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Supporting Breastfeeding in Times of Conflict

Brandel D. Falk
Jerusalem Israel
From: LEAVEN, Vol. 39 No. 3, June-July 2003, pp. 62-64.

Times of conflict bring very special difficulties to families. Leaders who are helping mothers in countries experiencing unrest may be faced with questions and situations that are virtually unheard of in other times and places. This article provides insights based on the experiences of Leaders in Israel during the 1990 Gulf War.

In times of conflict, civilians may be instructed to use protective equipment when there is a threat of an attack. This may consist of gas masks for every adult and older child and a special collapsible plastic tent for babies and toddlers. Called a "babysitter kit," it is similar to an incubator but with a large filter on the back. It covers the baby’s head and upper torso. Children who are too old for the babysitter kit may have problems finding a properly fitting mask, as they usually come in a limited number of sizes, so the fit may not be perfect. Keeping atropine injections on hand may be recommended, as it is a drug that would need to be administered if there is exposure to nerve gas.

The authorities may recommend a sealed room, prepared by covering all windows and other openings with heavy plastic. Placing a rag drenched with bleach at the base of the door after everyone is inside seals it. The sealed room needs to be stocked with canned food and a large covered container of water. During a stay in the sealed room, a radio is essential, and families may want to bring in a TV and a telephone. With the reports from news media covering the globe, those with close friends and family in other areas may receive international phone calls even in their sealed rooms.

In an area where such concerns are prevalent, LLL Leaders may be asked if it is a good idea to start a baby on a bottle from birth. Breastfeeding is impossible in the babysitter kit, which might be used several times a week, and often for long periods. A related question might be whether to put artificial baby milk or water in a bottle that comes with the kit if/when it is used. These are not the usual questions for an LLL Leader! In fact, there is no right answer for every baby. The LLL Leader needs to empathize and explore options with the mother so that she can find an answer that works for her family. Similar questions might also involve pumping the mother’s milk if pumps are available.

During any conflict, stress is an issue. Many people leave radios on day and night to listen for air raid sirens and news. Although sirens may be blown throughout the country, some homes may be too far away from the nearest one to be sure to hear it. Because many attacks occur in the middle of the night, sleep deprivation may be common. Families with young children have to help each child into a babysitter kit or mask. In addition to all the major fears, there are all kinds of relatively minor worries, such as whether the plastic bag that is part of the young children's gas masks was tied tight enough (and loose enough!), whether children would "unlearn" the rule about never putting a plastic bag over their heads, how to know when to use the atropine, or even whether you could actually manage to inject yourself or your child with the atropine if needed.

Pets are another concern, since they can be brought into a sealed room, but gas masks are not available. One Leader who lived through a conflict situation remembers that her cat learned to run to the sealed room as soon as the siren went off! Information about what is happening may also be limited. These concerns add up to a lot of stress.

Interestingly enough, during my personal experience with the first Gulf War, I don't remember any mothers asking about low milk supply because of stress. If stress does become a problem, Leaders may want to give information about the milk-ejection reflex (Breastfeeding Answer Book, 2003 edition, pp. 41-43; 1997 edition, pp. 32-34) or suggest using relaxation techniques such as those used in childbirth preparation.

During a conflict, it may be nearly impossible for the mother of a young child to leave the house. Many families in conflict areas may not own cars and travel may be restricted. Going out may mean walking or taking a bus. In addition to her own gas mask, a mother with a baby has to fold up the babysitter kit and take it with her and the baby. The weight of the babysitter kit makes shopping difficult. The mother may need to decide whether to leave the baby at home or buy less food. Again, a Leader can help a mother find the best means of handling this situation for her individual family.

Conflict brings worries about the loss of essential services—water, gas, electricity, phone, or public transport. The loss of any of these may make it impossible to artificially feed a baby and make breastfeeding all the more important. Leaders may get questions about relactating or how to safely use breast pumps.

During times of conflict, mothers can become more isolated from friends and family who live at a distance. Fear and anxiety lead some people to withdraw. Others rally in support of their loved ones. A Leader can encourage a mother who is feeling isolated to reach out to her friends and family and tell them how much she needs their support.

Birth may be complicated by a conflict, as well. Some women who might have otherwise chosen a home birth give birth in hospitals, since midwives might find it difficult to travel during an air raid. Hospitals need a number of sealed rooms, including the nursery and all delivery rooms. During air raids, women may give birth wearing gas masks, and newborns may be immediately placed in a babysitter kit. Extra staff or volunteers may be needed in some hospitals. Sometimes several nursery babies are placed in the same babysitter kit, so all babies need clear nametags to avoid confusion. More women may be placed in each room, especially the rooms nearest the nurses’ stations, to make the job easier. They may be released earlier than they may have been in peacetime. Some hospitals may close their maternity floor altogether, sending birthing women to a different and possibly unfamiliar hospital. Some hospitals may eliminate rooming-in, while others may introduce more rooming-in. Stress can lead to more "false labor," as well as premature labor, and there may be a higher cesarean rate. Hospitals may be reluctant to send mothers home in early labor because of the risk of travel during an air raid.

On the other hand, it seems that people are more considerate of others than usual. In my experience, it was almost as if nobody had time to be nasty. In my experience, war brings out the best in everyone.

References

Burleigh, N. Watching children starve to death: An exclusive look inside Iraq’s devastated hospitals. Time 1991; 10 June: 36-37.
Helsing, E. et al. How to Breastfeed During an Emergency: A Guide for Mothers. Copenhagen, Denmark: World Health Organization, 1995.
Jelliffe, D. and Jelliffe, P. Breastfeeding: A key measure in large-scale disaster relief. Disasters 1977; 1(3)199-203.
Perez-Escamilla, R. et al. Maternal anthropometric status and lactation performance in a low-income Honduran population: Evidence for the role of infants. Am J Clin Nutr 1995; 61(3):528-34.
Prentice, A. et al. Body mass index and lactation performance. Eur J Clin Nutr 1994; 48 Suppl 3:S78-89.
Smith, C. Effects of maternal undernutrition upon newborn infants in Holland (1944-1945). J Pediatr 1947; 30:229-43.

The 2003 Edition of The Breastfeeding Answer Book (BAB) has a section called "Breastfeeding in Emergency Situations."

  • Some misconceptions about breastfeeding in emergencies have led to unnecessarily high levels of infant mortality. For example, in Iraq during the Gulf War, some officials, journalists, and relief workers promoted the idea that breastfeeding was not possible due to malnutrition and psychological stress (Burleigh 1991).
  • Although stress can temporarily inhibit a mother's let-down, or milk-ejection reflex, this will not necessarily result in a decrease in milk production if the mother continues breastfeeding.
  • Research from developing countries and other parts of the world indicates that even mothers who are mildly malnourished produce an adequate supply of good quality milk for their babies and that only when a mother is in famine or near famine conditions for weeks or months will her milk supply or the composition of her milk be affected (Perez-Escamilla 1995; Prentice 1994).
  • Even in famine conditions, milk production may be only slightly affected if the mother has body stores from which to draw energy for milk production (Smith 1947). However, if a breastfeeding mother is in famine conditions and her milk supply is at risk, providing food supplements for the mother is a less costly and healthier strategy than providing formula supplements to the baby. No link has been found between fluid intake and milk supply.
  • One way to avoid infant deaths related to artificial feeding in emergency areas is to encourage women who had previously weaned or never breastfed to relactate (Helsing 1995; Jelliffe and Jelliffe 1977).
  • Basic strategies for relactation and induced lactation include stimulating milk production by:
  1. Putting babies to the breast to suck at each feeding and for comfort between feedings;
  2. Using hand-expression or a breast pump (whatever type is available);
  3. Using a nursing supplementer (if available and if conditions are sanitary enough to make its use safe) to provide formula supplementation while baby sucks at the breast;
  4. Taking herbs and/or medications that increase milk.

Adapted Information from a Position Paper recently published by
The International Lactation Consultant Association

  1. That all breastfed infants in emergency situations continue to be breastfed exclusively for six months and, when safe complementary foods are not available, beyond that point.
  2. That breastfeeding continue alongside complementary feeding well into the second year of life and beyond whenever possible.
  3. That humanitarian aid agencies adopt as part of their policy the promotion and support of breastfeeding in emergency situations. Training humanitarian aid workers to implement these policies is vital as many of them come from non-breastfeeding cultures where basic breastfeeding information and skills are lacking.
  4. That training of all humanitarian aid workers include essential breastfeeding messages:
    • Nearly every woman can breastfeed her baby (babies);
    • Mother’s milk alone has everything a baby needs to grow well in the first six months of life;
    • Breastfeeding is protective against infectious diseases, especially diarrhea and acute respiratory infections (ARI);
    • Even malnourished and traumatized mothers produce adequate quantities of good quality milk;
    • The hormones released by the mother in the course of breastfeeding help the mother relax and counteract some of the results of stress;
    • Feeding the breastfeeding mother is a cost-effective way of ensuring adequate nutrition for both mother and baby. (Donations of breast-milk substitutes which inappropriately target children during the breastfeeding period, may instead be used in powdered form as a protein enricher in cereals for babies over six months or to make nutritious hot drinks for mothers and older children.)
    • When breastfeeding has been stopped prematurely or has not gotten started, relactation is possible with adequate support and appropriate breastfeeding management.
  5. That breastfeeding be integrated in national emergency plans in all countries (including industrialized countries in which breastfeeding may not yet have become the norm).
  6. Public relations and media policies at local, regional, national, and international levels emphasize breastfeeding as a vital component in infant health and survival programs during emergencies. There should be a mechanism for quick reaction when media reports imply that emergencies compromise a mother’s ability to breastfeed her baby.

"Protecting, promoting and supporting breastfeeding in these areas will help ensure that those infants affected by these disasters will not be twice-victimized by long-term health and developmental problems that could be prevented by breastfeeding. For their mothers, too, there are health benefits to breastfeeding and, not insignificantly, breastfeeding has economic advantages which reduce the over-all cost of the disaster to both families and the nations affected. It is an investment that pays benefits many times over."

Further Reading Breastfeeding Answer Book, 2003: pp. 54-57, "Breastfeeding in Emergency Situations"
Web site showing protective equipment issued in Israel; http://www.idf.il/homefront/english/ie-index07.stm
International Lactation Consultant Association (ILCA) position paper on breastfeeding in emergencies can be found at: http://www.ilca.org/pubs/pospapers/InfantFeeding-EmergPP.pdf


Brandel D. Falk has been a Leader for 14 years. She and her husband, Yehuda, have four sons, Eli (22), Yoni (19), Mati (17), and Gabi (13), and a daughter, Pnina, born March 2003. They live in Jerusalem, Israel and are all—except for Pnina—survivors of the 1990 Gulf War. Working in collaboration with the author, Patty Spanjer prepared this article for publication. An LLL Leader for 25 years, Patty and her husband, Dick, live in Georgia, USA and are the parents of five children ranging in age from 6 to 29.

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