Dear Patti, Thanks for raising this issue. From what I have observed, the level of training and preparation of staff to cater for infant feeding in emergencies is variable, and is complicated by the need to post staff urgently to a situation with little chance for context-specific training. There are gaps in guidance on how to cater for formula feeding support at scale, and how to cater for families in transit in very difficult situations. There also appears to be many volunteer individuals and groups responding to help; this is great to see but does complicate coordinated effort. Amongst those refugees in transit and arriving to new countries, there is an urgent need to cater for the needs of both infants that are breastfed and those that are not. How to handle in infant formula in a way that minimises risks to all infants involved is a challenge and will require some compromises and pragmatism. Experiences in previous emergencies is that donations of infant formula do not help these situations but equally, there requires channels of 'official' supplies in order to meet needs. I'd encourage any agencies, groups or individuals to share your experiences of how you are handling this, any guidance or resources that you have developed in response (it is in these situations that there is much 'innovative brainstorming' which would be valuable to share with all.

Another thing to factor in is that many countries in which there are refugees in large numbers have not experienced an humanitarian crisis like this for a very long time and local authorities and organisations will likely be ignorant of how the environment for infant feeding might be different to that they are used to and/or the organisations involved may be those that do not usually deal with infant feeding. I've recently become involved in the issue of infant feeding support for asylum seekers in immigration detention in Australia and the lack of knowledge and disorganisation has been staggering. I can see that the same issues would be in play in Europe. I'd be interested to hear more about what is happening on the ground.

Patti and Marie, You may remember that when there were somewhat similar issues during the 90s, I believe that WHO finally supported Felicity Savage and other to do some lactation management training, which included both support for newborns, relactation and increasing milk supply. At the same time as agencies try to meet existing needs, it would be good to get UN agencies (especially WHO and UNICEF) to think about a similar initiative.

Watching footage of women carrying nothing more than their babies made me shudder last night. Unless there is someone else carrying for them, they have no nappies and no way to wash clothing. I can only think that breastfeeding must still be common amongst the fleeing populations. However, as Karleen notes, they are travelling into communities in which artificial feeding will be trusted over breastfeeding and local health care and humanitarian workers are unlikely to have breasfeeding support and management skills and even less likely to have specific knowledge of the challenges associated with the use of infant formula in precarious situations. I would also like to hear from anyone on the ground ... how can we help? (I imagine everyone is much too busy to be online, though.) cheers Nina

I imagine that implementers are also having to make the difficult decisions about accepting funding, if not actual products, from non-WHO Code compliant companies. This is tough, even outside emergencies. It might be timely to ensure that HQs of implementing NGOs are aware of the risks of collusion with non-compliant companies. This message could also be spread through InterAction, ACFID, and similar NGO alliances.

Dear Nina, It is important to note that some of these affected populations are very familiar with and practising formula feeding. Imagine a population in France or the UK or Greece in transit. So this is not just a case of breastfeeding mothers being exposed to communities who formula feed; this is about both breastfeeding mothers and formula feeding mothers being in very compromised situations. Relactation will not be a viable option for the vast majority of the formula dependent infants.

Hi all, Marie is right and the problem is further compounded by the fact that refugees are in transit and need quick assistance for 2-3 days before they depart on their journey. Our team on the ground has received many requests for infant formula for formula fed babies. Other agencies we've spoken to have reported the same. It's important as Marie noted that we respect personal choice and not set up unrealistic expectations. The goal is to protect the health of both breastfed and formula fed infants and children. We also do not want to undermine breastfeeding through unregulated donations. I look forward to hearing others experience on the ground and coordinating with other agencies on guidance for breast milk substitutes for transitory refugees.

Dear all I totally agree - the goal is to protect the health of both breastfed and formula fed infants and children. Indeed Baby Milk Action's two strap lines ( that we have to repeat because the industry likes to misrepresent what we do) are: Protecting Breastfeeding - Protecting babies fed on Formula We are not anti-formula - we are anti - irresponsible marketing. It is also true that there are high levels of bottle feeding in Syria. The question is how to ensure that there are needs assessments by qualified health and nutrition workers - ideally trained in infant feeding - so that deliberate exploitation and harm is avoided. Worth remembering that in the Philippines the companies attempted to weaken the legislation so that they could donate formula in emergencies. There is nothing they like more than being seen as a rescuer: http://info.babymilkaction.org/update/update46page18#2

I think this is an extremely challenging situation, which only increases the importance of having a good response. I recall, during the Asia Regional IYCF-E training meeting in Bali some years ago that a scenario not dissimilar to this situation in terms of large numbers of non-breastfed infants was given for consideration of developing a plan of response and no one wanted to touch it! Too difficult. I think it's important to note (and I am sure that this is well understood by those on the ground) that requests for formula are not necessarily an indication of need (they always occur) and that all of the other factors that impact infant feeding will be in play- so there will be many breastfeeding women who feel that their milk supply is being impacted by stress etc who are in need of support and not formula. And it is also important to note that supporting women in their informed choice is the goal which involves helping women and their families to understand the potential ramifications of infant feeding decisions in their changed circumstances. It's complicated, more complicated than usual. And there are well meaning individuals and organisations who do not understand this. For example, there have been people raising money to buy breast pumps to distribute in Calais refugee camps! Not very helpful.

Dear Colleagues, I now work for a Belgian government organisation who does the follow up of all children born until 3 years old. This includes any new arrivals to Belgium. I work in a small town, so the number of refugees we see is manageable, not the massive arrival of groups like it is in the capital or other major cities. The issue of breastfeeding is indeed a challenge. Mothers who breastfeed often change their feeding choice once formula is available free of charge (which is the case in the first couple of months they arrive), due to lack of time, stress, PTSD but also lack of qualified support. Quite often I have also seen that psychiatrists tell mothers with PTSD to stop breastfeeding in order to be able to prescribe medication. I put a big effort in helping mothers who give birth here to make an informed choice and help breastfeeding started, since free formula is only available during the period when they apply for a stay permit, it finishes once they get it or once their application is denied, then they are on their own. One of the organisations who provides housing and income was also reimbursing formula but once there was new funds available we managed to instate a system where women in difficult financial situations (Belgian and other nationality) get a small sum of money every month instead of having formula reimbursed. Still, the major challenge is that women deal with many health providers: family doctors, pediatricians, midwifes, nurses and there is very little consistency in the support (or lack of) of breastfeeding.

In the above comment I meant that only breastfeeding women get a small sum of money instead of having formula reimbursed.

An interim guidance note is currently being developed by UNICEF, UNHCR, Save the Children, a number of NGOs and experienced individuals, to address the immediate feeding challenges of infant and young children in transit, such as in the current European refugee crisis. Watch this space.

That's wonderful to hear Marie. I am looking forward to seeing it. I have been seeing reports of individuals and groups travelling to locations where refugees are located wanting to help with infant feeding. For example, LLLGB are fund raising to assist Greek LLLLs to provide breastfeeding support. I wonder how this is all going to play out on the ground- certainly the more information there is available written by those with emergency expertise the better.

That's good to hear that LLL GB and Greece are reacting. Equally (as in other "easy-to-access" situations) there will be well-intentioned individuals and groups who will pack the car/van with inappropriate donations, including formula, and drive to populations where they'll distribute inappropriately. It could be good for professionals on the ground to get some tips on how to deal with these self-funded people, e.g. asking what and how they intend to distribute, and ensuring that it will not do any harm.

From work I have been doing around poverty and crisis and the impact on breastfeeding here in Leicester where we have many refugees and asylum seekers, I have been shocked at the impact on bf. Rates of bf are certainly lower than would be expected for the communities involved. Women tell me they hear that bf is 'not allowed outside in the UK' from their peers - and believe it because they just don't see it.They do believe that formula must be better when they see row upon row in shops. Women tell me they are used to seeing bf promoted 'back home' - and compare it to the situation here. Pragmatism may be important but not complacency. Protecting promoting and supporting bf has to be thought thro very very carefully to ensure we do not undermine it further. And protecting babies who are not breastfed is vital. Unless there is a real strategy in place how on earth can women even begin to safely feed their babies for as long as they need to? I see the priority absolutely being to protect breastfeeding and provide clear simple campaigns and publicity to ensure the situation is not made worse by unsolicited donations. Leicester is awash with tiny charities asking for donations to buy formula and baby food for Syria. Bf rates do risk being decimated by this crisis. I apolgise for the outpouring but we must guard against almost literally throwing the baby out with the bathwater here.