Infant and young child feeding in emergencies: Organisational policies and activities during the refugee crisis in Lebanon.

Abstract Appropriate infant and young child feeding (IYCF) is key to reducing mortality amongst children aged under 2. Facilitating adherence to recommended IYCF practices during emergencies includes having relevant policies to support breastfeeding and complementary feeding as well as regulating the distribution of breast milk substitutes. In the current crisis, more than 1.2 million Syrian refugees are in Lebanon and it is timely to examine organisational IYCF policies and programmes. One hundred and thirty‐five non‐governmental organisations providing humanitarian aid in Lebanon were invited to participate in an online survey about organisational policies and programmatic activities on IYCF. Responses were obtained from 54 organisations: 29 International Non‐Governmental Organisations (INGOs) and 25 Local Non‐Governmental Organisations (LNGOs). In total, 8 (15%) reported having a written policy on IYCF, but only 1 policy (in draft format) was available for inspection. Twelve (8 INGOs and 4 LNGOs) indicated endorsing an external IYCF policy, but only 6 listed a valid policy. Four organisations (3 INGOs and 1 LNGO) had programme objectives that indicate protection, promotion, and support of IYCF. Three LNGOs reported receiving infant formula donations and 5 organisations (2 INGOs and 3 LNGOs) indicated distributing infant formula; 2 (1 INGO and 1 LNGO) did so in accordance with international and national policies. Few organisations violated IYCF guidance but organisational policies and activities on IYCF are not well established. In order to improve response in the current refugee crisis in Lebanon, there is a need to ensure policies are in place and implemented so that interventions support, promote, and protect IYCF.

and activities on IYCF are not well established. In order to improve response in the current refugee crisis in Lebanon, there is a need to ensure policies are in place and implemented so that interventions support, promote, and protect IYCF. KEYWORDS breastfeeding, emergencies, health policy, infant and young child feeding, infant feeding, refugees 1 | INTRODUCTION Appropriate infant and young child feeding (IYCF) is essential for adequate growth, development, and survival. The World Health Organisation (WHO) recommends exclusive breastfeeding for the first six months of age, thereafter introducing adequate complementary food, and ensuring breastfeeding is continued up to the age of two and even beyond (WHO & UNICEF, 2003). Worldwide, about 45% of child mortality has been reported to be related to malnutrition, with more than 800,000 deaths of infants and young children attributable to poor IYCF practices (Black et al., 2013).
Facilitating adherence to recommended IYFC practices becomes vital in emergency situations (e.g., civil unrest and natural disaster) where access to health care, clean water, and adequate nutrition can be compromised (WHO & UNICEF, 2003). The importance of breastfeeding becomes even greater in such contexts. For example, following the South East Asian tsunami in 2004, rates of diarrhoea were 3 times higher amongst children who were artificially fed compared to those who were breastfed (Adhisivam, Srinivasan, Soudarssanane, Deepak Amalnath, & Nirmal Kumar, 2006). During the Bosnian war in the 1990s, nonbreastfed infants under 4 months of age were reportedly more likely to become malnourished than their  (Andersson, Paredes-Solís, Legorreta-Soberanis, Cockcroft, & Sherr, 2010). In war-torn Iraq, Al-Sharbatti and AlJumaa (2012) reported that formula-fed infants had a 2.7-fold increased risk for acute respiratory infections compared to breastfed infants.
Despite the established value of supporting infant and young child feeding in emergencies (IYCF-E), IYCF practices continue to be undermined by inappropriate distribution of infant formula, milk, or milk products as well as the lack of support for breastfeeding mothers (Carothers & Gribble, 2014;Gribble, McGrath, MacLaine, & Lhotska, 2011 Group, 2007). The guidance includes the protection, promotion, and support for breastfeeding and "the need to minimise the risk of artificial feeding by ensuring that required breastmilk substitutes are purchased, distributed and used according to strict criteria." As per the OG, infant formula should only be provided to mothers or caregivers of infants who need them and donations of breast milk substitutes including bottles and teats should not be accepted (IFE Core Group, 2007). Although there are several examples of policy guidance on supporting IYCF-E, gaps in implementation are known to exist (Gupta et al., 2012). For example, during the Balkan crisis in the 1990s, it was estimated that around 1.4 metric tons of baby food were donated in the first weeks of the emergency in violation of IYCF-E policies (Borrel et al., 2001).
In the context of the Syrian crisis, Lebanon has been hosting around 1.2 million refugees from Syria (UNHCR, 2016 (Maclaine, 2006).
The report also highlighted a lack of commitment from International Non-Governmental Organisations (INGOs) and UN agencies to the Code and OG and a failure to support mothers to continue breastfeeding during and after the conflict. The report asserted that infant feeding was not a priority for lead agencies. Recently, Akik, Ghattas, Filteau, and Knai (2017)   According to the UNHCR online portal for Lebanon, around 90 organisations were active in the provision of humanitarian assistance to Syrian refugees of which around 45 were active in health, food security, or nutrition (UNHCR, 2016); the precise number fluctuates from one period to another. This study included all these agencies in addition to local organisations that were identified through the Lebanese NGO portal (daleel-madani.org). UN and government agencies were not included. One hundred thirty-five identified organisations registered as working in the following fields were invited to participate in the Key messages • During the current Syria refugee crisis, few of the surveyed local and international organisations providing humanitarian aid in Lebanon have written infant and young child feeding (IYCF) policies or endorse a valid external IYCF policy.
• Five organisations distributed infant formula; one did so in accordance with international and national policies.
• IYCF policies and activities are not well established and there is a need to ensure that policies are put in place and implemented so that IYCF interventions support, promote, and protect IYCF. Child Feeding (WHO & UNICEF, 2003). Accordingly, programme objectives were categorised as either belonging to "IYCF promotion," "IYCF support," or "IYCF protection" depending on the nature of the activity described. The research was approved by the University of Dundee Research Ethics Committee.

| RESULTS
Of the 135 NGOs that were sent the questionnaire, 11 (8%) failed to be delivered (incorrect email addresses). Therefore, it is assumed that 124 NGOs received the correspondence. Sixty-four NGOs (47%) responded, 54 (44%) completed the questionnaire, 9 (7%) responded that the questionnaire did not apply to their work, and one replied to say that they declined to participate. Fifty-three organisations answered online in English and one answered the Arabic language questionnaire by email.
Of the 54 organisations, 29 (54%) were INGOs (response rate 57%) and 25 (46%) Local Non-Governmental Organisations (LNGO; response rate 34%). The 54 organisations were divided based on their area of operations: 28 reported working at the national level, 14 reported working in more than one geographic region, and 12 reported working only in one geographic region. Figure 1 shows the number of NGOs that work in each of the regions.

| IYCF policies and programmatic activities
The organisations' basic activities varied, extending from provision of nonfood items (kitchen utensils, beddings, diapers, etc.) to school education and health care (including nutrition and food security; Table 1)   LNGOs), two of which had not previously indicated that they did endorse an external policy. One organisation that had indicated endorsing an external policy did not answer the question related to naming the policy.
Of the 13 organisations that answered this question, some mentioned more than one policy. Six mentioned existing policies and guidance, the rest had incomplete answers. 3 In summary, the policies and guidance reported were the OG, the The two organisations that did not receive infant formula distributed to selected mothers and infants; the rest used mass distribution. Tables 2 and 3 show a summary of responses received from the five organisations that indicated distributing infant formula.
The table describes the nature of the activities that these five organisations were engaged in as well as the extent to which the distribution of infant formula was in line with IYCF-E policies and guidance.
In summary, only one organisation had a programme with objectives encompassing the three pillars of promotion, support, and protection.
That same organisation was the only one distributing infant formula in compliance with IYCF-E policies and guidance.  Table 3, infant formula was distributed to up to 3,500 families by one organisation or more than 6,000 families by organisations collectively. Four organisations distributed infant formula that is branded and labelled in Arabic and one violated the guidance. It should be noted that the guidance (OG, Code) was Activities targeting PLWs and IYC Organisation reports having a system for promotion, support and protection of IYCF Note. Y = yes; Aligned = Aligned with IYCF-E guidance; N = no; Not aligned = not aligned with IYCF-E guidance; N/A = not applicable; DNK = does not know; NGO = Non-Governmental Organisations; LNGO = Local Non-Governmental Organisations; WASH = water, sanitation, and hygiene; PLWs = pregnant and lactating women; IYC = infants and young children; IYCF = infant and young child feeding.
violated by distributing infant formula labelled in a language different from that used by recipients. It is therefore evident that even with national policies and statements in place, these were not well implemented or reflected in the work being undertaken. This is consistent with the findings of Borrel et al.'s (2001) Balkans study which identified a lack of translation from policy to practice due in part to weak institutionalisation of policies, the absence of monitoring systems, and inadequate coordination mechanisms.
In Lebanon in 2006, Maclaine (2006 reported similar findings indicating violations of the Code and the IYCF OG. In that study, infant formula was distributed within baby kits by at least one INGO and three LNGOs, and around 1,500 baby kits were distributed (Maclaine, 2006). The numbers in Table 3   "missed the point." Dolan et al. (2014) noted that few interventions focused on breastfeeding but also that the needs of nonbreastfed infants were not met through targeted artificial feeding support.
Overall, the limited IYCF activities and lack of policies indicate a need to upscale action to respond to the needs of infants and young children. Despite the large pool of organisations that may be expected to work on IYCF, very few had programmes established. The concept of championing has been discussed in different situations where it has been linked to the success of national initiatives and has been included in recommendations for advocating nutritional and IYCF initiatives (Ashworth & Jackson, 2011;Kathumba, 2012;Sumner, Lindstrom, & Haddad, 2008). It could be that the presence of such a champion in Lebanon would contribute to improving policies and programmatic activities on IYCF. Our findings show that there is potentially at least one organisation that is dedicated to upholding IYCF and there is potential that such organisations might play a role in improving IYCF interventions.
Although organisations that responded had initiatives throughout the country, still, it should be pointed out that only half the contacted organisations responded. This may be due to the heavy workload that organisations are engaged in during the refugee response. International organisations were more likely to respond to the survey, which may reflect greater experience with research participation and/or greater overall capacity.
For a few organisations, there was some lack of clarity about whether they had a written IYCF policy or not. Although it was requested that the survey was completed by appropriate staff, it is possible that respondents may have not been familiar with existing organisational IYCF policies or terminologies including what a policy is. Within questions related to endorsing or having a policy, there were apparent contradictions in the answers between questions that were purely objective (yes and no answers) and questions that required an elaboration (such as naming or sharing the policy). This is also valid for questions related to programming on IYCF.

| CONCLUSION
Our findings show that despite the large number of organisations targeting infants and young children, IYCF-E is not being given priority within organisational programming. Very few organisations had established policies related to IYCF in the current refugee crisis in Lebanon. IYCF interventions were limited to promotion of breastfeeding but not support or protection for breastfeeding mothers.
Violations to national and international guidance occurred mainly in local organisations and IYCF was rarely integrated within programmes despite the fact that many organisations target PLWs and infants and young children.
In order to improve response during the current refugee crisis in Lebanon, and given the importance of ensuring adherence to recommended IYCF practices during emergencies, there is a need to ensure that policies are implemented within organisations that they guide everyday practice and that interventions support, promote, and protect IYCF.