The youngest children are the most vulnerable during emergencies. Risks associated with malnutrition and disease increase and child mortality can soar up to 70 times higher than average. Infant and Young Child Feeding (IYCF) is key to reducing the morbidity and mortality of children. Breastfeeding is the single most effective intervention to save children’s lives and could prevent 13% of all deaths among children under five years, while appropriate complementary feeding could prevent another 6% of deaths.+G. Jones et al., ‘Child Survival: How Many Child Deaths Can We Prevent This Year’, The Lancet, 362, 2003; N. C. Rollins et al., ‘Why Invest, and What Will It Take To Improve Breastfeeding Practices?, The Lancet, 387, 2016. This paper discusses Save the Children (SC)’s Infant and Young Child Feeding in Emergency (IYCF-E) response in Greece, through the opening of mother and baby areas in Kara Tepe and Moria camps on Lesvos and in Idomeni transit camp on the border with the Former Yugoslav Republic of Macedonia (FYROM).
The IYCF-E intervention
IYCF-E encompasses a range of key actions to support safe and appropriate feeding practices for infants from 0 to 11 months and young children aged 12 to 24 months:
- Protection, promotion and support of breastfeeding.
- Assessment of feeding practices and needs.
- Support for the non-breastfed infants and management of breast milk substitutes (BMS) such as infant formula.
- Support for timely, safe and appropriate complementary feeding for children from six months old.
- Support for pregnant and breastfeeding women.
SC launched a rapid assessment following the sudden arrival of more than 50,000 people on the Greek islands in July 2015. As the assessment team did not observe any visible signs of wasting or an alarming health or food security situation, and in the main countries of origin (Syria and Afghanistan) wasting levels are not critical, systematic screening/identification and wasting treatment programmes were not warranted. However, there was a critical need to protect optimal feeding practices: women reported reducing or discontinuing breast-feeding because of the lack of privacy and time and the stress they faced during their journey, and a misplaced belief that, because they were not eating well themselves, they did not have enough milk. Support to non-breastfed infants also appeared urgent due to the increased risk of diarrhoea related to the use of infant formula in camps where hygiene conditions were poor and access to drinking water was inconsistent. Facilities and equipment to safely prepare infant formula were limited, and some caregivers were observed feeding infants with undiluted powder milk or cow’s milk, not measuring water to be added to infant formula and using dirty bottles. A large number of unsolicited distributions of breast milk substitute (BMS) were also reported, in violation of the International Code of Marketing of BMS.
The primary goal of the IYCF-E intervention in Greece was to support breastfeeding and non-breastfeeding caretakers in mother and baby areas (MBAs), where they could rest, feed and play with their children, bath their babies and receive nutrition and psychosocial support. The MBAs were established in the same compound as the child friendly spaces (CFS) run by SC, enabling caretakers and children to safely circulate between the sites and to access a comprehensive package of services. Orientation on feeding practices was offered by skilled counsellors, using communication materials in appropriate languages. In-depth counselling was possible depending on the presence of interpreters in the camps, though this was limited given the challenges facing the women and their urgent desire to continue their journey. Infants requiring BMS were referred for provision of infant formula and safe preparation kits within the programme or through a medical partner.
Two MBAs opened in October 2015 on Lesvos, after an interim period where SC provided IYCF-E support through medical partners and the CFS, while the site to be allocated to the MBA was confirmed by the camp authorities. Another MBA was subsequently opened in Idomeni, though this site faced a number of challenges, including regular damage, temporary and unpredictable closures of the camp by the authorities and limited access for NGOs. When a nearby petrol station was turned into accommodation for the excessive number of people arriving at the border, a mobile unit was set up to cover a larger number of children.
In February 2016 a survey of caretakers of children below 24 months was conducted on Lesvos to quantify IYCF practices and identify priority needs. At this point, in the depths of winter, the daily number of arrivals had decreased and the situation was calmer. In total, 148 children were included in the assessment. The results confirmed the serious situation regarding IYCF practices and the general wellbeing of children and caretakers: breastfeeding patterns were far from optimal and the majority of mothers reported difficulties in breastfeeding. Around 30% of the caretakers were feeding their children infant formula that they had bought or received from charities. A majority of caretakers were using bottles but could not reach cleaning facilities. Feeding frequency was insufficient and dietary diversity poor due to the lack of fresh food during the journey, lack of money and distress of the mother and the child. Before the EU–Turkey deal in March 2016, NGOs and volunteers’ associations were the only ones providing food assistance, distributing more than 10,000 meals per day in some locations.
Since March 2016, the government has opened more than 50 formal camps, and in July 2016 SC was running eight MBAs covering 16 camps in FYROM, Attica, Lesvos and Chios. Between October 2015 and June 2016, IYCF activities reached approximately 11,000 children and 10,900 caregivers.
Coordinating IYCF activities
While a large number of humanitarian organisations are present in Greece, few are supporting nutrition. SC receives financial support from the UN High Commissioner for Refugees (UNHCR) and, more recently, technical support from Unicef, but remains the main nutrition actor in the response. Individuals and volunteer organisations were predominant from the outset of the emergency, and some volunteers’ associations, such as Project Nurture International, have started to focus on IYCF-E, improving the coverage of services.
In Lesvos, a health and nutrition working group led by UNHCR began meeting regularly from the end of summer 2015. Many humanitarian and non-humanitarian actors were not aware of international guidance on IYCF-E, and SC conducted several sensitisation sessions to protect breastfeeding practices and reduce untargeted distributions of BMS. It has not been possible to quantify the impact of the sensitisation sessions on reduced untargeted distributions of BMS. At the national level, health working group meetings covering nutrition issues started in February 2016. At the global level, international NGOs and UN agencies conducted bi-weekly calls, co-chaired by SC and UNICEF, to share relevant information, materials and resources, promote consistency in the application of global guidance and identify areas needing additional guidance. The platform was also used to highlight IYCF-E needs in the West Balkan countries.
Difficulties in implementation of IYCF-E interventions
A number of challenges specific to this crisis arose. First, people were moving rapidly, allowing only a limited time (from a few minutes to a few hours) for caretaker and child assessment, support and referral. The number of refugees arriving in transit areas varied greatly day by day, making forecasting and staffing of interventions difficult. Moreover, no demographic data for children less than two years was available. Second, a wealth of nationalities was represented and cultural mediators were urgently required. Their limited availability, the lack of people trained in IYCF and legal constraints on non-EU passport holders working in Greece markedly affected the quality of the intervention. Third, the high proportion of infants dependent on infant formula before the start of their journey led to frequent requests for BMS, while service coverage was too low to ensure prior counselling and suitable preparation. Lastly, there was insufficient attention to ensuring adequate complementary feeding by all responders and volunteers: the food distributed was either not suitable for young children (i.e. too hard) or consisted of jars of baby food unfamiliar to caretakers, and with no information in the appropriate language or confirmation that it was a halal product. Despite efforts in coordination and capacity-building, untargeted donations and distributions of BMS and bottles, by actors unaware of international guidance on IYCF-E interventions were regularly reported.
The response after the EU–Turkey deal
Following the implementation of the EU–Turkey deal in March 2016, programmes across Europe have been adjusted. Most of the former reception sites on the Greek islands have been turned into detention centres, and the government now manages more than 50 camps, with the support of UN agencies, international and local NGOs and volunteers.
Recent assessments highlight the persistent lack of coverage of IYCF services and the need to reinforce some aspects of interventions. Collaboration with the various ministries and key decision-makers involved is being developed by food security, health and nutrition working groups to prioritise IYCF, and provide appropriate food assistance for the most vulnerable, including the elderly and people with health conditions. In terms of IYCF, the main priority actions remain:
- The establishment of safe environments for caretakers with young children, along with strengthened outreach activities.
- Reinforcement of the screening of caretakers and children and support to breastfeeding and non-breastfeeding caretakers, with counselling adapted to a population no longer on the move (e.g. re-lactation support and maternal health activities and messages).
- The provision of adequate complementary food for children over six months to reduce risks of undernutrition and morbidity in a population entirely dependent on food assistance.
- The integration of IYCF-E within all services, but specifically protection and psychosocial support, to help reduce distress among caretakers and children.
The rapidly changing situation, high numbers of refugees and migrants and the specific transit context stretched the capacities of organisations and volunteers to respond effectively, indicating a need for better preparedness and coordination in a European context generally unknown to many of those involved. The presence of a larger number of organisations with nutrition capacities could have increased the coverage and effectiveness of IYCF-E interventions. Greater involvement by donors to advocate for IYCF interventions could have enabled more agencies to get involved in the crisis, while the IYCF-E sector itself still represents a challenge and a new area for many organisations, as seen in other crises including Syria, Lebanon and Jordan.
The difficulties inherent to this specific context have highlighted the need to revise and adapt IYCF-E guidelines to enable the quick provision of operational assistance. Lessons are currently being documented and analysed by global IYCF experts to inform existing guidelines and ensure that knowledge and practices gained during these past months can inform future programming.
Minh Tram Le is Nutrition Coordinator for the European Refugee and Migrant Crisis, Save the Children International. Claudine Prudhon is Researcher – Infant and Young Child Feeding in Emergencies, Save the Children UK. Anne-Marie Mayer is an independent consultant. Megan Gayford is Senior Humanitarian Nutrition Advisor, Save the Children UK. We would like to thank Mardjan Abidian and Nisrine Jaafar for their great work as interpreters during the infant and young child feeding assessment in February 2016.