Challenges of Infant and Child Feeding in Emergencies: The Puerto Rico Experience

Infants and young children are at greatest risk of food and water inequity. In Puerto Rico, after Hurricane Irma and Hurricane Maria, an innovative community-based model that uses equity as its primary focus has impacted lactation, relactation, safer formula preparation, and complementary feeding.

In the 24 hours after Hurricane Maria, 100% of Puerto Rico was without service from the electric power authority. Gas stations did not open for 6 days and gasoline was rationed, and a curfew law was in effect. Provisions were slow to arrive; water service was intermittent in some areas and nonexistent in others. Food offered by the military was nutritionally inadequate. ¹ A total of 83.1% of children under the age of 5 years in Puerto Rico qualify for the Women Infants and Children (WIC) program, ² but the WIC offices did not open for several weeks.

La Liga de la Leche, Area Caribe had made previous arrangements with Walmart corporation to store personal milk in the freezers of their stores for customers who requested it. ³ Many Walmarts did not open for weeks and lost their inventory and freezer contents. A lactating mother or parent might go to a United States Federal Emergency Management Agency (FEMA) line or to get gas and leave the baby with a family member, thinking it would take 3 or 4 hours, only to return 10 hours later and engorged. Families did not know how to express or store milk without electricity, and in many communities, ice could not be found. Visits to shelters revealed that the residents were not given access to the kitchen to boil water or sanitize equipment for bottle feeding or milk preparation and there were no breastfeeding or bottle-feeding areas.

Free lactation clinics and support groups were initially offered at the facilities of Mujeres Ayudando Madres, a maternal and child community health center, which opened and offered prenatal and birth services with pregnant and postpartum families. My colleague Yaheli Concepcion, a breastfeeding counselor, and I incorporated Alimentación Segura Infantil (ASI) with the technical assistance of a colleague in the United States who had functional Internet service.

In October, our first community training for community activists on Infant and Young Child Feeding in Emergencies (IYCF-E) covered equity as a core value, counseling skills, preservation of breastfeeding, relactation, hand expression, human milk storage, paced bottle feeding, infant feeding equipment sanitation, cup feeding, liquid ready to feed formula, the safer preparation of powdered infant formula, and transmittable diseases. From this training, we recruited our first portavoces or core group members who would receive moderate compensation in exchange for specialized training and mentorship. More portavoces were recruited from service recipients and applications after advertising. In the end, 12 portavoces, two of whom are also volunteers on the board, geographically distributed around the island, have received 80+ hours of training on infant and young child feeding and advanced lactation. They include clerks, doulas, a lactation educator, registered nurses, a midwife, and a graduated medical student. We also have a second community-trained International Board Certified Lactation Consultant (IBCLC) on staff and consider incorporating more.

Our service model has a strong emphasis on equity or doing outreach and recruitment in some of the most isolated communities. We believe that fighting poverty and social inequities should not be acts of charity, but rather concentrated efforts to include the marginalized voices in the service delivery and making services free or low cost and accessible.

Support groups are held regularly around the island facilitated by a portavoz. Since October 2017, ASI has provided support to >700 individuals and training to >300 community members.