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Infant feeding in emergencies

Infant feeding in emergencies

Reading Time: 6 minutes

 

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.

An image showing a 2007 booklet titles Infant and Young Child Feeding in EmergenciesThe 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.

Background

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.

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.

Risk Identification

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… 

Image of a hand drawn diagram on lined paper showing a triangle of factors, supply/demand, pinch points and interoperabilityEach 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:

Pinch points

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.

Interoperability

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.

Supply/demand

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?


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).

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.  
Some thoughts on professional societies

Some thoughts on professional societies

Reading Time: 3 minutes

Getting into any career is tricky. Employers are looking for the perfect combination of both knowledge and experience. Fresh out of University you have to try extra hard to demonstrate that you can actually do the job, not just talk about it.

That was the position I found myself in almost 13 years ago. I spent countless days completing applications; labouring the point that “yes, I might have only ever worked in a shop, but you can definitely trust me not to screw this up”.

One way I could show employers that they could put their faith in me was to join a professional association. These bodies are designed to represent the interests of those in the field, so if I was a member it would enhance my legitimacy. Not one to do things by halves, I joined no less than 4 professional associations.

I did my research beforehand, of course.

Some of these organisations had a specific focus, others were more general. Some had active online communities, others were more traditional.

As a fledgeling emergency manager, I thought it was a good idea to try and learn from as much of this as possible. That way I could tell employers I not just only understood the job, but I also understood the profession and the direction it was travelling.

I’m no longer a member of any of those organisations that I joined.

Professional societies, at least those that I joined, had failed to move with the times. The challenges facing the profession now are not the same as those before critical UK legislation was introduced. The risk environment has changed, and the profession seems to be struggling to keep up.

Although, I think there were more fundamental issues holding those societies back

  1. Ego – None of these societies are sufficiently large in membership that they require the level of process that most of them have. Beacurcracy tends to override what could be helpful information exchange platforms.
  2. Identity crisis – There’s a shift towards a more holistic concept of resilience which is not reflected in the scope of the professional bodies. Emergency Planning, that’s too focused on ‘plans’. Civil Defence – that’s an outdated term from the 50’s. Business Continuity – that’s too defined by formal standards.
  3. Lack of value to members – having been associated with a range of bodies for at least the last 8 years I cannot honestly say that it has been worth the investment either financially or in terms of benefits gained.
  4. Unrepresentative leadership – those employed in emergency management when I first started my career often had military or security backgrounds. At the practitioner level that is changing, and new perspectives are being introduced, but the makeup of the decision makers in many of the professional organisations has not kept pace with the changing demographics of the field.

I don’t like to just sit on the fringes and criticise. If I see an issue I want to try and resolve it. For one of the bodies, I worked with similarly enthusiastic colleagues to solve some of these problems. However, after 18 months of trying different things and volunteering my own time, the same issues remained.

That organisation in particular alienated its members through sporadic, ill-conceived communication and disrespected its own volunteers. For a body designed to support members, it showed an extreme lack of empathy.

Contrast that with the sense of camaraderie and community I’ve seen online from my SMEMchat colleagues. This eclipses anything I have seen in over 10 years of being a member of a society.

There are, of course, many ways of doing things; I’m not simply suggesting that everything should move online. But if professionals are going to continue to support each other (and I really hope they do) then it might be time for a more radical rethink of how this is best achieved.

I feel no sense of loyalty to bodies which didn’t demonstrate any to me. However, I do feel a sense of loyalty to my colleagues, whether I work directly with them, or our paths haven’t crossed yet.

Everything that we do as a profession is a team effort. There are many ways that we can collaborate without the stuffiness of societies.

The gestation of exercise artificiality

The gestation of exercise artificiality

Reading Time: 3 minutes

The theme for Business Continuity Awareness Week 2015 is about the value of exercising and testing plans. Having facilitated, participated and observed in my fair share of exercises over the last 8 years I’ve reached the conclusion that they’re a waste of time. Worse than that, I think a bad exercise can do more harm than good. I know that’s not going to be popular, so let me explain what I mean…

The process of exercising is designed to validate the assumptions in a plan (or elements of a plan). This is a process which I absolutely think is necessary, but one which, all to often, isn’t effective.

From full-blown reconstructions to glossy media injects, exercise planners or consultants do their best to make the exercise environment realistic. However, this realism tends to evaporate quickly.

I think the problem with exercising starts in the planning phase. Committees meet for months before an exercise to determine locations to use, dates and times, who should participate and what scenarios to use. I think these conversations are pointless, here’s why:

Location: Don’t take people out to a nice conference venue. Yes it’s lovely to have refreshments on tap, but does it familiarise people with the locations they could be working in? If your plan identifies an emergency operations centre, use it! If that facility has a ‘business as usual’ function then make staff there aware that it also serves another function and so they need a business continuity plan themselves! If your facilities are poor all the more reason to use them – it might just help secure investment!

Date and Time: Incidents often happen without warning, therefore so should your exercises. There are some dangers associated with no-notice exercises, but planning in advance can mitigate this. Nor do incidents always respect the convenience of occurring within office hours. Think about conducting your exercises outside of normal office hours. A plan that works effectively at 3am on a Sunday is a good plan!

Invitees: Don’t invite people to your exercise. That might sound a bit odd, but anyone with a defined role in a plan has a responsibility to participate in exercises. The planning process should identify 24/7 contact details for people able to undertake the roles identified. Use those contacts! For instance: if you have a Duty Director on-call, call them. If you use a telephone tree or other alerting system, test it in anger to see if it works.

Scenario: Unlike the three aspects above, picking the right scenario is important. However, beware of falling into the trap of picking a scenario and designing objectives to fit. The focus should be on your capability to respond to issues, the scenario is just a vehicle to facilitate that.

In my opinion, the only two aspects that should be discussed before an exercise are the objectives (what are you trying to learn) and the evaluation (how do you plan to learn it).

Objectives: Exercises really do work best when the objectives are specific and measurable. Specific objectives need to be developed at a high level in advance of the exercise. They should be made clear to all participants so they have a shred understanding about the purpose of the exercise. Don’t be scared of having lots of specific objectives, they’re far more useful than an all-encompassing generic objective like “demonstrate an understanding of plans and procedures”.

Evaluation: There is no correlation between the size of an exercise and its utility. If you’re only interested in whether people can communicate then think about a simple communications test. If you’re interested in how people perform under pressure then look at job-task analyses. The easier an objective is to measure objectively the more confident you can be in your evaluation. Part of your evaluation discussion should also identify the next steps. Have a system in place to make sure you don’t learn identical lessons from one exercise to the next.

Avoid the pitfalls, concentrate on the objectives and exercises can be useful in validating your plans. Happy Business Continuity Week!