My knowledge of infant feeding is scarce. I’ve got a few friends who’ve had babies recently, including one whose child is fed by nasogastric tube, so I’ve picked up some bits along the way, but haven’t given it much explicit thought, certainly not professionally. As a consequence, much of my own language around this is likely to be a bit clumsy, apologies upfront for any insensitivity; I hope that by talking about it I can learn more.
The issue of feeding babies and the link with emergency management gained a bit of attention this summer linked to a shortage of formula in the United States, and there are a couple of previous incidents which provide indications that this is a potential issue worthy of further work including:
- the 2008 Chinese milk scandal where infant formula (and other products) were deliberately contaminated with melamine causing kidney issues for infants or,
- the 2013 New Zealand recall of milk products used in the production of infant formula after suspected botulism-causing bacteria were found in 1,000 tonnes of product.
I first became aware of human milk banks through the Midland Freewheelers a ‘blood bike’ scheme where volunteers distribute blood and blood products in support of the NHS. But despite their name, blood bike schemes also transport human milk from milk banks (and solution for Faecal Microbiota Transplants, but I’ll let you have the pleasure of googling that).
This post pulls together my thoughts from a recent workshop convened by Gillian Weaver and Dr Natalie Shenker from the Human Milk Foundation. I’m sharing my reflections on the workshop to bring awareness to those who (like me) might not have thought about infant feeding in emergencies before, and to try to break down what is a complex and convoluted area.
Landmark workshop today from @milk_foundation and @LucyGoBag on “Emergency Planning in Human Milk Banking #InfantFeedingInEmergencies #IFEinUK #IYCFEinUK #MilkBanks #DonorMilk @LondonFire @stjohnambulance @UKAMB1 @wbtiuk @IFECoreGroup @BflgUk pic.twitter.com/GXfrqUGUNR
— Helen Gray (@HelenGrayIBCLC) November 11, 2022
There are two principal ways that infants can be fed – breastmilk or formula. This is a highly highly sensitive area of discussion; donated breastmilk helps to save the lives of premature and sick babies, supports those with feeding challenges, unable to lactate or who have no breast tissue, milk donors may be very recently bereaved, and there are cultural issues at play too. The priority of an emergency manager is ensuring needs are met rather than making any value judgements, in this case about how children are fed.
Discussion at the workshop revealed the potential for a range of different types of emergencies that could impact both ways of feeding in different ways. Thinking about these different scenarios quickly becomes a bit overwhelming. Two solutions to that, firstly to temporarily ‘take the human out of the equation’ and look just at the problem, and secondly, to try to break down the problem into more manageable chunks. There are lots of different scenarios which could impact infant feeding, but there are fewer ‘common consequences’, so it makes more sense to consider those.
It also makes sense to consider risks in the context of acute and chronic stressors, for instance:
- Acute stressors could be things like electricity disruption, which has short-term implications for keeping frozen milk frozen and perhaps the ability to communicate with milk donors.
- Chronic stressors could be attributes such as an apparent lack of common operating model and resource pressures, these have longer-term impacts on the day-to-day services and exacerbate, and can be exacerbated by, the acute stressors.
During the workshop discussion, I was drawn towards thinking about a trifecta of supply/demand imbalance, pinch points and interoperability, something like this…
Each risk scenario has differential impacts on each of those parameters; some are more obvious than others. For instance, lockdown restrictions might impact the ability to donate milk (supply/demand) but perhaps less obvious is research which shows that the stress of an emergency may impact the ability to donate milk (also supply/demand)
Having considered the risks based on those three factors, I would then move towards building resilience in each area – take each factor in turn and explore what could be done to mitigate the impact of risks:
Some people mentioned that there could be issues in terms of insufficient freezer space, so there is a very practical step of looking at options to increase capacity – the obvious place is to buy more freezers, but perhaps there are other options to consider the shelf life of human milk, ability to rapidly scale up and down donation services and to consider other storage options (there is exciting work to consider whether freeze-dried milk might offer a feasible alternative solution). Another aspect which came up as a potential pinch point related to supply chain issues affecting commercially produced infant formula, which could perhaps be counteracted by exploring options to increase domestic production.
That’s a bit of a jargony title, but essentially means working together. Not all risks will be geographically dispersed like a pandemic, some which be much more local. A degree of resilience would come through being able to turn to/offer help to other milk banks facing issues. However, different milk banks seem to do things differently, which means they’re less able to lean on each other for support in times of pressure. It could be a useful step to explore this starting with a kind of buddy system.
There is a background context of changing usage to be aware of here, milk bank use has increased over recent years and continues that trend. In addition, there could be situations where there are short-term changes to supply. The most recent fuel supply issues in the UK had a notable impact on donations, presumably because people couldn’t travel to drop off or collect donations. Supply chain issues for formula (such as those in America, China or New Zealand) may lead people to divert to milk bank usage, increasing demand. As mentioned already, the stress of an emergency can impact milk production – so another ‘easy win’ would be for there to be better support on this issue for people who are displaced, perhaps considering deploying lactation support workers to rest centres?
— WBTiUK Breastfeeding (@wbtiuk) November 11, 2022
The contamination of formula with cronobacter sakazaki and the complexity of the infant formula production network received specific consideration from Simon Cameron from Queens University Belfast; this links to existing food chain biosecurity considerations (as described briefly on page 61 of the National Risk Register).
@SJS_Cameron taking us through the terrifying risks to our formula #SupplyChain especially #ClimateCrisis and other #emergencies #InfantFeedingInEmergencies #IYCFEinUK #IFEinUK pic.twitter.com/xiFeu7do47
— Helen Gray (@HelenGrayIBCLC) November 11, 2022
Charting a course to overcome the challenges
Many of these issues are business continuity issues for the milk banking and formula sector to resolve, and better data would help understand the scale of the challenges and the costs of action and inaction. However, they have friends in the public health, environmental health, healthcare and emergency management communities. A large part of emergency management is making friends before you need them rather than when you need them.
In my experience, current arrangements for supporting breastfeeding and infant feeding in an emergency in the UK are inadequate. People affected by an emergency may be taken to a ‘survivor reception centre’ or ‘rest centre’, they might get a cup of tea and a pamphlet explaining what support is available. It is unlikely that there will be specific, adequate and appropriate facilities for preparing infant formula. Making sure these locations are accessible for people with mobility needs is standard, why isn’t that the case for infant feeding needs? Emergency planners should give this greater consideration.
There is international guidance on this (from UNHCR in 2007, and more recently this guidance from the Philippines and this guide from the US CDC in 2022), so this isn’t starting from scratch, and there is clearly a wealth of experience in the human milk and infant feeding sector that should be tapped into. However, the most shocking thing to me is that this is all voluntary, seemingly run by volunteers. That there is no national service for human milk is astounding, and perhaps the most effective risk mitigation would be for the importance of this service to be recognised.
Another area where I think emergency managers could assist is to invite milk bank and infant feeding representatives into relevant conversations and exercises. It’s not just the practical element of feeding infants, but also the psychosocial impacts on parents, and considering this practical issue may help reduce distress for adults. We agreed to explore opportunities for observer attendance at rest centre exercises to start building stronger bridges between sectors, so I look forward to reporting back on that before too long.
Finally, perhaps each of us can take action as individuals too:
- Learn more about human milk donation – the UK Association of Human Milk Banking is a good place to start.
- Ask friends and family with children under 5 years old what steps they have taken to consider emergencies. Encourage them to join the Priority Services Register of their energy company to get extra support.
- Find your local milk bank and consider making a donation (they accept donations of cash as well as milk!)
- Consider writing to your MP to bring this issue to their attention and ask them to lend their support to this much-needed service.