available options discussed. The reference document talks about Suspected: 3a. Case definition to be used by mobile teams or health stations and health centres and Probable 3b. Case definition for exclusive use by hospitals and surveillance teams” Should we assume both are valid as far as a clinician determines that the mother meets one of the criteria? Yes, both case definitions are valid, as long as it is determined by someone trained on assessing Ebola (the emphasis is on the training rather than necessarily a clincian). We don’t want untrained workers to take decisions that would affect breastfeeding in the general population. Should this be done in an Ebola treatment centre? Identification of suspected cases (see case definition 3a) does not necessarily have to happen in an Ebola treatment centre. Usually there’s a triage room/space within the ETC compound, separate from the place where confirmed and probable patients are. 2. “Breastfeeding mothers with confirmed Ebola; asymptomatic child under 6 months of age Guidance: 1) Cessation of breastfeeding. Options are: a. Expressing and heat treating the expressed milk (details to be added)”. Heating? Are we expecting further advice on it? In the field would it be difficult to assess heating time/temperature? As far as I know heating should not be less than 30min at quite high temperature or boiling for several minutes? Overheating might also destroy antibodies, enzymes and nutrients so what are the benefits of considering utilization of expressed breast milk "heat treated" against the risk of handling and using breast milk that could still be contaminated? As you reflect, the most important issue concerning this option is that the breastmilk of an Ebola patient is a contaminated product that needs to be handled with care. The over-riding question then is whether this would be feasible in the concerned setting. Your question prompted a discussion on this issue amongst WHO, UNICEF and members of the IFE Core Group. Given the context in West Africa and the risks of handling a contaminated product, we concluded and advise at this time that heat treatment of breastmilk is not a feasible option. We are updating the guidance note which we’ll post shortly. “At the moment, insufficient evidence is available about the recommended duration of breastmilk cessation after the mother's recovery from Ebola. It is therefore recommended to not resume breastfeeding unless testing of the milk has confirmed the absence of the virus in the milk”. Is this test available/systematic for lactating women survivors? Should lactating women be recommended to comeback for the test later on? Are they able to continue breastfeeding? Testing of breastmilk for lactating women survivors is available where it’s also available for blood testing, but is not done systematically. If possible, women should be recommended to return for testing. On consultation amongst the group, we suggest it is therefore recommended that mothers return to the health centre to have their breastmilk tested, 4 weeks after recovery. If there is no virus in the milk, mothers can resume breastfeeding. If there is virus in the breastmilk, breastfeeding should not recommence and the mother should be advised to return for repeat testing in 3-4 weeks. Mothers should be supported to re-establish breastfeeding once it is safe to do so, and based on the age of the child. A return to breastfeeding is in the interests of child survival, once it is safe to do so (as reflected above). Ultimately the decision will need to be taken on a case-by-case basis but generally speaking, mothers should be supported to re-establish breastfeeding once it is safe to do so. 3. Other issues to consider “3) All patients who recover from Ebola should receive nutritional screening and treated when they are found diagnosed with acute malnutrition. They should receive a discharge package, including nutritional support, upon discharge, and should be followed up”. When are they considered recovered? Clinically recovered and/or blood tested negative? According to the Daniel G. Bausch and All study, EBOV was found in body fluids while it was cleared up in blood samples. There’s a difference between ‘recovered’ and ‘discharged’: a patient can only be discharged after recovery and after two consecutive tests are negative on different days. Semen is considered to be infectious for several weeks, and breastmilk. That’s why male patients are asked to use condoms for 7 weeks. Whilst recognising these risks, it is important not to encourage irrational fear of recovered patients. 5) “ The risk of spreading Ebola from the use of anthropometric equipment is considered very low when following WHO's Infection Prevention and Control Guidance”. Even if the risk is low, crowed places could assemble potential cases increasing this risk. At community and even at health centre level, anthropometric materials will not be properly disinfected between 2 children? Materials are not easy to disinfect: MUAC tapes, wooden height boards and weighing scales pants. The risks of using length/height boards, weighing scale pants etc. are considered high if the materials are not disinfected after each use. If the frequent disinfection of materials is not feasible, another option would be to employ single use disposable covers (eg plastic) for weight and height measurement (which would then need to be destroyed) – this may only be viable for health centres. The risk is considered low if a MUAC tape is used but even still, it is recommend that alcohol be used to wipe the upper arm before the measurement and that usual hygiene measures, e.g. washing hands between measuring different children, be followed. Another option is that MUAC tapes are used as single use and destroyed; again, this may only be feasible at health centres and will depend on supplies. A third option is that the mother is supported to conduct the measure if possible. This question has prompted further discussion in the group. We are now examining this issue of anthropometric assessment in consultation with WHO Ebola ‘super-experts’ engaged in the Ebola response. We’ll post feedback on this as soon as possible. Amongst all this, it is important to note that non-symptomatic persons are not infectious and to not lose sight of the importance of hand hygiene between patients, which is an important aspect of basic health care that is often forgotten.

Dear all Sorry for the 'silence' in terms of further guidance, the group is actively consulting with experts and field teams and we should have an update soon. The challenge has been figuring out recommendations around infant feeding in the absence of hard evidence in an immensely challenging context. To help, we would like to appeal to any of you working in the Ebola response to share with us your experiences on infant feeding. One particularly valuable piece of information we would like to hear about is how many infants of breastfed mothers are sick when the mother presents herself (= test positive), and how many develop the disease later? Many thanks, Marie

Dear All Please find here an updated version of the [url=http://www.ennonline.net/infantfeedinginthecontextofebola2014]guidance on infant feeding in the context of Ebola[/url]. It replaces the previous guidance dated 22nd August 2014. The guidance has been produced through informal consultation involving UNICEF technical advisors at HQ, regional & country levels; WHO Infant and Young Child Feeding and Ebola specialists; CDC Atlanta; Ministry of Health and Social Welfare Liberia and in-country staff working as part of the Ebola response. Particularly valuable has been the 'reality check' made possible by a UNICEF visit to the region, allowing first hand consultation with field teams on the content. Please let us know how helpful (or not!) this guidance is and we will continue to update it as the situation evolves. Best regards Marie

Dear All CDC have also just produced a [url=http://files.ennonline.net/attachments/2177/CDC_Ebola-and-Breastfeeding-Guidance_Final_Cleared.pdf]guidance note[/url] on infant feeding/breastfeeding in the context of the Ebola outbreak. Regards, Marie

Thank you for putting this together, I have few questions: 1) What is the preconized approach for asymptomatic contact lactating women, I didn’t get what are the recommendations during the 21 days: - Should we recommend stopping breastfeeding given that mortality risk of Ebola is higher compared to mortality risk related to not breastfeeding - Should we recommend continuing breastfeeding given that contagion window opens only when first symptoms occur 2) Is there any further guidance on how to screen malnutrition (conventional technique) in a safe way considering the small probability of correctly disinfecting the anthropometric equipment? 3) In normal circumstances F75/F100 are intended only for acutely malnourished children and for infants (additionally to breastfeeding) indeed but acutely malnourished infants <6 could also be fed with infant formula additionally to breast milk*. Then could we say that in the current Ebola context RUIF is the safest option for both malnourished and not malnourished infants <6? 4) When testing milk is available and acknowledging variation between individuals, balancing breastfeeding benefits to the risk of releasing potentially infected milk, wouldn’t be safer to recommend to do the first test (milk from both breast) after few weeks instead of few days following recovery? 5) Will UNICEF take the lead on the procurement of RUIF at country/region/global level? *WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013. I think in all the cases we are between a rock and a hard place, thank you in advance for the answers. Jess

Posted on behalf of Cota Vallenas, WHO: Dear Jessica, Once two blood tests (PCR) come negative, the person's body fluids are considered free of virus except for semen, vaginal fluids and breastmilk. The time it persists in breastmilk is unknown as no one has studied/reported this. We need to be careful about saying that a discharged person still has the virus. It's true that the virus may still be found in isolated compartments of the body, but the person can resume a normal life. Unfortunately this isn't happening because these persons are terribly stigmatised rather than welcomed back after the ordeal they've suffered. Regards, Cota

Hi Cota, I totally agree, my concern was on the recommendation of asking lactating women to comeback for a milk test every 2-3 says after blood test negative, this might open the possibility of having the mother tested several times what could also contribute to stigmatisation. Thanks. Jess

Good evening,

I am currently developing tools for the training of trainers on the Family MUAC strategy.

I would like to inquire whether there are already toolkits concerning this strategy and tools already designed for monitoring (screening and referral) at the community level.

Thank you in advance.

Regards,

Thank you for the quick answers. Well noted on the RUIF procurement. Mothers doing MUAC will be challenging, when available I would be interested in reading Niger’s experience. Thank you. Jess

Dear all, An updated working document on Nutritional Care in Adults and Children infected with Ebola Virus Disease in Treatment Centres has been shared by Mija-Tesse Ververs and can be found [url=http://www.ennonline.net/whatshouldbethenutritionalsupporttoadultpatientswithebolavirusdiseaseevdintreatmentcentresinthecurrentcrisisareas]here[/url] To comment on the document, view or join the discussion, please go to the Prevention and treatment of moderate acute malnutrition forum area [url=http://www.en-net.org/question/1460.aspx#lastpost]here[/url] Best wishes, Tamsin

Having worked on maternal-infant transmission studies for HIV, I cant help but wonder if the amount of maternal viral load might have some effect on ebola transmission rates in breastfeeding.

Dear all We have received a query regarding the ebola and infant feeding guidance relating to newborn infants. The guidance recommends that for the newborn infant of an Ebola infected mother, the mother should be supported to breastfeed if she is capable of doing so. If not, the infant should be replacement fed and closely monitored for 21 days for the development of symptoms. This recommendation was based on the high likelihood that an infant has been infected during birth. However, there remains some uneasiness amongst our informal working group about recommending breastfeeding a newborn who is not showing signs of ebola infection. We would really appreciate hearing about field experiences in this regard - e.g. how such cases are managed in practice, what condition both mothers and infants are in, in such instances. Regards Marie, on behalf of the ebola and infants feeding informal working group

Dear Marie, You say : “This recommendation was based on the high likelihood that an infant has been infected during birth. However, there remains some uneasiness amongst our informal working group about recommending breastfeeding a newborn who is not showing signs of Ebola infection”. I understand the uneasiness about recommending breastfeeding in case of a mother infected by the Ebola virus. And the logic here is not correct. Breastfeeding is recommended for about 2 years, and incubation of Ebola virus is just a few days. Most breastfed children will be born uncontaminated, and the risk of infection through continuing breast feeding is real. Unless you consider that these children may get infected before the mother seeks helps, which arguably will be often the case.

Dear Andre, Many thanks for this feedback. I should have added to my posting that the guidance on newborns was also strongly influenced by feedback from an NGO, working in the Ebola response, who indicated that that the majority of infants born to Ebola confirmed mothers, were born infected. This is just one experience, and we really need more evidence - however 'grey' - from programmers. We are compiling a list of key 'evidence' questions that we will post shortly. Best regards Marie

Just a reminder that we must not fall into the same trap the "HIV community" did in 1998, focusing only on what it would take to avoid postnatal transmission. The issue here has to be optimizing "ebola-free survival" and from that perspective, avoidance of breastfeeding in many settings will hardly be a wise decision.

Dear Ted Thanks for a very important reminder and context to highlight where we have many lessons to draw upon. Rest assured that within the informal working group, we have been very mindful of this. Those contributing to thinking in the group have been involved in infant feeding support in the HIV context in guidance development and in direct programming support.There are parallels with the HIV experience that we have drawn upon but also some important differences: First, the severe lack of evidence on ebola transmission from mother to infant, how long it persists in breastmilk, whether viral load equates to infection risk, etc, etc, etc. Second, the extremely high mortality associated with ebola infection - we have heard unofficial 'on the ground' reports of 50-90% mortality in infants. So using the same balance of risks for ebola-free child survival, and in the absence of evidence, avoiding breastfeeding has been an inevitable consequence in some instances. We attempt to deal with the tricky area of wet nursing given that it is culturally practised in West Africa, and is normally the favoured option to maternal breastfeeding but in this context, may carry disproportionate risk for the wetnurse (where an infant has been a contact) and the infant (where the wetnurse has been). In our guidance, and reflecting the commitment of UNICEF and other agencies on the ground, every effort is being made to support safe alternatives to breastmilk where the advice is to cease breastfeeding. There is also guidance on reintroduction of breastfeeding if a mother survives - in the interests of child nutrition, health and survival.

Posting on behalf of senior advisor with international NGO working in the Ebola response: Having discussed the issue with field staff managing cases, they report that they have not seen any baby of a mother with ebola survive.

I am simple minded here but I'm asking.... If the mother has the Ebola virus, isn't her breastmilk making antibodies againt the virus that would be present in her milk and thus a baby that was positive for the virus would at least have a better chance fighting off the disease if s/he continues to receive breastmilk than to have it taken away? And also is the Ebola one of the viruses that is transmitted before a person has symptoms? If so, would it stand to reason that even infants in close contact with a mother who is exposed but not symptomatic would still be exposing her infant and thus the infant would still benefit from the antiviral and bacteriostatic properties of breastmilk?

Dear Anon 2681 These are very valid questions you raise, thanks for doing so. I am posting feedback on behalf of Suzanna McDonald, WHO consultant, who has a background in Infectious Disease Immunology: It would take at least 10-14 days from initial infection to make antibodies. IgM antibodies are produced initially. IgA is the predominant antibody in breast milk. Ebola virus is found in breast milk. It is NOT known if those viruses are viable or not - and therefore able to transmit the disease or not. Ebola virus is only transmitted once someone is symptomatic through direct contact with (various) bodily fluids,

Marie McGrath said, "Having discussed the issue with field staff managing cases, they report that they have not seen any baby of a mother with ebola survive." Sadly, this is not at all surprising. By the time a mother becomes symptomatic - and therefore contagious - she has likely already had the close contact with her baby that is both the necessary and sufficient condition for transmission. If a mother presents at a health facility with symptomatic ebola virus, it is probably safe to assume that the baby is also infected, if not already symptomatic. If I understand correctly, the mother will quickly become too unwell to breastfeed the baby. The question therefore becomes, how to feed the baby in the period between the mother becoming too ill to feed her and the baby falling ill. Wet-nursing is problematic, since there is a good chance the baby has contracted ebola from her mother and her own sweat and saliva will present a transmission risk to a healthy wet-nurse. Finding a wet nurse who has survived ebola might present a solution, if survival were not such a rare occurrence and if the break from breastfeeding caused by the wet-nurse's own illness did not see a significant reduction in a woman's lactation. It might also be difficult to secure agreement to wet nurse from a woman so recently traumatised and who has probably lost her own child (and most of the rest of her family) so recently to the epidemic. Sadly, it sounds like this problem might be largely theoretical. If infant feeding decisions are to be made, they will be need to be made on a case by case basis understanding that artificial feeding is very risky and unlikely feasible for more than a very very short period. And only then, perhaps while an inpatient in a health facility. In the unlikely event that an infant survives a mother's ebola infection, her best chance of survival into adulthood is still going to be human milk. The questions then become, how to secure that milk and how to deliver it, without putting the wet-nurse at risk.

Breast milk banking and sterilizing banked milk may be an option, albeit requiring refrigeration and storage and safe handling. Formula feeding, with similar requirements may be easier and safer under circumstances.

Dear All On October 8th, the Ebola Communication Network (ECN), was launched. The ECN is an online collection of Ebola resources, materials and tools from and for the global health community. Access and share resources at: [url]http://ebolacommunicationnetwork.org[/url]

Marie, given this, "Having discussed the issue with field staff managing cases, they report that they have not seen any baby of a mother with ebola survive" does this make the discussion about how infants of Ebola-infected mothers should be fed a moot point?? ie it doesn't really matter?? Karleen

Hi Karleen, Thanks for picking up on this. The experience I shared was in the context of the outcome of newborn infants of ebola infected mothers. Sorry if I wasn't clear. This experience was known to the group who produced and updated the guidance note and on balance, it still remained that in the context of non-newborn infants of an ebola infected mother, there are situations where avoidance of breastfeeding and active support of safe feeding alternatives and substitute care is indicated. Another important consideration is that this is just one experience that we have heard of. There may be others that are contrary or that share similar experiences. As ever we welcome experiences of those working in the response to inform the guidance note.

This follow up question has been posted by an anonymous member: Have we established guidance as what to recommend for families who have an Ebola symptomatic mother and a non-symptomatic baby? I know we are not recommending the use of a wet nurse. Do we tell them to buy formula or do we have to provide them with formula? What if we are only running treatment centers? This will be an additional burden and increased risk of exposure if the family members come to the treatment centers to get the formula. Any guidance? Thanks. Also to note that an expert group is working behind the scenes to bring some more guidance to this area and we hope to post further advice from that group on this thread within the next week or so. In the meantime, please don't hesitate to share what you are doing as practitioners in the field as this is extremely helpful to others Many thanks, Tamsin

Dear all, We would like to share with you this recent exchange concerning a question posted offline by Jessica Bourdaire of Save the Children and the response by the technical group: Thank you for the latest guidelines, much appreciated. I have a quick question. If both, lactating mother and infant (<6) are “survivors” (both discharged cured), technically, there is no reason to recommend to wait 8 weeks before resuming breastfeeding, even if breastfeeding was suspended during the treatment because mother was too weak to breastfed her infant. My understanding is that we recommend to wait 8 weeks before resuming breastfeeding when milk test is not feasible for those mothers that are discharged cured (blood test negative after being positive) having infants negative to EVD or asymptomatic (non-suspected). I assume that if both survive, they have antibodies so immunity. Consequently, wait 8 weeks will be only for lactating women having infants negative to EVD, if both are survivors, no need to wait to resume breastfeeding, it can even start before discharge if mother is strong/wish to do so? Dear Jessica, Thanks again for your mail and for the question. We consulted with WHO and agree that when both mother and infant are survivors, it makes perfect sense to allow breastfeeding. If that has happened it may be a good story for the media. We do think it is important to ensure nutritional support to the mother and any practical and emotional support she might need to relactate. It seems that discharge rations are a practice in many cases but it is especially important in this case. On another note, as you might know we are lacking data and information about breastfeeding mothers with Ebola and their infants (percentages of transmission from mother to child, survival rates, relactation). WHO is considering turning the current guidance into an official guidance document and looking for evidence on all aspects of infant feeding and Ebola. If organisations working with ebola affected populations would be able to share any information that would be very helpful and can be shared through email. Best regards, Maaike Arts, UNICEF

I am relieved to see support for mothers who abruptly wean and are separated from their infants addressed in the new guidance. I have a few questions about that: 1.Is there specific guidance for supporting breastmilk expression in terms of technique, timing, collection and disposal, etc.? That important note about supporting the mother who weans abruptly is missing from the flowchart. 2.What about moms who stop breastfeeding and recover from EVD but live where there is no lab to repeatedly test their milk for the virus--the recommendation in those cases is to avoid breastfeeding for 8 weeks after recovery. Is there guidance for supporting those moms to maintain or restart their milk supply? 3.Does anyone know if flash heating kills EV in breastmilk? Thanks, Jennifer Yourkavitch

Dear Jennifer Sincere apologies for the late response to your insightful questions. I'll post a reply shortly, based on a 'behind the scenes' mini-consultation. To immediately answer question 3, flash heating does inactivate the ebola virus. More to follow very soon. Marie

Dear All There remain critical gaps in the evidence base to inform policy guidance on infant feeding in the context of ebola. Programming staff report there is little time and opportunity to ‘conduct research’ in the current Ebola response. However observational data by programmers could help hugely in understanding what is happening to infants and young children and inform guidance. To date, programming questions and experiences have prompted fast tracked interim policy guidance that will continue to be updated quickly. We have listed below critical data that we are seeking to collect and collate. They are also detailed in this [url=http://files.ennonline.net/attachments/2272/Infant-feeding-and-ebola_building-evidence_SHARE.docx]document[/url] which you can complete to register your interest in sharing data or harmonising your efforts with others. Thanks to Prof Andrew Tomkins for his valuable input. If you have programme experiences to share, the ENN can support documenting them to feature in Field Exchange. We can turn very rough notes into tidy articles. We can also interview staff to draft articles. If you are interested in sharing data or experiences, please contact marieATennonline.net Best regards, Marie On behalf of a 'wee' working group UNICEF/WHO/CDC/ENN Key missing data 1. How many Mothers who have infants and young children (< 5 years) have been diagnosed with Ebola (including those in clinic based and community based centres)? 2. How many of these Mothers have died and how long after admission to the programme? 3. How many infants (<12 months) and young children (between 12 and 60 months) did each mother have? 4. How many of their infants and young children (up to 5 years) were tested for Ebola on admission to the programme? 5. How many of these infants and young children (up to 5 years) tested positive for Ebola on admission to the programme? 6. What percentage of breastfed children (0-23 months) whose Mother has tested positive develops Ebola? 7. How many of their infants (<12 months) have died and how long after admission to the programme? 8. How were these infants fed (exclusively breast fed by mothers/mixed breast feeding and other feeds by mothers/formula fed by mothers/formula fed by carers/ other? 9. How many of their young children (between 12 and 60 months) have died and how long after admission to the programme? 10. How were these young children fed (breast fed/formula fed/mixed feeds)?

A number of nutritionists from NGOs working in the ebola response in West Africa have been consulting with each other to address some very challenging situations arising around infant feeding. Below is a question and response they have shared with us. We welcome your inputs. From Óscar Serrano Oria, GOAL Sierra Leone Many mothers in the ebola treatment unit (ETU) refuse to allow their breastfeeding baby to be separated from them. Also, there is difficulty in transitioning from breastfeeding to cup/bottle feeding. Should we change the feeding device to finger feeding, Haberman feeder, syringe, etc? I think the priority should be given to methods that allow the baby to control the flow of milk that they receive. From Casie Tesfai, IRC Here is a response based on lactation management guidelines. It makes me think we need to put together more guidance around specific lactation/infant feeding management issues such as refusal to feeding, transitioning from breastfeeding to bottle/cup feeding, pros and cons of infant feeding devices, how to cup feed, feeding cues, etc. I’m just sharing this in case it is useful for others. I think if the baby is refusing the cup or bottle, then they will probably refuse other devices you try as well. You should probably see this as a refusal to feeding issue and address some of those issues why the baby might be refusing - instead of really looking for a different device. But of course, some babies will have special needs beyond a cup or bottle that will need to be determined on an individual basis. Based on the guidance I have for refusing cup/bottle feeding, this is what is [url=http://files.ennonline.net/attachments/2273/Suggestions-to-support-feeding-difficulties-in-context-of-ebola_171114.pdf]recommended[/url].

The above recommendation comes directly from Pocket Guide for Lactation Management (Karin Cadwell, Cindy Turner-Maffei) - a great resource for lactation practitioners

Posted on behalf of Cota Vallenas, WHO I’m very interested in the other concern raised in Sierra Leone, i.e. that “many mothers in the ETU refuse to allow their breastfeeding baby to be separated from them”. How is that being addressed? Is there any indication about transmission among babies breastfed by their Ebola-confirmed mothers? I have a lot more questions……the ethical issues related to Ebola and breastfeeding are quite complex, and this situation is a clear example.

Posted on behalf of Maaike Arts, UNICEF The issue of women who don't want to give up breastfeeding and/or their baby is very difficult. We need to remember that if the child is also symptomatic, he/she can stay with the mother. But if not, it might be difficult to separate mother & infant as this example shows. I think it would be very interesting to know how often this is occurring, and how this issue is dealt with. I would not be able to suggest a solution other than providing emotional support & counselling to the mother. I also have a lot of questions on these situations - are breastfeeding mothers less likely to seek Ebola treatment for fear of being separated from her child? The again highlights a key question already raised - what % of children who are separated from their mother ends up testing positive? If transmission risk is very high, the need for separation might not be there. We really need more evidence to confirm or modify the guidelines.

From Óscar Serrano Oria, GOAL Sierra Leone Speaking with another operational NGO in Sierra Leone, they have had a few cases in which this issue of separation was problematic. All of them pass by the support of the social workers and a careful explanation of the risks involved. In cases where the mother was ECD negative, and the infant was positive, all risks were carefully explained to them and finally mothers were provided a lighter version of the personal protective equipment (PPE), and encouraged to use an alternative feeding method. When the mother was positive, and the infant negative, all efforts were done to make her understand the risk of infecting her child, with nurses and the social worker spending long time reasoning with the mother. But in that particular case, the mother was traumatized after the death of her husband and proceeded with breastfeeding. At the end, everything passes by respecting the autonomy of the individual and I doubt there is any specific formula to apply unless ‘policing’ approaches are used, which I strongly discourage for a hundred obvious reasons. Maybe many mothers will feel relieved and more confident when they are offered the support of another woman who is recovering in the convalescent ward, just waiting for the final negative result of their tests. This is another approach that might work to help them make a decision that reduces significantly the risk for both mother and infant. Maybe other colleagues have been through this situation and found acceptable/feasible ways to deal with this issue or to accept that the little we can do is supporting the mothers with clear counselling and alternatives such as the help from survivors. I want to thank Casie again for the detailed explanations she provided me about the topic on how to support a baby who has been weaned abruptly. I am advocating for starting with the methods that allow the infant to regulate the flow of milk such as cup or spoon feeding, finger feeding and bottle feeding. Syringe and glove feeding do not seem advisable to me. Also, I attach this [url=http://www.health.qld.gov.au/breastfeeding/documents/feeding_cues.pdf]document[/url] from the Queensland Health department in Australia which explains very well the different stages of feeding cues an infant will pass through (page 1). I plan to use for training of the staff and to stick them in the walls at our ETC in Port Loko.

On the issue of babies refusing alternate feeding methods it is worth considering whether the issue is with the feeding method or with the milk. Some babies have strong objections to the taste of infant formula and this will present as bottle refusal. If breastmilk is available trying to feed with breastmilk will help to identify if this is the problem. If a limited amount of expressed breastmilk is available infants may be persuaded to eventually drink infant formula if it is introduced gradually (ie start with a mix of 75% breastmilk and 25% infant formula for example and then increase the % of infant formula). I have no idea how feasible this would be but it is important to know that the milk itself, rather than the method of delivery can be an issue. ALternatively, temporary addition of a sweetener, such as sugar, can improve the flavour to some infants such that they will accept infant formula. The other factor to consider is that grief and depression from separation from their mother can result in some babies refusing feeds or being reluctant to feed. The emotional needs of the infant should be considered. Thank you to everyone who has shared their experiences. It is indeed an extremely difficult situation. I was wondering, are the mothers who are refusing to be separated from their infants also continuing to breastfeed. I can imagine that mothers in this situation would want to continue close contact and can't help but wonder whether continuing to breastfeed would be beneficial given that the infant is likely being exposed to Ebola through that physical contact.

Thanks Karleen for your inputs. It is indeed a good point about the breast milk combination with the RUIF. The problem is that wet nursing, or in this case, expressed milk, is discouraged in the current settings as most available nursing women that come to an ETC are contact cases themselves, most likely to be in observation for 21 days, and those who survived have to have their milk tested in the lab or wait 8 weeks before resuming breast feeding. It is not an option in the short term but very interesting option for ETCs that have been open long enough to have a network of women who might be able and willing to collaborate. One problem there would be storage of that human milk, mostly safety and confidence that it will actually be conserved properly. It can be stored: - in the fridge for up to five days at 4°C or lower (any electricity disruption for more than 2 hours would mean that all stored milk has to be disposed of) - for two weeks in the ice compartment of a fridge (to be moved to the fridge immediately in the above case) - for up to six months in a freezer (needs to be defrosted in the fridge for a nearly a day) Feasibility of the whole idea is to be tested and I believe it could work with very close supervision, maybe other colleagues currently operating an ETC or similar breast milk related program can comment on that. Adding sweeteners is also a good option that can be easily tested. But also, for me, one of the problems with refusal to accept Infant Formula and alternative feeding methods as cups is the abrupt weaning quite long before it's gradual due time after the first six months of life. Upon arrival to triage the breast feeding will be interrupted, and if the mother or the child have a positive result, it will not be resumed again for a long time. This is a traumatic event for the mother and the child, as you mentioned, and I understand that it is more difficult to deal with the child than with the mother. More feedback on how to deal with this is required. Thanks again and please keep the ideas flowing.

When the mothers abruptly wean are they becoming engorged and if so, what are you doing to alleviate the engorgement? With ebola positive moms who insist on keeping their babies close and to continue breastfeeding, is it advisable to put the babies skin to skin? This has always been a strategy to calm the infant and perhaps if this is done prior to alternative feedings with another substance, the baby may not reject it. This strategy may also calm the mother. With weaning, we have always very slowly added infant formula to breast milk, one ounce/30cc at a time. Most babies do not like the difference in taste.

Hi Geraldine, About the engorgement, I will try to find out more, but basically they shall be requested to do as any other mother, express the milk as long as they have the strength to do it to alleviate the pain, and then discard the milk in a container that ends up in the incinerator. As answered in the previous post, mixing the breast milk with the RUIF is a solution to be tested as safe milk is not easy to come by and needs lab testing, but should be accounted among the ideas to help, in the longer term, infants to have more acceptability of the product. In the other hand, skin to skin contact with the mother is not recommended when she is EVD positive as it is a direct way to transmit the disease. Regards

Oscar, is it Ebola that milk must be tested for? Could flash heating not be an alternative?

Karleen, That is a good observation. In fact, pasteurization can kill the virus, but it is a process that not all ETC can do, and even if they have a laboratory, they will require specialized equipment. Our Lab is being set up now so we need to check the presence of the necessary equipment and consider the possibilities of doing it safely, but maybe another agency is equipped already and they can try it? Since patient testing takes priority, it might not be the first option but it is worth a try.

Hi Oscar, I was under the impression that flash heating will destroy Ebola in breastmilk and this does not require any high tech equipment as opposed to pasteurisation which does.

Dear All We have been exploring flash heating promoted by a question by Jennifer Yourkavitch on 31st October: Heat treatment inactivates the virus – it can be inactivated by heating for 30 mins to 60 mins at 60°C or boiling for 5 minutes. See more [url=http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/ebola-eng.php]information.[/url] However we could not find specific information on flash-heating. It would be great to hear if others have investigated this or whether a field laboratory could test this.

I am glad to see the information flowing. Thanks for the clarifications, indeed this simplifies the process and despite it still needs to be done at the lab, feels more feasible. I just checked some info on Flash Heating and control of temperature seems to be key, while boiling for 5 minutes would be the easiest and lowest maintenance procedure. Thanks for this Karleen and Marie. Looking forward to more comments on this.

hi, just a thought on the added value (risks/benefits) of heating/boiling it when HT and boiling might destroy nutrients, enzymes and protective cell, without mentioning changes on the taste Jess

Hi Jessica, In fact I agree with you. I am actually more interested on the taste side, checking on the idea proposed by Karleen about mixing breastmilk with RUIF in order to make it more attractive to weaned infants. nutrients, enzymes and protective cells are important too, but we already gave up on them once recommending the mother to stop breastfeeding. I think that the whole concept is a bit complicate right now in an Ebola setting, and while trying to make it easier for the infants in the ETC we may in fact be trying to loop the loop with little added value compared with the energy and work necessary to do it. Maybe you can share more on the effects of HT and boiling in the organoleptic properties of breastmilk? Thanks!

Heat treatment techniques trigger chemical reactions which affect ‘differently’ milk constituents, therefore, some changes in flavour. The boiling pot, feeding cup, mother’s new diet, medication can also interfere in BM ‘usual’ flavour. Infants can refuse to be fed for several other causes (stress, separation, unfamiliar environment, pain, disease, etc.). Personally, I will first explore the causes that are easy to address, what works for one might not work for all. How many infants have you seen refusing being cup/formula fed? Jess

Hi Jessica, I haven't seen any as our centre is not open yet, but Save the Children and MSF colleagues report that is a majority. I think it is a combination of the change of feeding methods with total suspension of the breastfeeding and separation from their mothers, being handled by strangers in PPE suits from the moment they arrive. What I am looking for is a way to make it less traumatic or at least help them get over it faster, mainly for the infants as mothers also suffer but at least can understand what is happening.. Cheers

Hi Oscar, just to clarify that we, Save the Children, haven’t admitted so far any child <2 years in our ETC in SL. So, we haven’t seen any infant or young child refusing cup/RUIF feeding. I imagine it can happen in the future so I will share relevant information if this arises. Thanks.

Hi Jessica. In fact, I had it mixed. Samuel confirmed it to me today. I have a visit from MSF, and they have had the experience. It is quite challenging in fact as for them even survivors that stay and help are to wear full PPE, which scares most children. Acceptance of the infant formula itself is difficult but the few they had have finally tolerated it with not much impact on their nutritional status. I am going to try an approach in which identified survivors will take care of the feeding of infants and toddlers with minimum protection equipment. That should help both the baby and the mother to accept the separation and its psychological effects. I will keep you posted. All the other ideas about mixing the IF with breast milk are far too complicated for this settings. Thanks and sorry for the misunderstanding.

In light of the Ebola outbreaks in Sierra Leone and Liberia, the Nutrition and Social Behaviour Change (SBC) Working Groups of the Core Group hosted a 1 hour webinar on Ebola and nutrition. A panel of speakers provided updates and activities related to programming adjustments, guidance notes and research needs and Social and Behavior Change Communication. A presentation on infant feeding and ebola, representing the work to date in developing the guidance note and the involvement of en-net, was presented. You can access the [url=http://www.coregroup.org/resources/webinars/475-ebolaandnutrition]recording[/url] online.

Some of you may be interested in this news article that discusses caring for an Ebola exposed infant [url]http://www.itv.com/news/2015-01-10/ebola-frontline-the-tragic-death-of-baby-mary/[/url]

I have read the story of the baby Mary that died from ebola, its a sad story. I am not a not a medical doctor by profession (am a nutritionist) but have been following the ebola outbreak. This story brings out the many challenges of managing ebola including the change in healthcare dynamics, ethical considerations and how much more we need to learn. I would wish to know what happened after discharge that could have contributed to re-infection/re-admission. thanks

Dear All A recent paper, co-authored by MSF, describes the management and outcomes of two pregnant women with EVD in Guinea. Both women survived but both fetuses died in utero. The paper discusses the poor foetal outcomes for EVD infected pregnant women. The full text article is available [url=http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20983]online[/url]. REF: Baggi FM, Taybi A, Kurth A, Van Herp M, Di Caro A, Wölfel R, Günther S, Decroo T, Declerck H, Jonckheere S. Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014. Euro Surveill. 2014;19(49):p=20983.

Dear All I am sharing with you a [url=http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21017]recent paper[/url] that describes two Ebola virus (EBOV) RT-PCR discordant mother–child pairs admitted to an Ebola Treatment Centre (ETC) of Médecins Sans Frontières (MSF) in Guéckédou, Guinea. In the first, blood from the breastfeeding mother, recovering from EBOV infection, tested negative twice but her urine tested positive. Her child became infected by EBOV and died. In the second, the breastfed child remained EBOV-negative, although the mother’s blood tested positive. The authors highlight possible benefits of EBOV RT-PCR testing in urine and breast milk, the need for hygiene counselling when those fluids are EBOV-positive and the need for prospective study on mother-child pairs for evidence based recommendations.

Dear programmers in Sierra Leone, Cota Vallenas at WHO (Geneva) will be visiting Freetown tomorrow (Wed 25th Feb) for 8 days (until 4th March). This is in relation to the clinical management meeting that WHO had here in January. The meeting group agreed that there is a need for expanding the child care portion of the EVD care pocket guide, so WHO will have a meeting with local paediatricians in Sierra Leone to identify key issues and local approaches for addressing them. The team hopes to have similar meetings in Liberia and Guinea soon. The issue of breastfeeding/infant feeding is mentioned in the preliminary agenda so there will be some time for discussion. In addition, Cota would like to meet with people in Freetown who have had direct experience with breastfeeding mothers and babies in the context of Ebola. If you are available to meet Cota during her trip, please contact her directly with your full name, available dates to meet and local mobile number . Please share this information with relevant colleagues. Cota's email is: vallenasc[AT]who.int

Dear all, The updated guidance on ebola and infant feeding is now available in French and can be found [url=http://www.ennonline.net/anjeebola?version=current]here[/url]

hi tamsin, thanks for posting the infant EVD guidelines in french - is there a translation of the guideline for adults available too do you know please? thanks

actually i have just found it - for others who are interested it is on the french who/oms site under publications - "Prise en charge nutritionnelle des enfants et des adultes atteints de maladie à virus Ebola dans les centres de traitement"

Sorry, I am just reading this today. Hope Cota had the opportunity to meet with Front liners/actors from the Ministry of Health and Sanitation - Nutrition Directorate, UNICEF and some other partners who have been in the front to share their ideas with her.

Dear en-net The WHO and UNICEF are planning an update of the infant feeding in the contact of EVD working guidance document shared above. They are very keen for field experiences to inform the update. Let us know if you have found the guidelines useful, have you encountered gaps, challenges or inconsistencies in implementing the recommendations, and is there anything you would like to see reflected in the next version. Examples of case management or programming situations you have worked in are incredibly valuable. You can post your headline feedback and experiences on en-net and we can follow up with you directly for more details. If you prefer, contact me directly (marieATennonline.net). The deadline for feedback is 20th June. Feedback is also sought regarding the [url=http://www.en-net.org/question/1460.aspx]nutrition support guidance in the context of EVD.[/url] Best regards, Marie

Dear All, Just a reminder, please use this forum or contact me directly for any last minute feedback regarding infant feeding and ebola experiences to help inform a WHO-led update of the interim guidance. Quantitative data is welcome but not necessary; first hand experience is incredibly valuable. Thanks to those who have contributed. Best regards, Marie, email: marie[AT]ennonline.net