ERITREAN POLICY ON INFANT AND YOUNG CHILD FEEDING

THE STATE OF ERITREA

MINISTRY OF HEALTH, NUTRITION UNIT

JULY 2013

Preface

Implementation of the Infant and Young Child feeding is a fundamental obligation to prevent morbidity and

mortality and to promote improved health and nutritional status of the population.

This Policy on IYCF is an integral part of the Operational Guidelines, which provides more detailed

guidance on the implementation at all levels of the proposed IYCF interventions in this policy. It is based

on evidence from different global and national studies, like nutrition surveys and the Eritrea Population

Health Survey of 2010. It is also guided by the Eritrean national health policy and national five years health

sector development plan with global evidence and recommendations.

With this IYCF Policy, Eritrea will take a strong stand that malnutrition and especially chronic malnutrition

that manifests itself in stunting will be addressed by the State as a priority. It is expected that by using the

IYCF Policy as well as the Operational Guidelines, all health personnel and concerned partners will bring

renewed focus and vitality into interventions for supporting and promoting maternal nutrition and infant and

young child feeding practices, which are evidence based cost-effective strategies for tackling the high rates

of malnutrition.

Implementation of IYCF policy will contribute further to the prevention of maternal and child mortality.

I express my sincere appreciation to the UNICEF Office for their financial and technical support in

developing the IYCF policy.

Minister for Health

TABLE OF CONTENTS

TABLE OF CONTENTS ............................................................................................................................. iii

Preamble ............................................................................................................................................... iv

Abbreviations ......................................................................................................................................... v

Definitions of Terms ............................................................................................................................... 6

Section 1: Policy Framework ................................................................................................................... 9

Vision ..................................................................................................................................................................................................................... 9 Goal ......................................................................................................................................................................................................................... 9 Objectives ............................................................................................................................................................................................................ 9 Policy Statements on Infant and Young Child Feeding .................................................................................................................. 10

2.1: Breastfeeding................................................................................................................................................................................................. 10 2.2: Complementary Feeding .......................................................................................................................................................................... 10 2.3: Maternal Nutrition ..................................................................................................................................................................................... 11 2.4: HIV and Infant Feeding ............................................................................................................................................................................. 12 2.5: Non-breastfed child .................................................................................................................................................................................... 13 2.6: Malnourished child ..................................................................................................................................................................................... 13 2.7: Feeding of Low Birth Weight Babies/ Preterm Infants ............................................................................................................. 13 2.8: IYCF in Emergencies ................................................................................................................................................................................... 13

Section 2: Operational Requirements .................................................................................................... 14

Strategy Development and Implementation ...................................................................................................................................... 14 National level ......................................................................................................................................................................................................... 14 Zoba and Sub-Zoba level ................................................................................................................................................................................... 15

Implementation.............................................................................................................................................................................................. 15 3.1: National Legislation on the Marketing of Breast Milk Substitutes ...................................................................................... 15 3.2: IYCF Interventions for Skilled Support by the Health System ................................................................................................. 15 3.3: Interventions for Community-Based Counselling and Support on Breastfeeding and Complementary Feeding

using Locally Available Ingredients ............................................................................................................................................................. 16 3.4: Social and Behaviour Change (SBC) Communication ................................................................................................................ 16 3.5: Use of Quality Industrially-Processed Fortified Complementary Foods............................................................................. 17

Section 3: Monitoring and Evaluation ................................................................................................... 17

Preamble

Infant and Young Child Feeding (IYCF) practices are a set of recommendations to achieve appropriate

feeding of infants and children under two years of age as well as their pregnant and lactating

mothers, so that they achieve optimal nutrition outcomes. The recommended IYCF practices include the

well-known behaviours of (1) initiating breastfeeding within one-half hour of birth, (2) exclusive

breastfeeding for the first six months (180 days of age) of life, (3) initiation of appropriate complementary

feeding from the age of 6 months and (4) continued breastfeeding for two years or beyond. Pregnant and

lactating women should eat extra food and obtain sufficient rest.

This Eritrean Policy on IYCF is an integral part of the Operational Guidelines, which provides more detailed guidance on the implementation at all levels of the proposed IYCF interventions in this policy. It is based

on evidence from different global and national studies, like nutrition surveys and the Eritrea Population Health Survey of 2010 and guided by the Eritrean national health policy and national five years health

sector development plan. Evidence and recommendations particularly important were:

-Recognizing relevant regional and global declarations on IYCF, -Cognizant that proper breastfeeding and complementary feeding are crucial for growth, health and nutritional well being during the first two years of life, -Recognizing the importance of sound IYCF for the health and development of the child, as an investment in the present and in the future, -Realizing that breastfeeding is the only natural method of infant feeding and therefore incorporating the international code of marketing of breast milk substitutes adopted by the World Health Assembly resolutions, -Informed of the current global evidence indicating that the most effective intervention for ensuring child survival is exclusive breastfeeding which is estimated to save 13% of under five deaths and that appropriate complementary feeding can save 6%, both significantly contributing to the attainment of the Millennium Development Goals, -Aware that caregivers' inadequate knowledge on optimal feeding and cultural beliefs contribute to increased child mortality and morbidity in Eritrea, -Realizing the need to build health workers' capacity in IYCF and to reinforce implementation, monitoring and supervision of IYCF activities,

With the Eritrean Policy on IYCF, Eritrea wants to take a strong stand that malnutrition and especially

chronic malnutrition that manifests itself in stunting, will be addressed by the State as a priority. It is

expected that by using the IYCF Policy as well as the Operational Guidelines, zobas will bring renewed

focus and vitality into programmes/interventions for supporting and promoting maternal nutrition and infant

and young child feeding practices, which are evidence based cost-effective strategies for tackling the high

rates of under nutrition.

The policy document is organised in the following way:

The first section describes the policy framework, including the goal, objectives and technical policy

statements on IYCF.

The second section includes the operational requirements with strategy development and implementation

at national and zoba-level, as well as outlining the proposed national IYCF activities.

The third section briefly deals with monitoring and evaluation.

Abbreviations

AIDS Acquired Immune-Deficiency Syndrome ARI Acute Respiratory Infection BFHI Baby Friendly Hospital Initiative BMI Body Mass Index BMS Breast Milk Substitutes CBTF Community-Based Therapeutic Feeding C-IMNCI Community-Based Integrated Management of Neonatal and Child illnesses CMAM Community-Based Management of Acute Malnutrition Code The International Code of Breast Milk Substitutes Codex Codex Alimentarius EDHS Eritrea Demographic and Health Survey HIV Human Immuno-Deficiency Virus HMIS Health Management Information Systems ILO International Labour Organisation IMAM Integrated Management of Acute Malnutrition IMNCI Integrated Management of Neonatal and Child illnesses kcal Kilocalories LAM Lactational Amenorrhea Method LBW Low Birth Weight M&E Monitoring and Evaluation MDG Millenium Development Goal MTCT Mother to Child Transmission NACOP National AIDS Co-ordination Programme NGO Non-Governmental Organisations NNSS National Nutrition Surveillance System NVP Nevirapine PHC Primary Health Care PMTCT Prevention of Mother to Child transmission RF Replacement Feeding SBC Social and Behaviour Change U5MR Under five Mortality Rate UN United Nations UNAIDS United Nations AIDS Programme UNICEF United Nations Children’s Educational Fund USAID United States of America International development VLBW Very Low Birth Weight WB World Bank WBW World Breastfeeding Week WHA World Health Assembly WHO World Health Organisation

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Definitions of Terms

Artificial Feeding: means feeding an infant on a breast milk substitute. An infant who is partially breastfed and who is in addition being given supplements of breast milk substitutes is also artificially fed.

Baby Friendly Hospital Initiative: means a program to transform maternity practices in health facilities as recommended in the Innocenti Declaration of 1990. UNICEF and WHO launched the BFHI in 1991. Baby friendly facilities are expected to practice all the Ten Steps to Successful Breastfeeding and to implement the International Code of Marketing of Breast Milk Substitutes. To acquire baby friendly designation, a hospital must be formally and externally assessed according to agreed upon procedures, using the global criteria.

Bottle-feeding: means feeding an infant from a bottle, whatever is in the bottle, including expressed breast milk. Bottle-feeding does not mean the same thing as feeding with infant formula or other breast milk substitutes, as these may be given by various techniques.

Breast Milk Substitutes: means any food being marketed or otherwise represented as partial or total replacement for breast milk, whether or not suitable for that purpose.

Cessation of Breastfeeding / Weaning: means stopping breastfeeding altogether. This may occur in the first week, or at any time during the recommended breastfeeding period. The ambiguous term weaning for the end of breastfeeding is now avoided in international usage.

Complementary Feeding (not “weaning”) means complementing breast milk with solid/semi-solid food after a child attains the age of six months. After that age, breast milk alone is no longer sufficient to meet the nutritional requirements of infants. However, infants are vulnerable during the transition phase, from exclusive breast milk to the introduction of complementary feeding. To ensure the nutritional needs of a young child, breastfeeding must continue along with observing the following practices for appropriate complementary feeding.

Timely – meaning that complementary food is introduced when the need for energy and nutrients exceeds what can be provided through exclusive breastfeeding;

Adequate – meaning that complementary food provides sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs;

Safe – meaning that complementary food is hygienically prepared and stored, and fed with clean hands using clean utensils, and not bottles and teats.

Cup Feeding: means feeding an infant or young child from an open cup. From birth, suitable breast milk substitutes can be given to non-breastfed infants, including those who are low birth weight, by cup.

Early Cessation of Breastfeeding: means stopping breastfeeding sooner than is usual. For HIV-positive mothers with HIV-negative children it is recommended to stop breastfeeding at 12 months, if a suitable replacement diet can be offered.

Early Initiation of Breastfeeding means breastfeeding as early as possible after birth, ideally

within first hour (including those born by caesarean section). Colostrum, the milk secreted in

the first 2-3 days, must not be discarded but should be fed to the newborn as it contains high

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concentration of protective immunoglobulin’s and cells. No pre-lacteal fluid should be given to

the newborn.

Exclusive Breastfeeding: means the infant receives only breast milk (from his/her mother or a wet nurse, or expressed breast milk) and no other liquids or complementary foods with only medically indicated exceptions. Water is not permitted.

Expressed Breast Milk: means milk, which has been taken out of the breasts by manual pressure or pumping.

Infant: means a person not more than 12 months of age.

Infant Formula: means a breast milk substitute formulated industrially in accordance with the Codex Alimentarius Standards (joint FAO/WHO food standards programme) to satisfy the normal nutritional requirements of infants up to six months of age.

The International Code: The International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly (WHA) in 1981and relevant WHA resolutions, referred to here as “the Code”. The aim of the Code is to contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breast milk substitutes when these are necessary, on the basis of adequate information and through appropriate marketing and distribution. The Code sets out the responsibilities of the infant food industry, health workers, national governments and concerned organizations in relation to the marketing of breast milk substitutes, bottles and teats.

International Labour Organization (ILO) Maternity Protection Convention 183 and Recommendations 191: Adopted by the General Conference in 2000. The Convention states that governments should adopt and enact legislation that entitles working mothers to maternity leave of not less than 14 weeks, and makes provision for mothers to continue breastfeeding after returning to work, through nursing breaks and provision of care facilities and facilities for expressing breast milk. Once ratified by a country, the Convention is legally binding.

Low Birth Weight (LBW): weight at birth less than 2500 g. LBW can be a consequence of preterm birth (defined as birth before 37 completed weeks of gestation), or due to Small size for Gestational Age (SGA, defined as weight for gestation <10th percentile), or both.

Mother Support Group: means a community based group of women providing each other support for breastfeeding, or for any other feeding option or replacement feeding. The group may be informal or part of a larger network providing information, help and support from trained counsellors. Today there are also groups that are formed by men or contain a mix of men and women.

Optimal Infant and Young Child Feeding: means exclusive breastfeeding in the first six months, and continued breastfeeding with appropriate complementary feeding to the age of two years or beyond.

Pre-lacteal Feeds: means any food, solid or liquid, given to an infant before the initiation of breastfeeding.

Re-lactation: means when a woman who has stopped breastfeeding her child, recently or in the past, resumes production of breast milk for her own or an adopted infant.

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Replacement Feeding: means the process of feeding a child who is not receiving any breast milk with a diet that provides all the nutrients the child needs for two years, until the child is fully fed on family foods. During the first six months this should be with a suitable breast milk substitute. After six months it should preferably be with a suitable breast milk substitute, and complementary foods made from appropriately prepared and nutrient-enriched family foods. If a suitable breast milk substitute is not available, appropriately prepared family foods should be further enriched and given more frequently.

Supplements: means any food, solid or fluid, other than breast milk given to an infant younger than six months of age.

Young child: For the purpose of this policy, young child means a child between the age of one and two years.

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Section 1: Policy Framework

Vision

Within the next 10 years, programmes/interventions supporting and promoting maternal nutrition

and infant and young child feeding practices are implemented throughout the State of Eritrea.

Thanks to those, Eritrea is free of malnutrition and especially chronic malnutrition that manifests

itself in stunting.

Goal

The overall goals of the Eritrean Policy on Infant and Young Child Feeding are to:

Provide national standards that must be adhered to by all institutions, organizations and individuals having contact with pregnant or lactating women and children 0-24 months.

• Create an environment that encourages appropriate maternal and infant and young child

feeding, at national, zoba and sub-zoba level; i.e. in health facilities, in the private sector, in the media, in all public activities, in communities and at family-level.

• Enhance protection, promotion and support to optimal nutrition for pregnant women,

lactating mothers and their children under two, thereby contribute to the reduction of child malnutrition, morbidity and mortality and ensuring the healthy development of Eritrean children and its nation.

Objectives

The objectives of these guidelines are: • To stress the importance of good maternal nutrition on the nutritional status of her unborn or

lactating child. • To increase rates of early initiation of breastfeeding, exclusive breastfeeding for six months

and continued breastfeeding up to two years of age or beyond. • To reduce mixed feeding before six months and starting at 6 months, promote timely,

adequate, safe and appropriate complementary feeding with continued breastfeeding. • To give effect to the principles and aim of the International Code of Marketing of Breast milk

Substitutes (BMS) and to subsequent relevant Health Assembly Resolutions. • To give effect to the principles and aim of the revised International Labour Organisation

(ILO) Maternity Protection Convention and its recommendations. • Contribute to the elimination of mother to child transmission of HIV/AIDS through correct

breastfeeding practices. • To provide guidance on IYCF in exceptionally difficult circumstances.

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• To create awareness on child survival strategies that significantly contribute to the reduction

of malnutrition-related childhood morbidity and mortality hence contribute to achievement of the Millennium Development Goals (MDG) 1 and 4.

• To encourage commitment of all stakeholders to optimal IYCF. • To create a supportive environment conducive to optimal IYCF.

Policy Statements on Infant and Young Child Feeding

2.1: Breastfeeding Breastfeeding should be promoted to mothers and other caregivers as the normal way of feeding all babies.

All pregnant women should be counselled on early initiation of breastfeeding within one hour of birth and not to give the newborn pre-lacteal feeds or other supplements, not even during the second or third day after birth.

All pregnant and lactating women should be counselled on exclusive breastfeeding for six months and continued breastfeeding up to two years of age or beyond.

All lactating women will be taught how to manually express their breast milk, during the first day after giving birth.

Every mother, especially first time mothers should receive breastfeeding support at the time of delivery from the doctors and the nursing staff, or community health workers in case of non-institutional birth.

On-going counselling and support should be provided in primary health services and in the community, complemented by comprehensive communication for Social and Behaviour Change (SBC).

Legislative measures like the International Code of BMS and the ILO Maternity Protection Convention to protect IYCF should be put in place.

2.2: Complementary Feeding Once a child reaches the age of five months, his/her mother should receive counselling on optimal complementary feeding, to prepare her for when the child reaches six months.

The importance of optimal complementary feeding will be emphasized at all contact points with mothers, as complementary feeding in Eritrea usually starts too late, with undiversified foods and in a low frequency.

When promoting optimal complementary feeding practices, the following recommendations will be kept in mind and adapted to the child's age:

(i) Introduction of solid, semi-solid or soft foods: Consistency of foods should be appropriate to the developmental readiness of the child in munching, chewing and swallowing but should be thick enough to provide enough calories in the volume provided.

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(ii) Minimum dietary diversity: The homemade staple food comprising of cereal-pulse mixture should be made nutrient rich with locally available products. Ideally, young children should receive foods from 4 or more food groups each day.

(iii) Minimum meal frequency: Adequate total energy intake should be ensured by addition of nutritious snacks between the main meals.

(iv) Consumption of iron-rich or iron-fortified foods: Iron-rich foods, mainly flesh foods like meat or fish, should be added to each meal. Adding green leafy vegetables and vitamin C will support iron absorption but will not provide sufficient iron. If assessments show that among some groups of the population, local foods are not sufficiently available and affordable to provide adequate intake of iron (and zinc), supplementation or home fortification should be considered.

(v) Responsive feeding: Young children should be encouraged to take food by praising them and their foods. Self-feeding should be encouraged despite spillage.

(vi) Hygiene: Caregivers should prepare and store food hygienically and should wash their hands before preparing food, before feeding the child, after toilet use and after having touched excreta. Drinking water should be treated.

The use of high-quality locally available foods will contribute to a better complementary diet through:

(i) Combining locally available low-cost foods to create adequate complementary foods

(ii) Employing traditional processes to improve the adequacy of plant-based complementary foods or to increase energy density

(iii) Including animal source foods to improve the quality of the diet

The consumption of iodized salt will be promoted.

All mothers with ill or sick children will be counselled on the importance of increasing the daily nutrient intake of the child for a period of two weeks or longer.

2.3: Maternal Nutrition In order to ensure that the unborn child receives all the nutrients s/he needs through his/her mother's placenta, all pregnant women should be counselled on eating a nutritionally adequate diet, which means one extra meal compared to when she was not pregnant (350 extra kcal in the 2nd trimester and 450 kcal in the 3rd).

All pregnant and lactating mothers will be provided with iron and folic acid supplements at their antenatal follow up clinic. Lactating women shall to continue to take iron supplement for three months post partum.

All women shall be encouraged to breastfeed their children, as this not only benefits the child's but also the mother's health.

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In order to replace the nutrients she loses through her breast milk, all lactating women shall be encouraged to take in an additional 500-800 kcal per day i.e. two extra meals or an extra meal and an extra snack, ensuring a variety of foods.

To avoid malaria, pregnant and lactating women and their babies should sleep under insecticide treated mosquito nets.

Malnourished pregnant and lactating women shall be referred for supplementary feeding.

All women and their partners should be provided counselling and support on child spacing.

Communities shall be encouraged to find ways to reduce heavy workload and provide support to pregnant women and those with young children.

Social change should be aimed at reducing pregnancies among adolescents.

2.4: HIV and Infant Feeding All following statements are in line with the national HIV policy.

Women whose HIV statuses are unknown should be offered HIV testing.

All pregnant HIV-positive women will be provided with life long anti-retroviral therapy (ART).

All infants born to HIV women should be provided with ARV-syrup for 6 weeks. They should be tested for HIV Feeding at 6 weeks after birth, and those tested negative again at 9 months of age.

For all infants born to HIV-infected women, exclusive breastfeeding for 6 months is recommended as the feeding method together with ARVs. In Eritrea, treatment option B+ is recommended for pregnant women testing HIV positive, providing triple ARV drugs beginning in the antenatal period and continuing for life, irrespective of CD4 count and clinical staging.

Mixed feeding should never be practiced during the first 6 months of life.

In situations where breastfeeding is not possible or where individual parents opt out of the national recommendation of breastfeeding with ARVs, replacement feeding may be considered if all the criteria for replacement feeding are met.

At 6 months, complementary feeding should be introduced gradually while breastfeeding continues until the child is at least 12 months old.

All HIV-positive mothers who have an HIV-negative infant at 9 months will be advised to practice early cessation at 12 months, if a suitable replacement diet can be offered. If the child is HIV-positive, breastfeeding should continue until 24 months or beyond. Mothers should always wean their children gradually.

When ARVs are not available, mothers should still be counselled to exclusively breastfeed in the first six months of life. They should continue breastfeeding thereafter unless environmental and social circumstances are safe for, and supportive of, replacement feeding.

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Every breastfeeding HIV positive woman should be counselled on how to avoid mastitis and cracked nipples and to immediately seek professional help when these occur.

Mothers known to be HIV-infected may consider expressing and heat-treating breast milk as an interim feeding strategy.

2.5: Non-breastfed child All caregivers of non-breastfed infants will be counselled on the need for more food, but also for contact, care and attention.

Cup feeding is the preferred feeding method for replacement milk: bottle-feeding or feeding from a spouted cup shall never be encouraged.

The State of Eritrea recognizes the following alternatives to breastfeeding:

For infants less than 6 months of age: Infant formula.

For children over 6 months of age:

• Infant formula: as long as the conditions to safely give replacement feeds are fulfilled. This should be combined with optimal complementary feeding.

• Animal milk: (boiled for infants under 12 months), as part of a diet providing adequate micronutrient intake. These infants should receive two additional complementary feeds as compared to babies who continue to receive breastfeeds. The total frequency of feeding should be five or more times per day, including milk-only feeds, other foods and combination of milk feeds and other foods.

2.6: Malnourished child Severely malnourished children will be managed following the Community-Based Management of Acute Malnutrition (CMAM) strategy.

IYCF will be integrated into CMAM, in order to place more efforts on prevention of malnutrition at the household level. The reasons for integration are all related to behaviour change of the caretaker: to avoid relapse of the child, to avoid malnutrition of siblings and to ensure that mothers understand and practice recommended IYCF practices.

2.7: Feeding of Low Birth Weight Babies/ Preterm Infants Mothers of low birth weight or premature infants who cannot breastfeed shall be encouraged and assisted to express breast milk and feed it by cup. Other important micronutrients shall be given as prescribed.

2.8: IYCF in Emergencies It is important that breastfeeding is promoted in all circumstances, and especially in emergencies. Health workers must have accurate and up to date information to support children in these situations.

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In emergency situations, the best food for all infants is their own mother’s milk unless medically contraindicated. The State of Eritrea considers protection, promotion and support for breastfeeding key life saving interventions in all emergencies.

In an emergency, all mothers of newborns will be supported to initiate breastfeeding within the first hour of delivery if possible.

Mothers of children under 6 months who are mixed-fed should be supported to start exclusive breastfeeding, and children over 6 months should continue to receive the nutritional and anti-infective benefits of continued breastfeeding.

Mothers who have interrupted breastfeeding recently due to the emergency should be supported to re-lactate if at all possible.

Only when the mother is dead, absent or otherwise unable to breastfeed will replacement feeding be considered, according to strict criteria, which must be clearly and widely communicated. The implementation of the International Code will be carefully monitored.

In such cases, the State of Eritrea will do everything to minimize the risks and dangers of artificial feeding, such as provision of clean water and fuel.

Under circumstances where commercial infant formula would be needed for infants with no possibility to breastfeed, normal procurement channels shall be used. If formula is procured, it shall only be for those children who really need it, and must be provided for as long as needed. Donations of formula shall never be sought and will not be accepted.

In relation to food aid, Eritrea has the "National Health Guideline for the IDP 2000" to be followed during the response to emergencies. Its implementation at all times will be monitored. Monitoring and evaluation of the emergency program should be done based on the standard package.

Section 2: Operational Requirements Strategy Development and Implementation

Harmonization of messages and integration of IYCF in all health initiatives targeting women and children such as Baby-Friendly Hospital Initiative (BFHI), Integrated Management of Maternal and Neonatal Childhood Illnesses (IMNCI), Integrated Management of Acute Malnutrition (IMAM), PMTCT and Reproductive Health (RH) will be pursued. Therefore the Health Promotion (HP) Department will be actively involved at all stages of planning and implementation for IYCF, at all levels. It will ensure the use of community based health workers, peer counsellors, and mother support groups as well as links with agricultural extension workers in the promotion of optimal IYCF.

National level The Ministry of Health (MOH) shall implement these guidelines following normal government procedures and structures. However, given the multidisciplinary nature of Infant and Young Child Feeding, the MoH will seek the support of diverse partners through an advocacy meeting.

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This meeting will give rise to the IYCF National Task Force, chaired by the Family and Community Health Unit of the MoH. Members will consist of the major players in IYCF: Child and Adolescent Health (CAH), Reproductive Health (RH), Health Promotion (HP), the Ministry of Agriculture, the Ministry of Environmental Health, the Ministry of Education, women groups, youth associations, WHO, UNFPA and UNICEF.

The IYCF National Task Force will be responsible to draft the IYCF national strategy.

Any agency/ partner involved in the procurement, management, distribution, targeting, and use of BMS and related products by children in difficult circumstances shall do so in accordance with the Code and should get clearance from the Ministry of Health.

Zoba and Sub-Zoba level At the zoba and sub-zoba level, the zoba Primary Health Care (PHC) coordinator shall be responsible for coordinating IYCF activities. It will be also under the PHC coordinator to orient health staff, community health services and local NGO’s on IYCF.

Implementation

3.1: National Legislation on the Marketing of Breast Milk Substitutes The State of Eritrea commits itself to adhere to the International Code of Marketing of Breast Milk Substitutes, published in 1981, and to its subsequent World Health Assembly Resolutions. The purpose of the Code is to contribute to safe and adequate nutrition for infants by protecting, promoting and supporting breastfeeding; and ensuring the proper use of breast milk substitutes (BMS), when they are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Eritrea is currently in the process of drafting its national Code, to be adhered to by all health workers and other relevant sectors i.e. institutions, organizations, the private sector and individuals having contact with pregnant or lactating women and children aged 0-24 months.

3.2: IYCF Interventions for Skilled Support by the Health System In-service training and pre-service education of health staff in IYCF is critical. The Nutrition Unit will develop a national IYCF training curriculum and organize trainings for three types of health providers: IYCF in the context of IMNCI/EPI, IYCF in the context of emergencies and IYCF in the context of the Baby Friendly Hospital Initiative (BFHI).

The state of Eritrea commits itself to build up teams of experienced trainers in IYCF. They will be responsible to systematically build the capacity of district managers and senior clinicians to plan for and conduct in-service training.

Because training sessions on their own do not produce capacity and sustained implementation of services and achievement of results, supportive supervision and performance monitoring mechanisms will also be put in place at the same time as training.

The BFHI is based on the Ten Steps of Successful Breastfeeding and forms a guideline for optimizing support for breastfeeding in maternity hospitals and facilities providing maternity services for mothers and babies. The State of Eritrea is committed to fully institutionalize the

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initiative and to go beyond breastfeeding, including maternal nutrition. Through this initiative, all pregnant and lactating women shall:

- Receive a full package of appropriate nutrition services to improve or protect their nutrition status during this vulnerable period.

- Be counselled on the importance of and be supported with early initiation of breastfeeding, exclusive breastfeeding for six months, and on the importance of continuing breastfeeding up to 2 years or beyond. Those health centres conducting outreach services to communities, will ensure that staff responsible for outreach are also trained in IYCF, in order to bring IYCF services closer to the communities.

3.3: Interventions for Community-Based Counselling and Support on

Breastfeeding and Complementary Feeding using Locally Available Ingredients A multi-sectoral strategy to improve IYCF at the community level will be developed and implemented, emphasizing zoba health authority leadership and the support of all stakeholders. The community health volunteers will be leading the activities in his or her community under the supervision of the health promotion unit, and in collaboration with the agriculture extension workers, women's and youth groups.

Four inter-related community-based interventions will be implemented:

1. IYCF counselling by CHWs during home visits 2. IYCF support groups for pregnant women and mothers with young children: where maternal

nutrition is stressed, mothers can practice breastfeeding, prepare complementary foods and feed it to their babies

3. SBC communication through community activities, like community events, theatre or dance (See 3.4: Social and Behaviour Change (SBC) Communication below)

4. Improving the quality of complementary foods through locally available ingredients

The nutrition community volunteers, who are already responsible for nutrition screening and referral, will be assigned the additional task of doing IYCF counselling. In those areas where Community Based Therapeutic Feeding (CBTF) and Community-based Integrated Management of Neonatal and Childhood Illnesses (C-IMNCI) are implemented, the nutrition component will be strengthened, preferably focusing on the selected Social and Behaviour Change (SBC) messages on IYCF SBC Communication.

The State of Eritrea will organize the analysis of local complementary foods to identify the main nutrient gaps in particular settings and groups in Eritrea. Locally available foods, which are able to fill the nutrient gaps, will be identified where possible. As much as possible, the community volunteers and the agriculture extension workers and fishery will collaborate at (sub) zoba-level to increase agricultural production of high quality local foods.

3.4: Social and Behaviour Change (SBC) Communication The State of Eritrea recognizes that communication should be viewed broadly: not as only a community-based action, or only a mass–media campaign, but as a comprehensive set of

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actions with a broad stakeholder base and participation, and the use of multiple communication channels.

The SBC communication activities will be implemented through two main axes:

1. SBC by health providers at the health facility- and community-level, which consists mainly of

counselling, group education sessions and the use of audio-visual aids.

2. SBC through Multiple Channels, which will follow the same approach as the community-

based activities, first in the pilot area and if the former has proven to have an impact, on a

national basis.

The 2008 and 2012 KAPs provides a solid base to start tackling the most pressing IYCF problems, and where necessary, additional small-scale operational research can help to detail certain communication messages and activities.

To ensure the support of all stakeholders, the implementation in these communities will be preceded by advocacy activities at the national and zoba/sub-zoba level.

In all zobas, SBC will still be implemented during World Breastfeeding Week, in anticipation of the scale-up.

3.5: Use of Quality Industrially-Processed Fortified Complementary Foods The State of Eritrea, through the Ministry of trade and industries, is in the process of making subsidized industrially processed fortified complementary foods available for the general population. DMK is a dry mixture of cereals, pulses and groundnuts, which is fortified with a mineral and vitamin mix. It is supposed to be prepared by the caretaker as a thick porridge.

Care will be taken that DMK will meet the nutrient requirements of young children 6-24 through the correct portion size. Factors such as time to cook, storage and packaging will be considered.

Section 3: Monitoring and Evaluation

Monitoring and evaluation will be done at all levels to ensure that the desired results are being achieved and documented. Process indicators will routinely be collected, IYCF outcome

indicators on a periodical basis. The National Task Force on IYCF (see p.14, National level) will be responsible to establish the Monitoring and Evaluation (M&E) system.

Where necessary, research will complement M&E data, for example in the (sub) zoba where the integrated package of community-based IYCF will be offered.