Challenges With Pediatric Mass Care Feeding

The national-level guidance on mass care feeding for state, local, tribal, and territorial organizations (SLTTs) comes from the Federal Emergency Management Agency (FEMA), and is  sourced from their toolkits and the National Mass Care Strategy website, which provides a consolidated and comprehensive set of guidance material from governmental and nongovernmental mass care experts. The U.S. Health and Human Services (HHS) Assistant Secretary for Preparedness and Response (ASPR) and the Centers for Disease Control and Prevention (CDC) have also produced a Maternal-Child Health (HHS MCH) Emergency Planning Toolkit. The HHS MCH Toolkit is primarily designed for healthcare providers, public health officials, social services providers, and others but has community partners, organizations, and emergency managers as a secondary audience.

State, local, tribal, and territorial organizations must review and revise their mass care feeding response plans to better support pediatric feeding needs.

In contrast, the primary audience for the CDC Infant and Young Child Feeding in Emergencies Toolkit are emergency preparedness and response personnel and disaster response organizations. These resources outline and highlight the need to make pediatric feeding a priority. Thus they should be reviewed, and their guidance incorporated into the SLTT’s emergency response planning.

Although these guidelines recommend how SLTTs should effectively and tactically provide this feeding support to infants and toddlers, they do not have the needed whole-community partnerships established for each SLTT. For example, while the Commonly Used Sheltering Items (CUSI) list and other FEMA doctrine strongly focus on feeding infants and toddlers with commercial infant formula, they omit the need for quick provision of breastfeeding supplies and support.  The U.S. Dietary Guidelines for Americans recommend exclusive breastfeeding for the first six months with continued breastfeeding while adding appropriate complementary foods for two years or beyond as long as mutually desired by the mother and child. Despite these recommendations, federal guidelines do not point SLTTs to vendors of breast pumps, non-governmental organizations (NGOs) who have breast pumps available for loan or donation, etc.  SLTTs must estimate and plan for the logistical distribution and cost of breastfeeding and re-lactation supplies along with safe alternatives to mothers’ breastmilk and other pediatric feeding items.

SLTTs must also eliminate barriers (such as the pre-disaster written authorization from a medical provider for breastfeeding equipment needs) to obtain breastfeeding support and supplies, understanding that breastfeeding is the best form of nutrition for most babies. Thus, procuring resources to support breastfeeding is an immediate critical and life-sustaining need. Breastfeeding supplies should be added to the Commonly Used Sheltering Items Catalog with durable medical equipment, personal assistance services, and consumable medical supplies to support people with Disabilities and Access/Functional Needs (DAFN) in congregate care shelters and other disaster sites where mass care feeding occurs. SLTTs must ensure that the process of obtaining personal assistance and medical supplies does not delay feeding, thus causing food insecurity for infants and toddlers.

SLTTs must perform these feeding missions through a culturally sensitive and equitable distribution model at disaster shelters, aid stations, and other locations where general population disaster feeding occurs. Challenges today include several erroneous assumptions on the part of emergency managers, for example:

  • Evacuating mothers have all the feeding supplies with them when they evacuate;
  • Switching feeding methods (commercial infant formula in lieu of human milk, a different type of formula than what the child normally has, etc.) is a reasonable accommodation and indemnifies the SLTT from its responsibilities for proper disaster mass care feeding of everyone adversely impacted;
  • Mothers are able to find their own feeding support, including milk storage, without the assistance of trained shelter staff and lactation providers;
  • Even with donations of some supplies – such as shown in the cover photo from Katrina – SLTT  shelters will not need provisions for human-milk production and storage, including durable medical equipment, associated consumable medical supplies (breast pumps and other lactation supplies: bottles, nipples, etc.), private space within the shelter, and other shelter protocols and procedures in support of breastfeeding by mothers for their – and potentially any other family’s – infants and toddlers; and
  • At the SLTT level, another entity, organization, etc. would be responsible for the proper feeding capabilities at congregate care disaster shelters and other disaster sites where mass care feeding occurs.
  • These disconnects are often exacerbated by existing low-levels of whole-community planning for people with DAFN, at the SLTT levels. A metric of adopting the CMIST Framework (Communication, Maintaining Health, Independence, Support, Transportation) for shelter resident intake is one measure of a positive application of planning for at-risk individuals with DAFN, including pregnant women and mothers with infants/toddlers.

SLTTs model their own logistical support for sheltering against the CUSI Catalog so they can be reimbursed on declared disasters. Those formula items are also part of infant/toddler kits that SLTTs can order through the same disaster resource request process as other items and mission assignments from FEMA. As with any other tactical federal assistance requests, these need to be prioritized by the SLTTs and requested as soon as possible. The Update to FEMA’s Individual Assistance Program and Policy Guide, Version 1.1, also omits breastfeeding. However, there are U.S. congressionally proposed plans to update the 2023 version to include breastfeeding.

Displaced Hurricane Katrina storm survivors look at a limited selection of donated infant food items inside the Houston Astrodome shelter (Texas), September 2, 2005 (Source: Ed Edahl/FEMA, Public domain, via Wikimedia Commons).

Benefits of Pre-Planning on a Whole-Community Basis

There are benefits to SLTTs and nongovernmental organizations beyond covering pediatric feeding needs when incorporating whole-community planning for mass care feeding.

The relationships established between steady-state governmental organizations with nongovernmental organizations for pediatric feeding benefit governmental organizations for their non-disaster work. For example, MOUs, MOAs, and other collaborations between milk banks and public health officials, child protective agencies, and social services organizations, will strengthen those SLTTs’ own daily operations and constituent support. Jefferson County, Colorado Public Health created a formal emergency plan and implemented a safe infant feeding project. The plans, training information, and resources specific for their jurisdiction are on their Emergency Preparedness page.

Nongovernmental organizations supporting the disaster needs of SLTTs should be integrated into the emergency response planning – including being identified as critical infrastructure/key resources (CI/KR) – and benefit from any mitigation efforts afforded to other CI/KR assets. Restoration of their functionality – if adversely impacted by a disaster – should be prioritized along with other CI/KR feeding assets such as food banks, USDA warehouses, etc.

The amplification of pediatric feeding needs within SLTTs should also elevate other children and disaster needs, as well as the disaster-impact needs of people with DAFN. Examples include positive impacts on interim and long-term recovery, community lifeline support, and other disaster cycle mission essential functions.

HHS MCH Toolkit Recommendations

The HHS MCH Toolkit is comprehensive on the checklist type of considerations the public and shelter operators need to incorporate before, during, and after disasters. FEMA indicated that this guidance, which expands well beyond just feeding, was created through whole-community coordination, including the U.S. Breastfeeding Committee and other groups.

The following list was adapted from the HHS-ASPR, May 2021, HHS MCH Toolkit, Shelter Considerations to Support MCH Populations in Emergency Response:

  • Require background checks for shelter personnel.
  • Train personnel to identify signs of human trafficking and abuse:
    • See the CDC website for resources for Shelter Personnel on Human Trafficking in the Wake of a Disaster;
    • Call the National Human Trafficking Hotline (888-373-7888 or text “HELP” to 233733); and
    • Report suspected child exploitation to the CyberTipline, The National Center for Missing & Exploited Children, at 1-800-THE-LOST.
  • Initiate a rapid needs assessment system for infants and young children to assess feeding support and resource needs.
  • Provide safe, private spaces for infant feeding equipped with comfortable chairs, footstools, outlets, a sink with clean water and dish soap, refrigerated space with bins to store breast milk/food, and signage for a designated breastfeeding area (a mother may breastfeed in any public or private space she is authorized by law).
  • Provide breastfeeding supplies, including: breast pumps (electric, battery-operated, and manual ones for disaster scenarios where continuous power at the shelter site may be in question); breast pump quick clean wipes and steam cleaning bags; breast milk storage bags; nursing pads and soothies; nipple cream or lanolin; nursing cover; nursing pillow; sound information about pumping, increasing milk supply, and re-lactating; and nutritious food and clean water for the mother.
  • Supply diapers, baby wipes, bottles, nipples, disposable cups, ready-to-feed infant formula, pacifiers, clean water, infant feeding and cleaning supplies, feminine hygiene products (e.g., sanitary napkins), and child-size equipment (e.g., beds, masks as advised by public health officials) to women who are pregnant, postpartum, or lactating as well as to infants and young children.
  • Adhere to safe sleep guidelines for infants and safer sleep guidelines for exclusively breastfed infants who meet specific criteria. For more information, see Planning Considerations for Infants (ages 0-12 months) in Emergencies.
  • Provide essential social services independently or through partnerships with local social service organizations, including nutrition, breastfeeding support, and healthcare referrals.
  • Initiate a referral system for women who are pregnant and go into labor, who show signs of labor or pregnancy loss, or who are in the postpartum period and show problems to healthcare providers and emergency medical services.
  • Initiate a referral system for lactating women who experience problems, such as difficulty feeding, breast pain, and low milk supply, to International Board-Certified Lactation Consultants (IBCLC) and healthcare providers.
  • Provide access to services for testing and treatment, such as sexually transmitted infections (STIs) and emergency contraception.
  • Staff individuals who represent the community in terms of demographics and culture.
  • Provide access to medical interpretation and translation services.

Applying the best practices found in the HHS MCS and CDC toolkit should benefit all SLTTs, which should undertake the deep dive needed for tactical logistics pre-planning for acquiring and distributing supplies and equipment for pediatric feeding. Multi-state disasters, including worldwide pandemics, can severely impact breastfeeding support. Even infant and specialty formula itself has been the subject of recent product-process disasters and significantly impacted socially vulnerable populations around the world, even without the additional adverse impacts from a natural or human-made disaster. Therefore, SLTTs should be better prepared to respond and recover from any type of disaster, and their ability to safely, effectively, equitably, and quickly provide pediatric feeding support is paramount.

Michael Prasad
Michael Prasad

Michael Prasad is a Certified Emergency Manager®, a senior research analyst at Barton Dunant – Emergency Management Training and Consulting (www.bartondunant.com), and the executive director of the Center for Emergency Management Intelligence Research (www.cemir.org). Mr. Prasad has held emergency management director-level positions at the State of New Jersey and the American Red Cross, serving in leadership positions on more than 25 disaster response operations, including Superstorm Sandy’s response and recovery work. He researches and writes professionally on emergency management policies and procedures from a pracademic perspective. His first book, “Emergency Management Threats and Hazards: Water,” is scheduled for publication by Taylor & Francis/CRC Press in September 2024 – and will now have updates based on this water-related incident. He holds a Bachelor of Business Administration degree from Ohio University and a Master of Arts degree in emergency and disaster management from American Public University. Views expressed do not necessarily represent the official position of any of these organizations.

Jennifer Russell

Jennifer Russell is a Registered Nurse and International Board-Certified Lactation Consultant with over 20 years of combined experience in pediatrics, lactation, public health, emergency preparedness, and disaster response. She is a Nursing Science Ph.D. Candidate at the University of Tennessee Health Science Center (UTHSC), where her dissertation research on the impact of disasters on the breastfeeding dyad will soon involve surveying emergency managers. She serves at the local, state, and national levels on initiatives to reduce infant mortality, improve access to lactation support, and improve disaster response capacity. She was formerly the Nurse Educator and Medical Reserve Corps Coordinator for the Shelby County Health Department and Clinical Faculty for Pediatric Nursing and Population Health Nursing at UTHSC in the College of Nursing. She holds a Bachelor of Science in Nursing from Union University and a Master of Science in Nursing from the University of Phoenix. You may contact her at jrussell@uthsc.edu. Views expressed do not necessarily represent the official position of any of these organizations.

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