Prevention, infant feeding and coordination

1Infant and young child feeding in emergencies (IYCF-E)

In a crisis, breastfeeding saves lives: it provides safe water, antibodies and food that is always available. The recommendations: initiation of breastfeeding within the first hour after birth, exclusive breastfeeding up to 6 months, then appropriate complementary foods and continued breastfeeding up to 2 years or beyond.

Unsolicited donations of breastmilk substitutes (powdered milk, bottles) are dangerous: they increase diarrhoea and mortality. The International Code of Marketing applies: substitutes are provided only to infants who really need them, after assessment, with follow-up and safe water. Donations received are reported to the Nutrition cluster.

2Prevention and micronutrients

Prevention costs less than treatment. Key actions: vitamin A supplementation and deworming for children, measles vaccination, micronutrient powders or fortified foods, iron and folic acid supplementation for pregnant women, and blanket supplementary feeding programmes when the situation is critical.

Prevention also relies on other sectors: water and sanitation against diarrhoea, cash transfers or rations for access to food, health for malaria and infections. A nutrition-sensitive programme sets explicit nutrition objectives.

3Assessments and surveys

The SMART survey is the reference method for measuring the prevalence of acute malnutrition and mortality. It relies on rigorous sampling, standardised measurements and quality control (data plausibility). Other tools complement it: exhaustive MUAC screening, programme data, nutrition surveillance systems, coverage surveys.

Nutrition data are children's personal data: minimal collection, secure storage, aggregated sharing. Results are validated with the Ministry of Health and the cluster before dissemination.

4The Nutrition cluster

The Nutrition cluster, led globally by UNICEF, coordinates the response with the Ministry of Health: joint analysis, 4W mapping, harmonisation of protocols and supplies, response plan and gap monitoring. It works closely with the Health, Food Security and WASH clusters, often within an integrated response framework.

For an NGO, taking part in the cluster means sharing its programme data every month, following common protocols, avoiding duplication and advocating together on supply or funding shortfalls.

5Implementing IYCF-E: the six areas of action and the breastmilk substitute pathway

The Operational Guidance on Infant and Young Child Feeding in Emergencies (IFE Core Group, version 3.0 of 2017, endorsed by the World Health Assembly) is the reference text. It is addressed to all actors in the response, not only nutritionists: logisticians, distribution managers, camp coordinators, donors. It organises action into six areas.

The six areas of action

1. Endorse or develop policies: a joint statement by the government and the cluster on IYCF-E, issued in the first days of the crisis, recalling the Code and the prohibition of donations of breastmilk substitutes. In at-risk countries, the cluster prepares a template statement in advance.
2. Train staff: orientation of all humanitarian staff, technical training in breastfeeding counselling for health and nutrition workers, specialised skills (relactation, management of artificial feeding) for a few focal points.
3. Coordinate: designate an IYCF-E coordination authority (often a working group of the Nutrition Cluster, co-chaired by the Ministry and UNICEF) and focal points in the other clusters.
4. Assess and monitor: integrate IYCF questions into initial multisectoral assessments, then standard indicators into surveys.
5. Protect, promote and support breastfeeding and appropriate complementary feeding: mother-baby areas, individual counselling, prioritisation of pregnant and lactating women in distributions (queues, shelter, water).
6. Minimise the risks of artificial feeding: controlled pathway for substitutes, management of donations, follow-up of non-breastfed infants.

The controlled breastmilk substitute pathway, step by step

The International Code of Marketing of Breast-milk Substitutes (1981) and subsequent World Health Assembly resolutions prohibit promotion and regulate distribution. In practice, in an emergency: no donations of substitutes, bottles or teats are solicited or accepted; donations received are reported to the coordination authority, stored and managed according to its instructions, and never distributed in a general way.

Complementary feeding and distributions

• From 6 months of age, the child needs nutritious foods in addition to breastmilk. In emergencies, general rations are often poor in suitable foods. The solutions: specific fortified foods (fortified blended flours or lipid-based nutrient supplements), cash transfers combined with counselling, home gardens in protracted crises.
• The standard WHO and UNICEF indicators (updated in 2021) make it possible to monitor the situation: early initiation of breastfeeding, exclusive breastfeeding under 6 months, continued breastfeeding, minimum dietary diversity (at least 5 of 8 food groups among children aged 6-23 months), minimum meal frequency, minimum acceptable diet, consumption of sweet beverages and unhealthy foods.

What IYCF-E requires of other sectors

• Shelter and camp management: private spaces for breastfeeding, priority for households with infants.
• Distributions: priority queues, no powdered milk included in general rations or food baskets.
• Cash transfers: messages to avoid the purchase of substitutes when breastfeeding is possible.
• Mental health and psychosocial support: stress does not "dry up" milk, but it can disrupt breastfeeding; appropriate support makes it possible to maintain it.

6Prevention in practice: which packages, for whom, and when

Preventing malnutrition in emergencies is not a set of good intentions: it is a series of interventions whose effectiveness, criteria and doses are defined. The choice depends on the severity of the situation, the season and what other sectors are already doing.

Interventions and their benchmarks

Nutrition-sensitive interventions

A food security, water and sanitation or social protection programme becomes nutrition-sensitive when it sets explicit nutrition objectives and organises its targeting and messaging accordingly. Concrete examples:

• Cash transfers targeting households with children under 2 or pregnant women, with an amount calculated on the basis of the cost of a nutritious food basket (a "cost of a healthy diet" analysis or WFP's "Fill the Nutrient Gap"), accompanied by IYCF counselling.
• WASH: hygiene kit and household water treatment for every child admitted to an OTP (the minimum package known as "WASH in Nut"), prioritisation of water points near nutrition centres.
• Agriculture and livelihoods: production of micronutrient-rich foods, small livestock, home gardens.
• Protection: attention to unaccompanied children, child-headed households, adolescent mothers.

The prioritisation rationale

In a critical situation with high mortality, the order of priority is generally: measles and vitamin A, sufficient quantities of water, an adequate general ration, treatment of SAM, then blanket supplementary feeding or TSFP depending on capacity. A response that opens OTPs without vaccinating against measles or securing water will treat children who will fall ill again.

7Conducting a SMART survey: from sample size calculation to validation

Day 1 showed how to read a survey. Here is how to conduct one. A standard SMART survey generally takes six to eight weeks between the decision and the dissemination of validated results, including about two weeks of fieldwork.

Typical timeline

Calculating the sample size

The ENA for SMART software calculates the number of children and households from parameters that the survey manager must justify:

• Estimated prevalence of GAM (often the upper bound of the confidence interval of the last survey, or an estimate derived from programme data).
• Desired precision: the higher the prevalence, the wider the precision can be (for example ± 3 points for an expected prevalence of 10 to 15%, ± 4 to 5 points for a prevalence of 20% or more).
• Design effect: generally 1.5 in the absence of data, more if there is strong geographical heterogeneity.
• Average household size, proportion of children under 5 and expected non-response rate, to convert the number of children into a number of households.

Example calculation for a fictional area: estimated prevalence 14%, precision ± 3.5 points, design effect 1.5, household size 6.2, proportion of under-5s 19%, non-response 5%. ENA calculates about 560 children to be measured. Each household has on average 6.2 × 0.19 ≈ 1.18 children under 5, i.e. about 1.06 children aged 6 to 59 months once infants under 6 months are removed. With 5% non-response, 560 / (1.06 × 0.95) ≈ 556 households are needed, i.e., with a team visiting 13 households per day and one cluster per team per day, about 43 clusters.

Sampling

1. First stage: selection of clusters (villages, neighbourhoods) with probability proportional to population size, from an up-to-date list. ENA does this automatically.
2. Second stage: selection of households within each cluster, ideally by simple random or systematic random sampling from a list drawn up on site with leaders; the older spin-the-bottle method (choosing a direction at random) should be avoided when a list can be drawn up.
3. Replacement: rules set in advance for inaccessible clusters, documented in the report.

Quality control during data collection

• Every evening, the coordinator imports the data into ENA and reads the plausibility report by team: excluded values, digit preference, standard deviation.
• The next morning, individual feedback to the teams; re-measurement of a sample of children by supervisors.
• Verification of reported oedema by a supervisor.
• Tablet-based data collection with automatic checks, GPS coordinates of households (stored securely and removed from the shared database).

The mortality module and additional modules

Retrospective mortality uses a recall period of about three months, with a memorable event as the starting point. Arrivals, departures, births and deaths in each household are recorded. Additional modules (vaccination, diarrhoea, IYCF, food security, water) enrich the analysis, but every question added lengthens the interview: beyond 30 to 40 minutes per household, quality declines.

A survey is not "yours": in most countries, its protocol and results must be validated by the assessment technical working group of the cluster or the Ministry. A survey that has not been validated cannot feed into the IPC or the humanitarian needs overview.

8Full example: the prevention and IYCF-E plan for Tindar camp

Fictional context: Tindar camp hosts 32,000 refugees who arrived over four months. Children under 5 represent 20% of the population, children aged 6-23 months 7%, infants under 6 months 2.5% and pregnant and lactating women about 8%. A validated SMART survey has just found GAM of 15.6% (CI 12.9 - 18.7%), SAM of 3.4%, under-5 mortality of 2.3 per 10,000 per day, measles coverage of 64%, exclusive breastfeeding of 38% among infants under 6 months and minimum dietary diversity of 14% among children aged 6-23 months. An association has announced that it will deliver 3,000 tins of infant formula. You are the nutritionist of the NGO responsible for nutrition in the camp, working with UNHCR and the cluster.

Step 1: target populations

Step 2: decisions and their justification

Step 3: product requirements for blanket supplementary feeding

A medium-quantity lipid-based nutrient supplement (about 92 g and 500 kcal per day, depending on the specification chosen by WFP) for 2,240 children over 180 days represents 2,240 × 180 = 403,200 daily rations, or about 37 tonnes of product. A margin is added for population growth (for example 10%), and the delivery lead time is checked with WFP. If the product will only arrive in three months, an interim decision must be discussed: locally available fortified blended flour, or expansion of the TSFP.

Step 4: monitoring indicators

• Coverage of the measles campaign (post-campaign coverage survey).
• Proportion of children aged 6-23 months who received supplementation each month (target 90%).
• Monthly admissions to the OTP and TSFP, and performance indicators.
• Number of non-breastfed infants identified, proportion followed up at least twice a month.
• Number of Code violations reported and addressed.
• Exclusive breastfeeding and dietary diversity measured during the next survey, planned in six months.

The reasoning to remember: start from validated data, calculate target populations, link each decision to a precise figure, and make visible what depends on other sectors. This is the reasoning that reviewers of a project proposal look for.

9Working with the Nutrition Cluster: obligations, tools and day-to-day coordination

At global level, the Global Nutrition Cluster is led by UNICEF. At national level, the cluster is generally co-led by UNICEF and the Ministry of Health, often with an NGO as co-facilitator. It fulfils the core functions defined by the Inter-Agency Standing Committee (IASC) in its Reference Module for Cluster Coordination at Country Level: supporting service delivery, informing strategic decision-making, planning and strategy development, monitoring and evaluation, building national preparedness and capacity, and advocacy, together with accountability to affected populations.

The tools and what they require of partners

Calculating people in need and targets

For the humanitarian needs overview, the cluster estimates for each area the number of people in need of nutrition interventions, using a method harmonised at global level and adapted to the country. The principle: the expected SAM and MAM caseload among children aged 6-59 months (population × prevalence × incidence factor), malnourished pregnant and lactating women, and the groups targeted by prevention (for example children aged 6-23 months in the worst-affected areas). The response plan target is the share that partners can reasonably reach, given access and capacity. An NGO proposing a target in an area must be able to show that it is consistent with the cluster's target and does not duplicate it.

Gap analysis

Cross-referencing the 4W matrix with the needs map reveals areas without services. The cluster prioritises these areas for new funding. The most frequent gaps: hard-to-reach areas, TSFPs absent for lack of WFP funding, distant stabilisation services, absence of IYCF counselling.

A partner that does not report its data to the cluster becomes invisible in the analysis, and therefore in funding priorities. Reporting is not an administrative constraint: it is what makes the needs of the area exist when decisions are made.

Data protection

Reports to the cluster are aggregated. Named registers stay at the health centre, under lock and key. Exchanges of lists between sectors (for example to refer mothers of children in an OTP to a cash transfer programme) take place under a signed data-sharing protocol, with the informed consent of families and the minimum necessary fields, in line with the IASC Operational Guidance on Data Responsibility in Humanitarian Action.

10Common mistakes, contextual variations, interview questions and references

Common mistakes

• Accepting donations of powdered milk "temporarily" so as not to offend a partner or an authority: once distributed, they cannot be recovered.
• Including powdered milk or feeding bottles in kits for families (hygiene kits, dignity kits, newborn kits).
• Launching blanket supplementary feeding without associated screening, thereby missing the opportunity to identify SAM cases.
• Designing a survey without consulting the technical working group, then discovering that it will not be validated.
• Adding too many modules to the SMART questionnaire, at the expense of the quality of anthropometry.
• Treating the cluster as a meeting rather than a system: not reading the minutes, not applying decisions, not reporting.

Variations by context

• Sudden-onset crisis: joint IYCF-E statement within 72 hours, key messages disseminated to all actors, measles and vitamin A campaign in camps from the first weeks, rapid assessment rather than a full survey.
• Protracted crisis: prevention programmes integrated into health services and social protection, sustainable IYCF support groups, nutrition surveillance, surveys in a fixed season.
• Urban area: wide commercial availability of substitutes and sugary drinks, active brand promotion; the emphasis is on counselling and Code monitoring.
• Limited access: training of local volunteers in basic IYCF counselling, messages by radio and phone, surveys with adapted methods and documentation of uncovered areas.
• Weak or absent coordination: the NGO can propose a sectoral coordination mechanism at local level with the health authorities, drawing on cluster tools.

Interview questions

1. "A camp manager tells you he has received 2,000 tins of infant formula and plans to distribute them tomorrow. What do you do within 24 hours?"

A good answer: immediate and respectful contact with the manager to explain the risks, reporting to the IYCF-E working group and the cluster, a proposal for secure storage, setting up or strengthening the controlled pathway for infants who really need it, and a message to other actors. It cites the Operational Guidance and the Code without being dogmatic.

2. "When would you recommend blanket supplementary feeding rather than a TSFP?"

The candidate cites severity (very high GAM, mortality), aggravating factors (epidemics, lean season), the impossibility of achieving sufficient coverage with a TSFP, and recalls that the decision is taken with the cluster, taking into account resources and the limited duration of the intervention.

3. "How do you calculate the sample size of a SMART survey?"

They list the parameters (estimated prevalence, precision, design effect, household size, proportion of under-5s, non-response), explain how they justify them and how they move from the number of children to the number of households and clusters.

4. "What are your obligations to the cluster as a partner?"

Quality monthly reporting, compliance with protocols, alignment of areas and targets, participation in technical working groups, sharing of stock-out alerts, contribution to assessments and joint advocacy.

5. "A mother in a camp tells you she has no more milk because of stress. What do you tell her?"

Listening, assessment of breastfeeding, explaining that milk production depends mainly on the frequency of feeds, practical support (positioning, attachment, frequent feeds), psychosocial support, mother-baby area and monitoring of the infant's weight; referral for specialised assessment if the infant is losing weight.

Key references

• Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers, version 3.0 (2017): IFE Core Group.
• International Code of Marketing of Breast-milk Substitutes (1981) and subsequent World Health Assembly resolutions: WHO.
• Indicators for assessing infant and young child feeding practices (2021): WHO and UNICEF.
• The Sphere Handbook (2018), standards on IYCF, micronutrient deficiencies and food security: Sphere Association.
• SMART Methodology Manual and ENA for SMART software: SMART Initiative.
• Reference Module for Cluster Coordination at Country Level: IASC.
• Operational Guidance on Data Responsibility in Humanitarian Action: IASC.
• Global Nutrition Cluster tools and guidance, in particular on calculating people in need and reporting.
• "Fill the Nutrient Gap" analyses: WFP.