TY - JOUR
AU - McCool-Myers, Megan, E
AB - Abstract The use of commercial complementary food (CCF) in humanitarian emergencies is an emerging topic in nutrition policy. Food safety guidance is helpful for the prevention of foodborne illnesses in infants and young children, but whether current global operational guidance on infant and young child feeding in emergencies (IYCF-E) adequately addresses food safety for CCF in humanitarian emergencies is unknown. The aim of this review was to identify and synthesize available food safety guidance on the use of CCF in humanitarian emergencies. A narrative review that included a systematic content analysis and thematic synthesis of global operational guidance on IYCF-E was conducted. Fourteen global guidance documents were selected. Forty-nine excerpts specific to CCF were identified, of which 10 (20%) were rated as relevant to the prevention of foodborne illness. Assessment of inter-rater reliability showed 80% agreement, with a Cohen’s kappa coefficient (κ) of 0.52 (moderate agreement). Content was synthesized in 3 themes: donations of CCF, quality assurance and quality control, and water, sanitation, and hygiene principles. Little salient guidance for the safe use of CCF in emergencies was identified. Global operational guidance on IYCF-E should be updated by incorporating food safety considerations for the use of CCF. commercial complementary food, complementary feeding, humanitarian emergencies, nutrition policy, food safety, hygiene, infant and young child feeding in emergencies INTRODUCTION During infancy and early childhood, contaminated complementary foods account for a substantial proportion of diarrheal illnesses.1–4 An estimated 580 000 (6%) of child deaths globally could be avoided each year through safe and appropriate complementary feeding practices.5 The risk of contracting diarrheal diseases is heightened during humanitarian crises, especially in armed conflicts and refugee settings, as outbreaks of diarrheal diseases from contaminated foods and water spread easily in crowded human settlements.6–8 Food safety is defined as the conditions and measures necessary to ensure food is safe for consumption.9 Complementary foods can become hazardous disease vehicles when stored at ambient temperatures, as nutrients allow bacteria to grow to pathogenic quantities and produce potentially fatal toxins within the time span of only a few hours.1–3,10–12 In addition, food safety and hygiene challenges increase when potable water, fuel, and cleansing agents are limited or unavailable and hygienic feeding environments do not exist.13 In general, it is recommended that complementary foods be prepared from locally available foods.14 However, this can be unrealistic in emergencies when locally available foods are unavailable or difficult to prepare into a soft or semisolid form.14,15 This may, in part, explain why commercial complementary food (CCF), commonly known as industrial baby food, has been distributed in recent humanitarian emergencies.16–20 Field reports from United Nations (UN) agencies, international nongovernmental agencies, and the North Atlantic Treaty Organization have reported distributions of CCF during humanitarian emergencies in Bosnia and Herzegovenia,16 Croatia,17 Indonesia18 Kosovo,19 Lebanon,18 Macedonia,19 and Ukraine.20 Given the general heightened risk of food contamination due to potential lack of access to refrigeration, fuel, and safe water during humanitarian crises, operational guidance on the safe use of CCF in emergencies is necessary for the prevention of foodborne illnesses. Interim operational guidance for infant and young child feeding in emergencies (IYCF-E) published in 2015 suggested that CCF could be used to fill an important gap in transitory refugee and migrant settings in Europe.21 However, it is unclear what guidance on the safe use of CCF in emergencies exists at the global level. This narrative review aims to identify and synthesize guidance on the safe use of CCF in humanitarian emergencies from global IYCF-E operational guidance documents. METHODS A narrative review of global IYCF-E operational guidance documents was conducted. Key IYCF-E documents published by global health and nutrition authorities were retrieved through a selective, web-based literature search of the electronic databases of the World Health Organization (WHO) Institutional Repository for Information Sharing and the Emergency Nutrition Network. Both websites were searched using the search string “infant and young child feeding in emergencies.” Additional documents were found by manually searching the reference lists of all documents identified. The methodology used for selection of documents and analysis of content is shown in Figure 1. Figure 1 View largeDownload slide Flow diagram of the process for selection, analysis, and synthesis of global operational guidance documents. Figure 1 View largeDownload slide Flow diagram of the process for selection, analysis, and synthesis of global operational guidance documents. For inclusion in the review, guidance documents were required to be global in scope and offer programmatic or operational IYCF-E guidance for humanitarian practitioners, programmers, and decision makers and to be authored by nongovernmental organizations, UN agencies, or a global consortium. Only guidance documents that were published from 2000 to 2017 in English were included. Table 1 outlines the criteria for selection of guidance documents. Table 1 Inclusion and exclusion criteria for selection of documents Category Included Excluded Document type Global operational and programmatic guidance National, regional, and international policies or position papers; scoping reviews; scientific journal articles; field reports; videos; 1-page articles; web pages; event announcements; online training courses; articles or announcements published on social media; summary sheets; information, education and communication materials for caregivers Authoring agency United Nations agencies, global public health and nutrition authorities, international nongovernmental agencies, international health or nutrition consortiums National public health authorities; individuals; private companies Target audience Humanitarian practitioners, programmers and decision makers working in infant and young child feeding in emergencies Researchers; humanitarians working in sectors other than infant and young child feeding in emergencies; humanitarians working in emergency preparedness and resilience nutrition, international development, or nonemergency contexts Population of interest Infants and young children 0–36 mo of age in humanitarian crises Older children, adolescents, or adults; populations unaffected by humanitarian crises Humanitarian cluster of interest Nutrition, food security, health, WASH (water, sanitation, and hygiene) Logistics; emergency telecommunications; education; protection; shelter; camp coordination and management; emergency recovery Exposure of interest Commercial complementary foods Homemade complementary foods; commercial infant formula; commercial follow-on formula; toddler milks; beverages; day care meals; staple foods; micronutrient powders; ready-to-use supplementary foods; ready-to-use therapeutic foods Health outcomes of interest Mortality, foodborne disease, waterborne disease, diarrheal and emetic disease, fever, dehydration, malnutrition Other infectious and chronic diseases Publication year(s) 2000–2017 Earlier versions of included documents; documents published before 2000 Language(s) English Any other language Category Included Excluded Document type Global operational and programmatic guidance National, regional, and international policies or position papers; scoping reviews; scientific journal articles; field reports; videos; 1-page articles; web pages; event announcements; online training courses; articles or announcements published on social media; summary sheets; information, education and communication materials for caregivers Authoring agency United Nations agencies, global public health and nutrition authorities, international nongovernmental agencies, international health or nutrition consortiums National public health authorities; individuals; private companies Target audience Humanitarian practitioners, programmers and decision makers working in infant and young child feeding in emergencies Researchers; humanitarians working in sectors other than infant and young child feeding in emergencies; humanitarians working in emergency preparedness and resilience nutrition, international development, or nonemergency contexts Population of interest Infants and young children 0–36 mo of age in humanitarian crises Older children, adolescents, or adults; populations unaffected by humanitarian crises Humanitarian cluster of interest Nutrition, food security, health, WASH (water, sanitation, and hygiene) Logistics; emergency telecommunications; education; protection; shelter; camp coordination and management; emergency recovery Exposure of interest Commercial complementary foods Homemade complementary foods; commercial infant formula; commercial follow-on formula; toddler milks; beverages; day care meals; staple foods; micronutrient powders; ready-to-use supplementary foods; ready-to-use therapeutic foods Health outcomes of interest Mortality, foodborne disease, waterborne disease, diarrheal and emetic disease, fever, dehydration, malnutrition Other infectious and chronic diseases Publication year(s) 2000–2017 Earlier versions of included documents; documents published before 2000 Language(s) English Any other language Table 1 Inclusion and exclusion criteria for selection of documents Category Included Excluded Document type Global operational and programmatic guidance National, regional, and international policies or position papers; scoping reviews; scientific journal articles; field reports; videos; 1-page articles; web pages; event announcements; online training courses; articles or announcements published on social media; summary sheets; information, education and communication materials for caregivers Authoring agency United Nations agencies, global public health and nutrition authorities, international nongovernmental agencies, international health or nutrition consortiums National public health authorities; individuals; private companies Target audience Humanitarian practitioners, programmers and decision makers working in infant and young child feeding in emergencies Researchers; humanitarians working in sectors other than infant and young child feeding in emergencies; humanitarians working in emergency preparedness and resilience nutrition, international development, or nonemergency contexts Population of interest Infants and young children 0–36 mo of age in humanitarian crises Older children, adolescents, or adults; populations unaffected by humanitarian crises Humanitarian cluster of interest Nutrition, food security, health, WASH (water, sanitation, and hygiene) Logistics; emergency telecommunications; education; protection; shelter; camp coordination and management; emergency recovery Exposure of interest Commercial complementary foods Homemade complementary foods; commercial infant formula; commercial follow-on formula; toddler milks; beverages; day care meals; staple foods; micronutrient powders; ready-to-use supplementary foods; ready-to-use therapeutic foods Health outcomes of interest Mortality, foodborne disease, waterborne disease, diarrheal and emetic disease, fever, dehydration, malnutrition Other infectious and chronic diseases Publication year(s) 2000–2017 Earlier versions of included documents; documents published before 2000 Language(s) English Any other language Category Included Excluded Document type Global operational and programmatic guidance National, regional, and international policies or position papers; scoping reviews; scientific journal articles; field reports; videos; 1-page articles; web pages; event announcements; online training courses; articles or announcements published on social media; summary sheets; information, education and communication materials for caregivers Authoring agency United Nations agencies, global public health and nutrition authorities, international nongovernmental agencies, international health or nutrition consortiums National public health authorities; individuals; private companies Target audience Humanitarian practitioners, programmers and decision makers working in infant and young child feeding in emergencies Researchers; humanitarians working in sectors other than infant and young child feeding in emergencies; humanitarians working in emergency preparedness and resilience nutrition, international development, or nonemergency contexts Population of interest Infants and young children 0–36 mo of age in humanitarian crises Older children, adolescents, or adults; populations unaffected by humanitarian crises Humanitarian cluster of interest Nutrition, food security, health, WASH (water, sanitation, and hygiene) Logistics; emergency telecommunications; education; protection; shelter; camp coordination and management; emergency recovery Exposure of interest Commercial complementary foods Homemade complementary foods; commercial infant formula; commercial follow-on formula; toddler milks; beverages; day care meals; staple foods; micronutrient powders; ready-to-use supplementary foods; ready-to-use therapeutic foods Health outcomes of interest Mortality, foodborne disease, waterborne disease, diarrheal and emetic disease, fever, dehydration, malnutrition Other infectious and chronic diseases Publication year(s) 2000–2017 Earlier versions of included documents; documents published before 2000 Language(s) English Any other language A systematic content analysis was performed on the included global guidance documents. First, documents were saved in a portable document format (.pdf) or Word file (.docx). Next, they were searched for text pertaining to CCF. The search functions in Adobe Acrobat Reader and Microsoft Word were used with the following search terms: “commercial,” “packaged,” “formulated,” “processed,” “industrial,” “manufactured,” “baby food,” and “infant food.” Where any search term produced a hit, contiguous text was reviewed for relevance to CCF. An assumption was made that food safety guidance for safe and hygienic preparation and storage of CCF would differ from food safety guidance for raw or homemade complementary foods. Therefore, selection criteria for excerpts were as follows: (1) text clearly refers to food intended as a complementary food; and (2) text refers to commercial production. If both criteria were met, contiguous text was extracted and saved into a table. If different search terms generated identical excerpts, duplicate excerpts were excluded. Excerpts were then blindly rated by 2 investigators for their relevance to foodborne illness prevention. Each excerpt was given a dichotomous rating (0/1) for its relevance to foodborne illness prevention per the following prompt question: Is the extracted text potentially relevant guidance for the prevention of foodborne illness? After excerpt ratings were tallied, inter-rater reliability was calculated using Cohen’s kappa coefficient (ĸ) and evaluated using the guideline outlined by Landis and Koch.22 Excerpts were then categorized into 3 key themes and summarized using a thematic synthesis approach. Some excerpts addressed more than one theme and were included accordingly under each corresponding theme. RESULTS Characteristics of included guidance documents Fourteen global IYCF-E guidance documents were selected for inclusion. Table 223–25,27–37 lists the selected global guidance documents, their target audience, and the document aims. Table 2 Description of the 14 included global operational guidance documents on infant and young child feeding in emergencies No. Commissioning agencies (year of publication) Document name Target audience Document aim 1 World Health Organization, United Nations Children’s Fund, LINKAGES Project, International Baby Food Action Network, and Emergency Nutrition Network (2001)23 Infant Feeding in Emergencies. Module 1 for Emergency Relief Staff: Manual for Orientation, Reading and Reference Emergency relief staff Provides concise guidance on how to ensure appropriate IYCF-E (pg 46) 2 World Health Organization (2004)24 Guiding Principles for Feeding Infants and Young Children During Emergencies National authorities and international and nongovernmental organizations Includes 10 guiding principles intended to serve as a starting point for organizing sustained pragmatic field interventions to ensure appropriate feeding and care for infants and young children at all stages of an organized emergency response (pg 57) 3 United Nations Children’s Fund (2005)25 Emergency Field Handbook: A Guide for UNICEF Staff UNICEF staff Developed to guide UNICEF staff in planning and organizing actions in response to an emergency. Chapter 5.1, “Health and Nutrition,” specifically aims to guide UNICEF staff on implementing the health and nutrition components of the Core Commitments for Children in Humanitarian Action (pg III)26 4 Emergency Nutrition Network, International Baby Food Action Network—Geneva Infant Feeding Association, Fondation Terre des hommes, Action Contre la Faim, CARE USA, LINKAGES Project, United Nations Children’s Fund, United Nations High Commissioner for Refugees, World Health Organization, and World Food Programme (2007)27 Infant Feeding in Emergencies Module 2, Version 1.1 for health and nutrition workers in emergency situations, for training, practice and reference Health and nutrition workers directly concerned with mothers and caregivers in emergencies Provides specific, practical knowledge for supporting mothers and caregivers with IYCF-E (pg 7) 5 Emergency Nutrition Network, Infant Feeding in Emergencies (IFE) Core Group, Inter-Agency Standing Committee (2009)28 Integration of IYCF Support into CMAM: Facilitator’s Guide Healthcare personnel and workers, policy makers, and relevant technical staff involved with CMAM programming Aims to train healthcare personnel and community health workers in the integration of recommended IYCF practices within CMAM. Also useful for government officials at the ministry of health level and the district level, for NGO personnel, and for UN technical staff involved in the management of acute malnutrition (pg 4) 6 The Sphere Project (2011)29 The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (chapter: Minimum Standards in Food Security and Nutrition; section 2, Infant and Young Child Feeding) Practitioners involved in planning, managing, or implementing a humanitarian response Focuses on key actions and indicators to be undertaken by humanitarian actors to protect optimal feeding practices, to maximize survival, and to reduce morbidity in children under 24 mo of age (pg 158) 7 Emergency Nutrition Network, Inter-Agency Standing Committee, US Agency for International Development, Nutrition Works (2011)30 The Harmonised Training Package (HTP): Resource Material for Training on Nutrition in Emergencies. Version 2. Module 17: infant and young child feeding in emergency situations Trainers in the NiE sector The HTP is designed to provide trainers from any implementing agency or academic institution with information from which to design and implement an NiE training course. Module 17 specifically addresses IYCF-E and the protection and support of optimal feeding for infants and young children in all emergencies 8 United Nations Children’s Fund (2012)31 Infant and Young Child Feeding: Programming Guide UNICEF staff and a broad range of partners involved in IYCF programming Comprehensive and detailed programming information on IYCF. Includes guidance on breastfeeding, complementary feeding, and infant feeding both in general and in especially difficult circumstances, such as in emergencies and in the context of HIV (pg iv) 9 Save the Children (2014)32 IYCF-E Toolkit: Rapid Start-up for Emergency Nutrition Personnel. Version 2.0 Emergency nutrition program managers, coordinators, and advisors Designed to promote best practice and rapid implementation of IYCF-E among those responsible for program design and for implementation and management of IYCF-E programs (pg 3) 10 Directorate-General for European Civil Protection and Humanitarian Aid Operations (2014)33 Infant and Young Children Feeding in Emergencies: Guidance for Programming General practitioners Offers guidance on ensuring that the specific needs of infants and young children are assessed and addressed adequately in programming. A checklist for integrating IYCF considerations in emergencies is provided at the end of the document (pg 2) 11 United Nations High Commissioner for Refugees (2015)34 Infant and Young Child Feeding Practices: Standard Operating Procedures for the Handling of Breastmilk Substitutes (BMS) in Refugee Situations for Children 0–23 mo. Version 1.1 UNHCR staff and partners Standard operating procedures for the management of artificial feeding of infants and young children in refugee contexts to protect both breastfed and non-breastfed children. Particular consideration is given to emergency contexts, to high-burden, resource-poor settings, and to pastoral communities (pg 10) 12 Global Nutrition Cluster (2016)35 Tips on Nutrition Interventions for the Humanitarian Response Plan Country nutrition clusters and nutrition cluster partners Provides tips for nutrition clusters and partners to facilitate the planning of a collective response and the development of humanitarian response plans for NiE interventions. Also intended for use by other clusters to help guide the inclusion of nutrition-sensitive interventions in their respective sectoral plans (pg 4) 13 Action Against Hunger, European Civil Protection and Humanitarian Aid Operations, United Nations Children’s Fund (2017)36 WASH’Nutrition: A Practical Guidebook on Increasing Nutritional Impact Through Integration of WASH and Nutrition Programmes. For Practitioners in Humanitarian and Development Contexts WASH and nutrition field practitioners and program managers working in humanitarian and development contexts Responds to the need for more practical guidance on WASH and nutrition integration at the field level. Can also be used as a practical tool for donors and institutions (such as ministries of health) to prioritize strategic activities and funding options (pg 7) 14 Infant Feeding in Emergencies Core Group (2017)37 Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers. Version 3.0 Policy makers, decision makers, and programmers working in emergency preparedness and response Provides concise, practical guidance on how to ensure appropriate IYCF-E (pg 2) No. Commissioning agencies (year of publication) Document name Target audience Document aim 1 World Health Organization, United Nations Children’s Fund, LINKAGES Project, International Baby Food Action Network, and Emergency Nutrition Network (2001)23 Infant Feeding in Emergencies. Module 1 for Emergency Relief Staff: Manual for Orientation, Reading and Reference Emergency relief staff Provides concise guidance on how to ensure appropriate IYCF-E (pg 46) 2 World Health Organization (2004)24 Guiding Principles for Feeding Infants and Young Children During Emergencies National authorities and international and nongovernmental organizations Includes 10 guiding principles intended to serve as a starting point for organizing sustained pragmatic field interventions to ensure appropriate feeding and care for infants and young children at all stages of an organized emergency response (pg 57) 3 United Nations Children’s Fund (2005)25 Emergency Field Handbook: A Guide for UNICEF Staff UNICEF staff Developed to guide UNICEF staff in planning and organizing actions in response to an emergency. Chapter 5.1, “Health and Nutrition,” specifically aims to guide UNICEF staff on implementing the health and nutrition components of the Core Commitments for Children in Humanitarian Action (pg III)26 4 Emergency Nutrition Network, International Baby Food Action Network—Geneva Infant Feeding Association, Fondation Terre des hommes, Action Contre la Faim, CARE USA, LINKAGES Project, United Nations Children’s Fund, United Nations High Commissioner for Refugees, World Health Organization, and World Food Programme (2007)27 Infant Feeding in Emergencies Module 2, Version 1.1 for health and nutrition workers in emergency situations, for training, practice and reference Health and nutrition workers directly concerned with mothers and caregivers in emergencies Provides specific, practical knowledge for supporting mothers and caregivers with IYCF-E (pg 7) 5 Emergency Nutrition Network, Infant Feeding in Emergencies (IFE) Core Group, Inter-Agency Standing Committee (2009)28 Integration of IYCF Support into CMAM: Facilitator’s Guide Healthcare personnel and workers, policy makers, and relevant technical staff involved with CMAM programming Aims to train healthcare personnel and community health workers in the integration of recommended IYCF practices within CMAM. Also useful for government officials at the ministry of health level and the district level, for NGO personnel, and for UN technical staff involved in the management of acute malnutrition (pg 4) 6 The Sphere Project (2011)29 The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (chapter: Minimum Standards in Food Security and Nutrition; section 2, Infant and Young Child Feeding) Practitioners involved in planning, managing, or implementing a humanitarian response Focuses on key actions and indicators to be undertaken by humanitarian actors to protect optimal feeding practices, to maximize survival, and to reduce morbidity in children under 24 mo of age (pg 158) 7 Emergency Nutrition Network, Inter-Agency Standing Committee, US Agency for International Development, Nutrition Works (2011)30 The Harmonised Training Package (HTP): Resource Material for Training on Nutrition in Emergencies. Version 2. Module 17: infant and young child feeding in emergency situations Trainers in the NiE sector The HTP is designed to provide trainers from any implementing agency or academic institution with information from which to design and implement an NiE training course. Module 17 specifically addresses IYCF-E and the protection and support of optimal feeding for infants and young children in all emergencies 8 United Nations Children’s Fund (2012)31 Infant and Young Child Feeding: Programming Guide UNICEF staff and a broad range of partners involved in IYCF programming Comprehensive and detailed programming information on IYCF. Includes guidance on breastfeeding, complementary feeding, and infant feeding both in general and in especially difficult circumstances, such as in emergencies and in the context of HIV (pg iv) 9 Save the Children (2014)32 IYCF-E Toolkit: Rapid Start-up for Emergency Nutrition Personnel. Version 2.0 Emergency nutrition program managers, coordinators, and advisors Designed to promote best practice and rapid implementation of IYCF-E among those responsible for program design and for implementation and management of IYCF-E programs (pg 3) 10 Directorate-General for European Civil Protection and Humanitarian Aid Operations (2014)33 Infant and Young Children Feeding in Emergencies: Guidance for Programming General practitioners Offers guidance on ensuring that the specific needs of infants and young children are assessed and addressed adequately in programming. A checklist for integrating IYCF considerations in emergencies is provided at the end of the document (pg 2) 11 United Nations High Commissioner for Refugees (2015)34 Infant and Young Child Feeding Practices: Standard Operating Procedures for the Handling of Breastmilk Substitutes (BMS) in Refugee Situations for Children 0–23 mo. Version 1.1 UNHCR staff and partners Standard operating procedures for the management of artificial feeding of infants and young children in refugee contexts to protect both breastfed and non-breastfed children. Particular consideration is given to emergency contexts, to high-burden, resource-poor settings, and to pastoral communities (pg 10) 12 Global Nutrition Cluster (2016)35 Tips on Nutrition Interventions for the Humanitarian Response Plan Country nutrition clusters and nutrition cluster partners Provides tips for nutrition clusters and partners to facilitate the planning of a collective response and the development of humanitarian response plans for NiE interventions. Also intended for use by other clusters to help guide the inclusion of nutrition-sensitive interventions in their respective sectoral plans (pg 4) 13 Action Against Hunger, European Civil Protection and Humanitarian Aid Operations, United Nations Children’s Fund (2017)36 WASH’Nutrition: A Practical Guidebook on Increasing Nutritional Impact Through Integration of WASH and Nutrition Programmes. For Practitioners in Humanitarian and Development Contexts WASH and nutrition field practitioners and program managers working in humanitarian and development contexts Responds to the need for more practical guidance on WASH and nutrition integration at the field level. Can also be used as a practical tool for donors and institutions (such as ministries of health) to prioritize strategic activities and funding options (pg 7) 14 Infant Feeding in Emergencies Core Group (2017)37 Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers. Version 3.0 Policy makers, decision makers, and programmers working in emergency preparedness and response Provides concise, practical guidance on how to ensure appropriate IYCF-E (pg 2) Abbreviations: CMAM, Community Management of Acute Malnutrition; IYCF, infant and young child feeding; IYCF-E, infant and young child feeding in emergencies; NGO, nongovernmental organization; NiE, nutrition in emergencies; WASH, water, sanitation, and hygiene; UN, United Nations; UNHCR, United Nations High Commission for Refugees; UNICEF, United Nations Children’s Fund. Table 2 Description of the 14 included global operational guidance documents on infant and young child feeding in emergencies No. Commissioning agencies (year of publication) Document name Target audience Document aim 1 World Health Organization, United Nations Children’s Fund, LINKAGES Project, International Baby Food Action Network, and Emergency Nutrition Network (2001)23 Infant Feeding in Emergencies. Module 1 for Emergency Relief Staff: Manual for Orientation, Reading and Reference Emergency relief staff Provides concise guidance on how to ensure appropriate IYCF-E (pg 46) 2 World Health Organization (2004)24 Guiding Principles for Feeding Infants and Young Children During Emergencies National authorities and international and nongovernmental organizations Includes 10 guiding principles intended to serve as a starting point for organizing sustained pragmatic field interventions to ensure appropriate feeding and care for infants and young children at all stages of an organized emergency response (pg 57) 3 United Nations Children’s Fund (2005)25 Emergency Field Handbook: A Guide for UNICEF Staff UNICEF staff Developed to guide UNICEF staff in planning and organizing actions in response to an emergency. Chapter 5.1, “Health and Nutrition,” specifically aims to guide UNICEF staff on implementing the health and nutrition components of the Core Commitments for Children in Humanitarian Action (pg III)26 4 Emergency Nutrition Network, International Baby Food Action Network—Geneva Infant Feeding Association, Fondation Terre des hommes, Action Contre la Faim, CARE USA, LINKAGES Project, United Nations Children’s Fund, United Nations High Commissioner for Refugees, World Health Organization, and World Food Programme (2007)27 Infant Feeding in Emergencies Module 2, Version 1.1 for health and nutrition workers in emergency situations, for training, practice and reference Health and nutrition workers directly concerned with mothers and caregivers in emergencies Provides specific, practical knowledge for supporting mothers and caregivers with IYCF-E (pg 7) 5 Emergency Nutrition Network, Infant Feeding in Emergencies (IFE) Core Group, Inter-Agency Standing Committee (2009)28 Integration of IYCF Support into CMAM: Facilitator’s Guide Healthcare personnel and workers, policy makers, and relevant technical staff involved with CMAM programming Aims to train healthcare personnel and community health workers in the integration of recommended IYCF practices within CMAM. Also useful for government officials at the ministry of health level and the district level, for NGO personnel, and for UN technical staff involved in the management of acute malnutrition (pg 4) 6 The Sphere Project (2011)29 The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (chapter: Minimum Standards in Food Security and Nutrition; section 2, Infant and Young Child Feeding) Practitioners involved in planning, managing, or implementing a humanitarian response Focuses on key actions and indicators to be undertaken by humanitarian actors to protect optimal feeding practices, to maximize survival, and to reduce morbidity in children under 24 mo of age (pg 158) 7 Emergency Nutrition Network, Inter-Agency Standing Committee, US Agency for International Development, Nutrition Works (2011)30 The Harmonised Training Package (HTP): Resource Material for Training on Nutrition in Emergencies. Version 2. Module 17: infant and young child feeding in emergency situations Trainers in the NiE sector The HTP is designed to provide trainers from any implementing agency or academic institution with information from which to design and implement an NiE training course. Module 17 specifically addresses IYCF-E and the protection and support of optimal feeding for infants and young children in all emergencies 8 United Nations Children’s Fund (2012)31 Infant and Young Child Feeding: Programming Guide UNICEF staff and a broad range of partners involved in IYCF programming Comprehensive and detailed programming information on IYCF. Includes guidance on breastfeeding, complementary feeding, and infant feeding both in general and in especially difficult circumstances, such as in emergencies and in the context of HIV (pg iv) 9 Save the Children (2014)32 IYCF-E Toolkit: Rapid Start-up for Emergency Nutrition Personnel. Version 2.0 Emergency nutrition program managers, coordinators, and advisors Designed to promote best practice and rapid implementation of IYCF-E among those responsible for program design and for implementation and management of IYCF-E programs (pg 3) 10 Directorate-General for European Civil Protection and Humanitarian Aid Operations (2014)33 Infant and Young Children Feeding in Emergencies: Guidance for Programming General practitioners Offers guidance on ensuring that the specific needs of infants and young children are assessed and addressed adequately in programming. A checklist for integrating IYCF considerations in emergencies is provided at the end of the document (pg 2) 11 United Nations High Commissioner for Refugees (2015)34 Infant and Young Child Feeding Practices: Standard Operating Procedures for the Handling of Breastmilk Substitutes (BMS) in Refugee Situations for Children 0–23 mo. Version 1.1 UNHCR staff and partners Standard operating procedures for the management of artificial feeding of infants and young children in refugee contexts to protect both breastfed and non-breastfed children. Particular consideration is given to emergency contexts, to high-burden, resource-poor settings, and to pastoral communities (pg 10) 12 Global Nutrition Cluster (2016)35 Tips on Nutrition Interventions for the Humanitarian Response Plan Country nutrition clusters and nutrition cluster partners Provides tips for nutrition clusters and partners to facilitate the planning of a collective response and the development of humanitarian response plans for NiE interventions. Also intended for use by other clusters to help guide the inclusion of nutrition-sensitive interventions in their respective sectoral plans (pg 4) 13 Action Against Hunger, European Civil Protection and Humanitarian Aid Operations, United Nations Children’s Fund (2017)36 WASH’Nutrition: A Practical Guidebook on Increasing Nutritional Impact Through Integration of WASH and Nutrition Programmes. For Practitioners in Humanitarian and Development Contexts WASH and nutrition field practitioners and program managers working in humanitarian and development contexts Responds to the need for more practical guidance on WASH and nutrition integration at the field level. Can also be used as a practical tool for donors and institutions (such as ministries of health) to prioritize strategic activities and funding options (pg 7) 14 Infant Feeding in Emergencies Core Group (2017)37 Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers. Version 3.0 Policy makers, decision makers, and programmers working in emergency preparedness and response Provides concise, practical guidance on how to ensure appropriate IYCF-E (pg 2) No. Commissioning agencies (year of publication) Document name Target audience Document aim 1 World Health Organization, United Nations Children’s Fund, LINKAGES Project, International Baby Food Action Network, and Emergency Nutrition Network (2001)23 Infant Feeding in Emergencies. Module 1 for Emergency Relief Staff: Manual for Orientation, Reading and Reference Emergency relief staff Provides concise guidance on how to ensure appropriate IYCF-E (pg 46) 2 World Health Organization (2004)24 Guiding Principles for Feeding Infants and Young Children During Emergencies National authorities and international and nongovernmental organizations Includes 10 guiding principles intended to serve as a starting point for organizing sustained pragmatic field interventions to ensure appropriate feeding and care for infants and young children at all stages of an organized emergency response (pg 57) 3 United Nations Children’s Fund (2005)25 Emergency Field Handbook: A Guide for UNICEF Staff UNICEF staff Developed to guide UNICEF staff in planning and organizing actions in response to an emergency. Chapter 5.1, “Health and Nutrition,” specifically aims to guide UNICEF staff on implementing the health and nutrition components of the Core Commitments for Children in Humanitarian Action (pg III)26 4 Emergency Nutrition Network, International Baby Food Action Network—Geneva Infant Feeding Association, Fondation Terre des hommes, Action Contre la Faim, CARE USA, LINKAGES Project, United Nations Children’s Fund, United Nations High Commissioner for Refugees, World Health Organization, and World Food Programme (2007)27 Infant Feeding in Emergencies Module 2, Version 1.1 for health and nutrition workers in emergency situations, for training, practice and reference Health and nutrition workers directly concerned with mothers and caregivers in emergencies Provides specific, practical knowledge for supporting mothers and caregivers with IYCF-E (pg 7) 5 Emergency Nutrition Network, Infant Feeding in Emergencies (IFE) Core Group, Inter-Agency Standing Committee (2009)28 Integration of IYCF Support into CMAM: Facilitator’s Guide Healthcare personnel and workers, policy makers, and relevant technical staff involved with CMAM programming Aims to train healthcare personnel and community health workers in the integration of recommended IYCF practices within CMAM. Also useful for government officials at the ministry of health level and the district level, for NGO personnel, and for UN technical staff involved in the management of acute malnutrition (pg 4) 6 The Sphere Project (2011)29 The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (chapter: Minimum Standards in Food Security and Nutrition; section 2, Infant and Young Child Feeding) Practitioners involved in planning, managing, or implementing a humanitarian response Focuses on key actions and indicators to be undertaken by humanitarian actors to protect optimal feeding practices, to maximize survival, and to reduce morbidity in children under 24 mo of age (pg 158) 7 Emergency Nutrition Network, Inter-Agency Standing Committee, US Agency for International Development, Nutrition Works (2011)30 The Harmonised Training Package (HTP): Resource Material for Training on Nutrition in Emergencies. Version 2. Module 17: infant and young child feeding in emergency situations Trainers in the NiE sector The HTP is designed to provide trainers from any implementing agency or academic institution with information from which to design and implement an NiE training course. Module 17 specifically addresses IYCF-E and the protection and support of optimal feeding for infants and young children in all emergencies 8 United Nations Children’s Fund (2012)31 Infant and Young Child Feeding: Programming Guide UNICEF staff and a broad range of partners involved in IYCF programming Comprehensive and detailed programming information on IYCF. Includes guidance on breastfeeding, complementary feeding, and infant feeding both in general and in especially difficult circumstances, such as in emergencies and in the context of HIV (pg iv) 9 Save the Children (2014)32 IYCF-E Toolkit: Rapid Start-up for Emergency Nutrition Personnel. Version 2.0 Emergency nutrition program managers, coordinators, and advisors Designed to promote best practice and rapid implementation of IYCF-E among those responsible for program design and for implementation and management of IYCF-E programs (pg 3) 10 Directorate-General for European Civil Protection and Humanitarian Aid Operations (2014)33 Infant and Young Children Feeding in Emergencies: Guidance for Programming General practitioners Offers guidance on ensuring that the specific needs of infants and young children are assessed and addressed adequately in programming. A checklist for integrating IYCF considerations in emergencies is provided at the end of the document (pg 2) 11 United Nations High Commissioner for Refugees (2015)34 Infant and Young Child Feeding Practices: Standard Operating Procedures for the Handling of Breastmilk Substitutes (BMS) in Refugee Situations for Children 0–23 mo. Version 1.1 UNHCR staff and partners Standard operating procedures for the management of artificial feeding of infants and young children in refugee contexts to protect both breastfed and non-breastfed children. Particular consideration is given to emergency contexts, to high-burden, resource-poor settings, and to pastoral communities (pg 10) 12 Global Nutrition Cluster (2016)35 Tips on Nutrition Interventions for the Humanitarian Response Plan Country nutrition clusters and nutrition cluster partners Provides tips for nutrition clusters and partners to facilitate the planning of a collective response and the development of humanitarian response plans for NiE interventions. Also intended for use by other clusters to help guide the inclusion of nutrition-sensitive interventions in their respective sectoral plans (pg 4) 13 Action Against Hunger, European Civil Protection and Humanitarian Aid Operations, United Nations Children’s Fund (2017)36 WASH’Nutrition: A Practical Guidebook on Increasing Nutritional Impact Through Integration of WASH and Nutrition Programmes. For Practitioners in Humanitarian and Development Contexts WASH and nutrition field practitioners and program managers working in humanitarian and development contexts Responds to the need for more practical guidance on WASH and nutrition integration at the field level. Can also be used as a practical tool for donors and institutions (such as ministries of health) to prioritize strategic activities and funding options (pg 7) 14 Infant Feeding in Emergencies Core Group (2017)37 Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers. Version 3.0 Policy makers, decision makers, and programmers working in emergency preparedness and response Provides concise, practical guidance on how to ensure appropriate IYCF-E (pg 2) Abbreviations: CMAM, Community Management of Acute Malnutrition; IYCF, infant and young child feeding; IYCF-E, infant and young child feeding in emergencies; NGO, nongovernmental organization; NiE, nutrition in emergencies; WASH, water, sanitation, and hygiene; UN, United Nations; UNHCR, United Nations High Commission for Refugees; UNICEF, United Nations Children’s Fund. Box 1Thematic synthesis of guidance for commercial complementary foods rated as relevant for the prevention of foodborne illness in humanitarian emergenciesa,b Theme 1: Donations of commercial complementary foods (n = 7 excerpts) Do not distribute feeding bottles/teats; promote cup feeding. Do not distribute dried skim milk unless mixed with cereal. Add complementary foods to breastfeeding at about 6 mo Avoid [CCF].23 Procurement, management, distribution, targeting and use of breast-milk substitutes, bottles and teats should be strictly controlled and comply with The International Code. Control of the procurement of breast-milk substitutes, bottles, teats and [CCF]. Donations or subsidised breast-milk substitutes, bottles and teats and [CCF] should be systematically refused. Unsolicited donations should be collected from all ports of entry and recipient agencies and stored centrally under the control of a single agency and under the guidance of the infant feeding coordinating body. A plan for their safe use, monitored and under supervision, or their eventual destruction, will need to be developed by the infant feeding co-ordinating body to prevent indiscriminate distribution.23 [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Communications should: State that donations of BMS, [CCF] and bottles and teats are not needed and expose infants and young children to risk of illness and death.34 Each agency should, at central level, endorse or develop a policy that addresses: Infant and young child feeding in emergencies, stressing the protection, and support of breastfeeding and adequate complementary feeding. Procurement, distribution and use of breast-milk substitutes (BMS), [CCF] and drinks and infant feeding equipment in compliance with The International Code.23 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Theme 2: Quality assurance and quality control of commercial complementary foods (n = 5 excerpts) Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH (Water, Sanitation and Hygiene) conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Complementary foods must meet nutrient requirements of children aged 6–23 mo through an appropriate portion size. Factors such as time to cook, organoleptic properties, storage, and packaging should be considered. Currently, information is available regarding labelling, hygiene practices, standards for processed cereal-based foods for infants and young children and the guidelines on formulated supplementary foods for older infants and young children (through the Codex Alimentarius). Ideal composition of [CCF] and recommendations for production has also been proposed.31 [CCF] should be manufactured and packaged in accordance with the Codex Alimentarius standards (international food standard setting agency) and have a shelf-life of at least 6 months at time of receipt in country. Labels must be in the language of the beneficiary population and must adhere to the specific labelling requirements of The International Code.23 Work to ensure that local/[CCF] meet minimum standards.37 Theme 3: Water, sanitation, and hygiene principles for commercial complementary foods (n = 3 excerpts) [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Theme 1: Donations of commercial complementary foods (n = 7 excerpts) Do not distribute feeding bottles/teats; promote cup feeding. Do not distribute dried skim milk unless mixed with cereal. Add complementary foods to breastfeeding at about 6 mo Avoid [CCF].23 Procurement, management, distribution, targeting and use of breast-milk substitutes, bottles and teats should be strictly controlled and comply with The International Code. Control of the procurement of breast-milk substitutes, bottles, teats and [CCF]. Donations or subsidised breast-milk substitutes, bottles and teats and [CCF] should be systematically refused. Unsolicited donations should be collected from all ports of entry and recipient agencies and stored centrally under the control of a single agency and under the guidance of the infant feeding coordinating body. A plan for their safe use, monitored and under supervision, or their eventual destruction, will need to be developed by the infant feeding co-ordinating body to prevent indiscriminate distribution.23 [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Communications should: State that donations of BMS, [CCF] and bottles and teats are not needed and expose infants and young children to risk of illness and death.34 Each agency should, at central level, endorse or develop a policy that addresses: Infant and young child feeding in emergencies, stressing the protection, and support of breastfeeding and adequate complementary feeding. Procurement, distribution and use of breast-milk substitutes (BMS), [CCF] and drinks and infant feeding equipment in compliance with The International Code.23 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Theme 2: Quality assurance and quality control of commercial complementary foods (n = 5 excerpts) Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH (Water, Sanitation and Hygiene) conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Complementary foods must meet nutrient requirements of children aged 6–23 mo through an appropriate portion size. Factors such as time to cook, organoleptic properties, storage, and packaging should be considered. Currently, information is available regarding labelling, hygiene practices, standards for processed cereal-based foods for infants and young children and the guidelines on formulated supplementary foods for older infants and young children (through the Codex Alimentarius). Ideal composition of [CCF] and recommendations for production has also been proposed.31 [CCF] should be manufactured and packaged in accordance with the Codex Alimentarius standards (international food standard setting agency) and have a shelf-life of at least 6 months at time of receipt in country. Labels must be in the language of the beneficiary population and must adhere to the specific labelling requirements of The International Code.23 Work to ensure that local/[CCF] meet minimum standards.37 Theme 3: Water, sanitation, and hygiene principles for commercial complementary foods (n = 3 excerpts) [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Abbreviations: BMS, breast milk substitutes; CCF, commercial complementary food; WASH, water, sanitation, and hygiene; WHO, World Health Organization. a Boldface added by authors of the current review. b [CCF] used for consistency in this box because terms used for commercial complementary food differed from document to document. Theme 1: Donations of commercial complementary foods (n = 7 excerpts) Do not distribute feeding bottles/teats; promote cup feeding. Do not distribute dried skim milk unless mixed with cereal. Add complementary foods to breastfeeding at about 6 mo Avoid [CCF].23 Procurement, management, distribution, targeting and use of breast-milk substitutes, bottles and teats should be strictly controlled and comply with The International Code. Control of the procurement of breast-milk substitutes, bottles, teats and [CCF]. Donations or subsidised breast-milk substitutes, bottles and teats and [CCF] should be systematically refused. Unsolicited donations should be collected from all ports of entry and recipient agencies and stored centrally under the control of a single agency and under the guidance of the infant feeding coordinating body. A plan for their safe use, monitored and under supervision, or their eventual destruction, will need to be developed by the infant feeding co-ordinating body to prevent indiscriminate distribution.23 [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Communications should: State that donations of BMS, [CCF] and bottles and teats are not needed and expose infants and young children to risk of illness and death.34 Each agency should, at central level, endorse or develop a policy that addresses: Infant and young child feeding in emergencies, stressing the protection, and support of breastfeeding and adequate complementary feeding. Procurement, distribution and use of breast-milk substitutes (BMS), [CCF] and drinks and infant feeding equipment in compliance with The International Code.23 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Theme 2: Quality assurance and quality control of commercial complementary foods (n = 5 excerpts) Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH (Water, Sanitation and Hygiene) conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Complementary foods must meet nutrient requirements of children aged 6–23 mo through an appropriate portion size. Factors such as time to cook, organoleptic properties, storage, and packaging should be considered. Currently, information is available regarding labelling, hygiene practices, standards for processed cereal-based foods for infants and young children and the guidelines on formulated supplementary foods for older infants and young children (through the Codex Alimentarius). Ideal composition of [CCF] and recommendations for production has also been proposed.31 [CCF] should be manufactured and packaged in accordance with the Codex Alimentarius standards (international food standard setting agency) and have a shelf-life of at least 6 months at time of receipt in country. Labels must be in the language of the beneficiary population and must adhere to the specific labelling requirements of The International Code.23 Work to ensure that local/[CCF] meet minimum standards.37 Theme 3: Water, sanitation, and hygiene principles for commercial complementary foods (n = 3 excerpts) [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Theme 1: Donations of commercial complementary foods (n = 7 excerpts) Do not distribute feeding bottles/teats; promote cup feeding. Do not distribute dried skim milk unless mixed with cereal. Add complementary foods to breastfeeding at about 6 mo Avoid [CCF].23 Procurement, management, distribution, targeting and use of breast-milk substitutes, bottles and teats should be strictly controlled and comply with The International Code. Control of the procurement of breast-milk substitutes, bottles, teats and [CCF]. Donations or subsidised breast-milk substitutes, bottles and teats and [CCF] should be systematically refused. Unsolicited donations should be collected from all ports of entry and recipient agencies and stored centrally under the control of a single agency and under the guidance of the infant feeding coordinating body. A plan for their safe use, monitored and under supervision, or their eventual destruction, will need to be developed by the infant feeding co-ordinating body to prevent indiscriminate distribution.23 [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Communications should: State that donations of BMS, [CCF] and bottles and teats are not needed and expose infants and young children to risk of illness and death.34 Each agency should, at central level, endorse or develop a policy that addresses: Infant and young child feeding in emergencies, stressing the protection, and support of breastfeeding and adequate complementary feeding. Procurement, distribution and use of breast-milk substitutes (BMS), [CCF] and drinks and infant feeding equipment in compliance with The International Code.23 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Theme 2: Quality assurance and quality control of commercial complementary foods (n = 5 excerpts) Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH (Water, Sanitation and Hygiene) conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Complementary foods must meet nutrient requirements of children aged 6–23 mo through an appropriate portion size. Factors such as time to cook, organoleptic properties, storage, and packaging should be considered. Currently, information is available regarding labelling, hygiene practices, standards for processed cereal-based foods for infants and young children and the guidelines on formulated supplementary foods for older infants and young children (through the Codex Alimentarius). Ideal composition of [CCF] and recommendations for production has also been proposed.31 [CCF] should be manufactured and packaged in accordance with the Codex Alimentarius standards (international food standard setting agency) and have a shelf-life of at least 6 months at time of receipt in country. Labels must be in the language of the beneficiary population and must adhere to the specific labelling requirements of The International Code.23 Work to ensure that local/[CCF] meet minimum standards.37 Theme 3: Water, sanitation, and hygiene principles for commercial complementary foods (n = 3 excerpts) [CCF] have featured in some emergency contexts, often arriving as donated items. They vary greatly in nutrient content, contribute to problems of waste disposal and in general, should not be included as a relief item.30 Create a mechanism for coordinating and monitoring infant-feeding activities. A lead agency should be nominated to manage infant-feeding issues. A framework for action should be agreed upon. Representatives of national and international agencies involved in food aid, social services and health/nutrition should meet regularly in a specific forum to address infant-feeding issues. Monitoring of interventions includes: (1) mortality/morbidity of infants; (2) provision of infant-feeding support; (3) procurement, distribution and end use of breast-milk substitutes or [CCF]; and (4) quality of infant foods supplied and or/used by the affected population.24 Key considerations in determining complementary feeding response include pre-existing and existing nutrient gaps; seasonality; socio-cultural beliefs; food security; current access to appropriate foods; quality of locally available complementary foods, including [CCF]; compliance to the [International] Code and with WHO Guidance on ending inappropriate promotion of [CCF]; cost; proportion of non-breastfed infants and children; reports of children with disability-associated feeding difficulties; maternal nutrition; WASH conditions; the nature and capacity of existing markets and delivery systems; national legislation related to food and drugs, particularly importation; and evidence of impact of different approaches in a given or similar contexts.37 Abbreviations: BMS, breast milk substitutes; CCF, commercial complementary food; WASH, water, sanitation, and hygiene; WHO, World Health Organization. a Boldface added by authors of the current review. b [CCF] used for consistency in this box because terms used for commercial complementary food differed from document to document. Included documents were published between 2001 and 2017. Ten of the 14 documents were published by or in conjunction with UN agencies, including the United Nations Children’s Fund (UNICEF), the United Nations High Commissioner for Refugees, WHO, and the Inter-Agency Standing Committee. Other global guidance documents were published by the Sphere Project, the European Commission, and the international nongovernmental organizations Action Against Hunger and Save the Children. The target audience of most documents (n = 13) was humanitarian nutrition practitioners involved in IYCF-E programming. The exception was one guidance document for trainers in the Nutrition in Emergencies sector. Six of the guidance documents were updated from previous versions. One document was updated in 2010 to an e-learning module that was not included in the systematic content analysis because it was inaccessible in .pdf or .docx format. In this case, the original version from 2001 was included.23 One guidance document was a tool kit that consisted of a .zip file of multiple separate Word documents.32 For the tool kit, all documents were downloaded in a .docx version and reviewed.32 Systematic content analysis The systematic content analysis revealed that 10 of 14 guidance documents (71.4%) referred specifically to CCF.23–25,27,30–34,37 Among all 10 documents, 49 excerpts mentioned CCF at least once (range, 1–16 excerpts per document). Of the 49 excerpts identified, 10 (20.4%) were rated as relevant for the prevention of foodborne illness by both raters. Inter-rater reliability was tallied at 80.0% agreement between raters. Cohen’s kappa coefficient (ĸ) was calculated (ĸ = 0.52, moderate rater agreement). Thematic synthesis Three main themes emerged from the 10 excerpts: (1) donations of commercial complementary foods; (2) quality assurance and quality control; and (3) water, sanitation, and hygiene (WASH) principles. Box 123,24,30,31,34,37 lists the 10 extracted excerpts (A through K) by their respective themes. Theme 1: Donations of commercial complementary foods The first theme identified, “donations of commercial complementary foods,” centered on the issue of donations in relation to the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions (known as “the Code”).38 It offers guidance on the marketing of breast milk substitutes for the protection of breastfeeding. Breast milk substitutes are defined as “any food being marketed or otherwise presented as a partial or total replacement for breast milk, whether or not suitable for that purpose.”38 Commercial complementary foods that are marketed to replace human milk, for example, by recommending CCF introduction before 6 months of age, omitting messages on the importance of continued breastfeeding, cross-promoting infant formula, or recommending portion sizes that are too large, are considered breast milk substitutes.39,40 The Code and operational guidance for IYCF-E discourage accepting, soliciting, or distributing donations of CCF during emergencies.37,38 Of the 10 extracted excerpts on CCF, 7, obtained from 5 documents, gave direct guidance on the importance of controlling procurement and donations of CCF in emergencies.23,24,30,34,37 Two excerpts used language that strongly discouraged the use of CCF, stating that CCF should be avoided (Excerpt A)23 and not be included as a relief item (Excerpt C).30 Other excerpts did not discourage CCF generally but discouraged CCF donations, stating that donations should be systematically refused (Excerpt B)23 and were “not needed [in emergency settings]” (Excerpt D).34 Reasons given for rejecting or avoiding CCF donations were as follows: risk of illness or death to infants and young children (Excerpt D),34 compliance with the Code (Excerpts B, E, and G),23,37 wide variance in nutrient content (Excerpt C),30 and contribution to problems of waste disposal (Excerpt C).30 Three of the 7 excerpts, sourced from 2 separate guidance documents, called for improved monitoring and coordination of CCF use, emphasizing that agencies should develop plans and mechanisms to monitor procurement, distribution, and end use (Excerpts E and F)23,24 or “eventual destruction” of donated CCF (Excerpt B).23 One document stated that unsolicited donations of CCF “should be collected from all ports of entry and recipient agencies and stored centrally under the control of a single agency and under the guidance of the infant feeding coordinating body” (Excerpt B).23 Theme 2: Quality assurance and quality control The second theme identified, “quality assurance and quality control,” focused on the quality of CCF as stipulated by the Codex Alimentarius,43 an international code for food standards. The Codex Alimentarius standards for CCF were first developed in 1981 and were updated in 2017 as recommendations for quality standards of CCF labeling, ingredients, and additives.44–48 The Codex Alimentarius stipulates that CCF food labels must have directions for safe preparation and use of foods, including storage and keeping before and after opening.49 Of the 10 extracted excerpts on CCF, 5, obtained from 4 guidance documents, mentioned quality standards for CCF.23,24,31,37 In 2 excerpts, monitoring the quality of infant foods (Excerpts F and G)24,37 or ensuring that CCF meets minimum standards (Excerpt K) was recommended.37 No further specifications on the terms quality and standards were given. In terms of local laws on the quality control of imported or locally sourced CCF, one guidance document stated that “national legislation related to food and drugs, particularly importation” was a key consideration in the complementary feeding response (which encompasses the planning and provision of complementary foods), in addition to “the nature and capacity of existing markets and delivery systems” (Excerpt G).37 Two guidance documents mentioned various topics that pertained to CCF quality and safety, including manufacturing, packaging, storage, hygiene practices, shelf life, labeling, nutrient content, portion size, cooking time, and organoleptic properties, referring specifically to the Codex Alimentarius for further guidance (Excerpts H and J).23,31 One guidance document gave specific guidance on CCF labeling and shelf life, recommending expiration dates of a minimum of 6 months from the time of receipt in country and ensuring that food labels are in the language of the beneficiary population (Excerpt J).23 In terms of nutritional quality, one document mentioned appropriate portion sizes for infants aged 6 to 23 months, stating that the “ideal composition of [CCF]” is proposed within the Codex Alimentarius (Excerpt H).31 No minimum nutritional recommendations for CCF, or general recommendations for the types of CCF appropriate for emergency settings, were specified in any of the documents reviewed. No guidance was given on the safe preparation, reconstitution, cooking, or storage of CCF. Theme 3: Water, sanitation, and hygiene principles The third theme identified was “WASH principles.” The WASH principles are defined as the conditions and measures necessary to prevent fecal–oral transmission of diseases through the promotion of good hygiene practices, the provision of safe drinking water, and the reduction of environmental health risks.29 Of the 10 extracted excerpts on CCF, 3, sourced from 3 documents, gave guidance related to WASH principles.24,30,37 One document mentioned WASH principles as a key consideration in determining the complementary feeding response but did not specify which WASH principles should be applied to the use of CCF (Excerpt G).37 No guidance on ensuring access to safe water and soap for handwashing before feeding CCF, reconstituting CCF, washing implements, or creating hygienic environments for preparing and feeding CCF was found. In terms of sanitation, 2 excerpts mentioned the issue of excess garbage from CCF packaging in emergencies, stating that CCF packaging “contribute to problems of waste disposal” (Excerpt C)30 and that the end use of CCF should be monitored (Excerpt F).24 No strategies were given to reduce food waste, garbage, or packaging from CCF or to mitigate disease vectors like flies and rodents. DISCUSSION The results of this review show that guidance on the safe use of CCF in emergencies does not seem to be uniformly integrated into global operational guidance documents on IYCF-E. Some global guidance documents included in this review did not mention CCF at all.28,29,35,36 Other documents mentioned CCF but did not give advice on how to use them safely.25,27,32,33 The number of excerpts identified through the systematic content analysis and rated by both investigators as useful for the prevention of foodborne illness was rather limited, with only 10 excerpts identified. The following 3 sections discuss gaps and inconsistencies in global IYCF-E operational guidance by theme. Gaps in guidance on donations Excerpts on CCF that were identified from global IYCF-E guidance documents and included in this review offered conflicting advice on the use of CCF in emergencies. For example, 2 global guidance documents stated that CCF should be avoided23 or not be included as a relief item.30 Other global guidance did not state that CCF should be avoided but that unsolicited donations of CCF should be avoided23,34,37 and that procurement and distribution of CCF should be closely monitored.24,35 The most recent version of Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers (version 3.0),37 published in 2017 by the Emergency Nutrition Network, implies that CCF can be suitable for emergency response if it is locally procured, is in compliance with nutritional and hygienic specifications from the Codex Alimentarius, and is in compliance with the Code. Operational guidance documents issued by WHO, UNICEF, the UN High Commissioner for Refugees, and the US Agency for International Development clearly discourage humanitarian practitioners from soliciting or distributing donations of CCF in emergencies.23,24,30,34,37 The UN High Commissioner for Refugees stated in operational guidance issued in 2015 that it does not accept donations of breast milk substitutes, bottles, teats, or CCF for its work with refugee operations.34 Rationales given for discouraging donated CCF include variable nutrient contents,30,37,50 potential noncompliance with labeling requirements as recommended by the Code,37 potential sociocultural unsuitability,37,50 supply of CCF in volumes that are disproportionate to need,37 inadequate continuity and sustainability of donated supplies,38 lack of time and resources necessary to manage and mitigate the risks of donated foods,37 potential displacement of local foods,37; concerns over potential commercial exploitation of emergency-affected populations; and creation of dependency on foreign aid and products.25,37 Moreover, one empirical study demonstrated that untargeted distributions of commercial porridges to households following a humanitarian emergency in Java increased the risk for premature introduction of CCF to young infants.51 Procurement of CCF, as opposed to donations, allows humanitarian actors to ensure an appropriate quantity and quality of CCF for a given emergency response. In addition, procurement ensures adequate labeling and programmatic planning of CCF distribution within realistic expiration dates. In practice, there seems to be poor adherence to IYCF-E operational guidance that discourages donations of CCF, as evidenced by several humanitarian reports.16–20 It is unclear why donations of CCF persist in emergency response. One reason may be that humanitarian actors and the general public are unfamiliar with IYCF-E guidance on CCF. Alternatively, continued donations might be due to conflicting operational guidance, as indicated by the excerpts highlighted previously in this review (Excerpts A–K, Box 1). Ambiguous terminology used for CCF in global operational IYCF-E documents may be another reason. For example, some IYCF-E guidance refers only to breast milk substitutes, a term that encompasses CCF marketed in ways that replace breast milk.41 However, the term usually refers to infant formula. The Sphere guidelines advise humanitarian actors to “avoid soliciting or accepting donations of breast milk substitutes, other milk products, bottles and teats,” yet there is no mention of CCF.29 Therefore, clearer language about the use of CCF in international IYCF-E guidance is likely needed. Gaps in guidance on quality assurance and quality control Documents from WHO, UNICEF, and the Infant Feeding in Emergencies Core Group mention quality standards for CCF.23,24,31,37 Three excerpts recommended that quality be monitored or considered, or should meet standards, with 3 excerpts referring to the Codex Alimentarius standards.23,31,37 Since CCF is industrially processed, often treated under high temperatures, and marketed as ready to eat, it is a common misconception that CCF products are sterile. In fact, CCF products are not sterile.12,52 While only a few outbreaks of foodborne illness linked to CCF have been reported in the scientific literature,53–58 several disease surveillance studies have noted concerning levels of bacterial and aflatoxin contamination of CCF purchased from retail outlets and markets worldwide.52,59–71 Therefore, CCF should be sourced exclusively from manufacturers with a record of meeting national or Codex Alimentarius hygiene standards. Guidance pertaining to safe storage of CCF before opening was not included in any of the documents reviewed. Yet in emergency situations, safe transport and storage of CCF before distribution is highly relevant. Technical guidance on ideal conditions for the prevention of food spoilage from moisture, sunlight, and extreme temperatures, especially during extreme weather and flooding, is also necessary. Guidance about the ideal types of packaging for the prevention of breakage, leakage, and spoilage during transport was also lacking. The packaging of CCF has not been specifically designed for the purpose of emergency nutrition assistance; therefore, more guidance on the types of CCF packaging that are safe and appropriate for emergency nutrition response is needed. Sometimes, CCF products are already expired before they are delivered to emergency settings, or they may expire when they are stored for long periods of time at distribution centers. For example, one field report from Croatia stated that a large shipment of nearly expired CCF was donated by a baby food company during a humanitarian emergency in Europe.17 Interim IYCF-E guidance published during that emergency gave advice on adherence to expiration dates for infant formula donations but did not mention potential risks associated with expired CCF donations.21 Only one global guidance document included in the present review mentioned the importance of adhering to expiration dates of CCF products and gave a time frame for CCF distribution in country.23 This type of practical food safety guidance is pertinent for mitigating the risk of foodborne illness from CCF in emergencies. Only one guidance document stated that CCF should be labeled in the language of the beneficiary population.23 This issue has been described as problematic in humanitarian field reports.17,50 For food safety purposes, instructions on food labels should also be communicated with simple messaging.72 In multilingual or low-literacy populations, illustrations on food labels are also useful.72 In this regard, global IYCF-E operational guidance documents should give advice on appropriate messaging for CCF labels. In emergency settings, food safety advice regarding storage of leftovers is even more relevant than in nonemergency situations because of the lack of refrigeration or cool storage spaces. Interim guidance published in 2015 during a large influx of refugees and migrants to Europe noted that “animal source foods, such as yogurt and cheese, are good nutrient sources but bear in mind that storage (refrigeration) options will be lacking.”21 However, no such guidance was given for refrigeration of CCF products after opening. A number of empirical studies have investigated the safety of CCF and beverages after reconstitution with liquids and have shown that reconstituted CCF products have the potential to grow pathogenic bacteria when stored at unsafe temperatures.73,74 Studies on commercial infant cereals recommended that cereals be consumed immediately or held at temperatures below 8°C and consumed within 48 hours.12 This is because even low numbers of pathogenic bacteria in CCF grow to large populations when reconstituted with liquids.10 The current review found gaps in technical food safety advice regarding time frames and storage temperatures for CCF leftovers, a lack of best practices guidance in circumstances of limited refrigeration, and gaps in recommendations for packaging sizes, which are needed because smaller portions are more likely to be consumed by infants within a safe time frame. The rationale for the gaps in operational guidance regarding the use of CCF in emergencies is unknown but may be linked to broader international gaps in food safety guidance for complementary foods. At the global level, WHO and the Food and Agriculture Organization of the United Nations have published a number of guidelines on how to safely prepare powdered infant formula.75–77 However, the most recent guidance on safe preparation of complementary foods was published more than 20 years ago, in 1996.78 Some food safety content is included in the 2003 publication Guiding Principles on Complementary Feeding of the Breastfed Child,79 and information pertaining to non-breastfed children was added in the 2005 Guiding Principles for Feeding Non-Breastfed Children 6–24 Months of Age.80 However, none of these documents provide food safety guidance on CCF specifically.78 This brings to light the need for updated and comprehensive guidance on CCF quality assurance and control in everyday circumstances as well as in humanitarian emergencies. Gaps in guidance on water, sanitation, and hygiene principles Since WASH principles are a key consideration in determining the complementary feeding response,37 global IYCF-E guidance should more clearly specify which WASH principles should be considered when distributing CCF in emergencies. Among the excerpts reviewed, there were gaps in guidance to ensure that safe water is used for preparation and reconstitution of dried or powdered CCF, such as commercial infant cereals. There were no recommendations to wash the hands of adults and children with clean water and soap before feeding CCF, or to use clean water and soap when washing bowls and feeding implements. There was also no advice to avoid feeding CCF directly from baby food jars and no guidance on maintaining hygienic feeding environments. These are food safety concepts that have been proposed for safe feeding of CCF by the US Department of Health and Human Services in nonemergencies,81 which may be even more important to reinforce during humanitarian emergencies. It is critical to specify these WASH practices for CCF explicitly, since many CCF products are marketed and used as ready-to-eat, on-the-go foods. When infants and young children are fed with these types of pre-prepared foods, there is no direct handling of raw foods, and therefore important food safety measures like handwashing and maintenance of clean feeding environments might be mistakenly disregarded. Two excerpts about excess garbage from CCF mentioned issues of sanitation,24 but more specific technical guidance is likely needed to ensure that CCF packaging is cleaned and discarded in ways that reduce the occurrence of flies and rodents near human dwellings. LIMITATIONS This narrative review addresses guidance for the safe use of CCF and does not address the use of homemade complementary foods, infant formulas, nutrition supplements, or multiple micronutrient powders. The scope of this review was limited to guidance published by key global health and nutrition authorities. A review of nationally published documents may have yielded more detailed and context-specific guidance. Global guidance documents are a type of grey literature and do not undergo a traditional, academic peer-review process. This review should not be interpreted as a synthesis of scientific evidence on this subject or as a provision of recommendations, but it functions as a comprehensive synthesis of themes and gaps in existing global IYCF-E operational guidance for the safe use of CCF in humanitarian emergencies. CONCLUSION The use of CCF in humanitarian emergencies is an emerging topic in nutrition policy. Field reports from recent humanitarian emergencies detail distributions of CCF in a variety of emergency contexts in multiple countries.16–20 This narrative review aimed to identify and synthesize available global guidance on the safe use of CCF in humanitarian emergencies from IYCF-E operational guidance documents. The results show that the use of CCF is not uniformly mentioned or addressed in global IYCF-E documents. There are gaps in both practical and technical guidance for the prevention of foodborne illness from CCF in humanitarian emergencies. All complementary foods are potential vehicles for foodborne illness during emergencies.1–3,10–12 The risk of foodborne illness is augmented because of overcrowding and poor WASH infrastructure. Moreover, diarrheal diseases are one of the most important causes of child morbidity and mortality in emergencies.8 Future global operational guidance on IYCF-E should address issues around the use of CCF in emergencies. It should reflect the complex and multifactorial nature of emergency settings, including uncertain access to resources such as clean water, appropriate feeding tools, and refrigeration. Development of technical food safety guidance will require input from multiple sectors such as nutrition, health, WASH, and others in order to adequately address this emerging issue in nutrition. Acknowledgments Author contributions. M.A.T. conceptualized the review; designed the systematic content analysis, tables, and figures; authored scientific content; and performed statistical calculations and revisions. A.L.H. conducted research on food safety, supported finalization of tables, rated excerpts, and performed statistical calculations. L.B.G. conducted research on WASH, rated excerpts, participated in the document search, and reviewed scientific literature. M.E.M-M. contributed to the writing and revisions of text and tables. All authors reviewed the final version of the manuscript and agree to be accountable for all aspects of the work. Funding/support. No external funds supported this work. Declaration of interest. M.A.T. has worked as an independent consultant for UNICEF Headquarters in New York, NY. A.L.H. works for Action Against Hunger (ACF-USA), New York, NY. L.B.G. works at the Children’s Home Society of Washington in Seattle, WA, USA, and has collaborated with Alive & Thrive, Washington, DC. M.M-M. is a faculty member at Emory University School of Medicine, Atlanta, GA, USA. This work was completed through autonomous collaboration without prior knowledge, involvement, influence, or endorsement from these institutions. References 1 Motarjemi Y , Kaferstein F , Moy G , Quevedo F. Contaminated weaning food: a major risk factor for diarrhoea and associated malnutrition . Bull World Health Organ . 1993 ; 71 : 79 – 92 . Google Scholar PubMed 2 Kaeferstein FK. Food safety: the fourth pillar in the strategy to prevent infant diarrhoea . Bull World Health Organ . 2003 ; 81 : 842 – 843 . Google Scholar PubMed 3 Motarjemi Y , Kaferstein F , Moy G , Quevedo F. Contaminated food, a hazard for the very young . World Health Forum. 1994 ; 15 : 69 – 71 . Google Scholar PubMed 4 Kirk MD , Angulo FJ , Havelaar AH , Black RE. Diarrhoeal disease in children due to contaminated food . Bull World Health Organ. 2017 ; 95 : 233 – 234 . Google Scholar Crossref Search ADS PubMed 5 Jones G , Steketee RW , Black RE , et al. . How many child deaths can we prevent this year? Lancet. 2003 ; 362 : 65 – 71 . Google Scholar Crossref Search ADS PubMed 6 Lemonick DM. Epidemics after natural disasters . Am J Clin Med . 2011 ; 8 : 144 – 153 . 7 Polonsky JA , Ronsse A , Ciglenecki I , et al. . High levels of mortality, malnutrition, and measles, among recently-displaced Somali refugees in Dagahaley camp, Dadaab refugee camp complex, Kenya, 2011 . Confl Health. 2013 ; 7 : 1 . doi:10.1186/1752-1505-7-1 Google Scholar Crossref Search ADS PubMed 8 Hershey CL , Doocy S , Anderson J , et al. . Incidence and risk factors for malaria, pneumonia and diarrhea in children under 5 in UNHCR refugee camps: a retrospective study . Confl Health. 2011 ; 5 : 24 . doi:10.1186/1752-1505-5-24 Google Scholar Crossref Search ADS PubMed 9 World Health Organization . The Role of Food Safety in Health and Development: Report of a Joint FAO/WHO Expert Committee on Food Safety. Geneva, Switzerland: World Health Organization; 1984 . WHO Technical Report Series 705. 10 Jaquette CB , Beuchat LR. Survival and growth of psychrotrophic Bacillus cereus in dry and reconstituted infant rice cereal . J Food Prot. 1998 ; 61 : 1629 – 1635 . Google Scholar Crossref Search ADS PubMed 11 Richards GM , Gurtler JB , Beuchat LR. Survival and growth of Enterobacter sakazakii in infant rice cereal reconstituted with water, milk, liquid infant formula, or apple juice . J Appl Microbiol. 2005 ; 99 : 844 – 850 . Google Scholar Crossref Search ADS PubMed 12 Beuchat LR , Kim H , Gurtler JB , et al. . Cronobacter sakazakii in foods and factors affecting its survival, growth, and inactivation . Int J Food Microbiol. 2009 ; 136 : 204 – 213 . Google Scholar Crossref Search ADS PubMed 13 Action Contre la Faim International . Infant and Young Child Feeding in Emergencies: Position Paper . Version 2.0. Paris, France : Action Contre la Faim International ; 2015 . 14 United Nations High Commissioner for Refugees , United Nations Children’s Fund, World Food Programme, World Health Organization. Food and Nutrition Needs in Emergencies . Geneva , Switzerland: World Health Organization ; 2004 . 15 World Health Organization, United Nations Children’s Fund . Global Strategy for Infant and Young Child Feeding . Geneva, Switzerland: World Health Organization ; 2003 . 16 NATO Euro—Atlantic Disaster Response Coordination Centre (EADRCC) . EADRCC situation report no. 6: Bosnia and Herzegovina—floods. https://www.nato.int/nato_static_fl2014/assets/pdf/pdf_2014_05-bih-floods/20150302_140519-bih-floods-06.pdf. Reported June 2, 2014 . Accessed January 1, 2017. 17 Modigell I , Fernandes C , Gayford M. Save the Children’s IYCF-E rapid response in Croatia. Field Exch . 2016 ;( 52 ): 106 – 109 . 18 Maclaine A , Corbett M. Infant feeding in emergencies: experiences from Indonesia and Lebanon. Field Exch. 2006 ;( 29 ): 2 – 4 . 19 Emergency Nutrition Network . Infant feeding practices: observations from Macedonia and Kosovo . Field Exch . 1999 ;( 8 ): 27 – 29 . 20 Ziolkovska A. Nutrition coordination in Ukraine: experiences as a sub-cluster of health . Field Exch . 2016 ;( 52 ): 76 – 79 . 21 United Nations High Comissioner for Refugees, United Nations Children’s Fund, World Health Organization, Save the Children, Emergency Nutrition Network. Interim operational considerations for the feeding support of infants and young children under 2 years of age in refugee and migrant transit settings in Europe. Version 1.0. https://www.ennonline.net/attachments/2403/Infant-and-Young-Child-Feeding-in-Transit-011015_FINAL.pdf. Published October 1, 2015. Accessed January 1, 2017. 22 Landis JR , Koch GG. The measurement of observer agreement for categorical data . Biometrics . 1977 ; 33 : 159 – 174 . Google Scholar Crossref Search ADS PubMed 23 World Health Organization, United Nations Children’s Fund , LINKAGES, International Baby Food Action Network, Emergency Nutrition Network. Infant Feeding in Emergencies. Module 1 for emergency relief staff: manual for orientation, reading and reference. Dublin, Ireland : Emergency Nutrition Network ; 2001 . 24 World Health Organization . Guiding principles for feeding infants and young children during emergencies . Geneva, Switzerland : World Health Organization ; 2004 . 25 United Nations Children’s Fund . Emergency Field Handbook: A Guide for UNICEF Staff. New York, NY : The United Nations Children’s Fund ; 2005 . 26 United Nations Children’s Fund. Core Commitments for Children in Humanitarian Action. http://www.unicefinemergencies.com/downloads/eresource/docs/1/2010-CCC-FinaI.pdf. :Published April 2010. Accessed January 1, 2017. 27 Emergency Nutrition Network, International Baby Food Action Network-GIFA, Terra des hommes , et al. . Infant Feeding in Emergencies. Module 2, Version 1.1 for health and nutrition workers in emergency situations for training, practice and reference. Oxford, England: Emergency Nutrition Network; 2007 . 28 Mary L , Maryanne-Stone J , Network EN. Integration of IYCF Support into CMAM: Facilitator’s Guide. Oxford, United Kingdom : Emergency Nutrition Network ; 2009 . 29 The Sphere Project . The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response . Geneva : Switzerland ; 2011 . 30 NutritionWorks, Emergency Nutrition Network, Global Nutrition Cluster . Module 17: infant and young child feeding in emergency situations. In: Walters T , ed. The Harmonised Training Package (HTP): Resource Material for Training on Nutrition in Emergencies . Version 2. Oxford, England : Emergency Nutrition Network ; 2011 . 31 Mangasaryan N , Rudert C , Cheung E , et al. . Infant and Young Child Feeding: Programming Guide. New York, NY: United Nations Children’s Fund; 2012 . 32 Save the Children, TOPS Program, US Agency for International Development . IYCF-E Toolkit: Rapid Start-up Resources for Emergency Nutrition Personnel. Version 2.0. https://sites.google.com/site/stcehn/documents/iycf-e-toolkit. Released September 19, 2014. Accessed January 1, 2017. 33 Richardson L , Walters T. Infant and Young Children Feeding in Emergencies: Guidance for Programming. Brussels, Belgium : European Commission Directorate-General for Humanitarian Aid and Civil Protection ; 2014 . 34 United Nations High Comissioner for Refugees . Infant and Young Child Feeding Practices: Standard Operating Procedures for the Handling of Breastmilk Substitutes (BMS) in Refugee Situations for Children 0–23 Months. Version 1.1 . Geneva, Switzerland : United Nations High Comissioner for Refugees ; 2015 . 35 Global Nutrition Cluster . Tips on Interventions for the Humanitarian Response Plan . United Nations Children’s Fund : Geneva, Switzerland ; 2016 . 36 Dodos J , Action Against Hunger, United Nations Children’s Fund. WASH’Nutrition: A Practical Guidebook on Increasing Nutritional Impact Through Integration of WASH and Nutrition Programmes. For Practitioners in Humanitarian and Development Contexts. Paris, France: Action Contre la Faim; 2017 . 37 Angood C , Infant Feeding in Emergencies Core Group. Infant and Young Child Feeding in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers . Version 3.0. Oxford, England : Emergency Nutrition Network ; 2017 . 38 World Health Organization . International Code of Marketing of Breast-milk Substitutes . Geneva , Switzerland: World Health Organization ; 1981 . 39 Theurich MA. World Health Assembly Resolution 69.9 calls for an end to unethical marketing of “baby foods” . J Hum Lact. 2018 ; 34 : 272 – 275 . Google Scholar Crossref Search ADS PubMed 40 World Health Organization; Scientific and Technical Advisory Group on Inappropriate Promotion of Foods for Infants and Young Children. Technical paper on definition of inappropriate promotion of foods for infants and young children; 2013 . http://www.who.int/nutrition/events/2013_STAG_meeting_24to25June_recommendations.pdf?ua=1;Accessed January 1, 2017. 41 World Health Organization . The International Code of Marketing of Breast-Milk Substitutes: Frequently Asked Questions (2017 Update) . Geneva , Switzerland: World Health Organization ; 2017 . 42 World Health Organization, Sixty-Ninth World Health Assembly . World Health Assembly resolution 69.9: ending inappropriate promotion of foods for infants and young children. http://apps.who.int/gb/ebwha/pdf_files/wha69/a69_r9-en.pdf. May 28, 2016. Accessed January 1, 2017. 43 Joint WHO/FAO Codex Alimentarius Commission. Codex Alimentarius international food standards. Rome, Italy: Food and Agriculture Organization of the United Nations, World Health Organization. http://www.fao.org/fao-who-codexalimentarius/en/. Accessed January 1, 2017. 44 Food and Agriculture Organization of the United Nations, World Health Organization . Standard for canned baby foods. Codex Stan 73-1981. http://www.fao.org/fao-who-codexalimentarius/sh-proxy/ru/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCODEX%2BSTAN%2B73-1981%252FCXS_073e.pdf. Adopted 1981. Last amended 2017. Accessed January 1, 2017. 45 Food and Agriculture Organization of the United Nations, World Health Organization . General standard for the labelling of and claims for prepackaged foods for special dietary uses. Codex Stan 146-1985. http://www.fao.org/fao-whocodexalimentarius/shproxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCAC%2BGL%2B2-1985%252FCXG_002e.pdf. Adopted 1985. Amended 2009. Accessed January 1, 2017. 46 World Health Organization, Food and Agriculture Organization of the United Nations . Guidelines on formulated complementary foods for older infants and young children. CAC/GL 8-1991. http://www.fao.org/fao-who-codexalimentarius/sh-proxy/pt/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCAC%2BGL%2B8-1991%252FCXG_008e.pdf. Adopted 1991. Revised 2013. Accessed January 1, 2017. 47 World Health Organization, Food and Agriculture Organization of the United Nations . Guidelines for use of nutrition and health claims. CAC/GL 23-1997. http://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCAC%2BGL%2B23-1997%252FCXG_023e.pdf. Adopted 1997. Revised 2004. Last amended 2013. Accessed January 1, 2017. 48 World Health Organization, Food and Agriculture Organization of the United Nations . Guidelines on nutrition labeling. CAC/GL 2-1985. http://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCAC%2BGL%2B2-1985%252FCXG_002e.pdf. Adopted 1985. Revised 2011. Last amended 2017. Accessed January 1, 2017. 49 World Health Organization, Food and Agriculture Organization of the United Nations . Standard for processed cereal-based foods for infants and young children. Codex Stan 74-1981. http://www.fao.org/fao-who-codexalimentarius/sh-proxy/en/?lnk=1&url=https%253A%252F%252Fworkspace.fao.org%252Fsites%252Fcodex%252FStandards%252FCODEX%2BSTAN%2B74-1981%252FCXS_074e.pdf. Adopted 1981. Revised 2006. Amended 2017. Accessed January 1, 2017. 50 Theurich M , Grote V. Are commercial complementary food distributions to refugees and migrants in Europe conforming to international policies and guidelines on infant and young child feeding in emergencies? J Hum Lact . 2017 ; 33 : 573 – 577 . Google Scholar Crossref Search ADS PubMed 51 Hipgrave DB , Assefa F , Winoto A , Sukotjo S. Donated breast milk substitutes and incidence of diarrhoea among infants and young children after the May 2006 earthquake in Yogyakarta and Central Java . Public Health Nutr. 2012 ; 15 : 307 – 315 . Google Scholar Crossref Search ADS PubMed 52 Chap J , Jackson P , Siqueira R , et al. . International survey of Cronobacter sakazakii and other Cronobacter spp. in follow up formulas and infant foods . Int J Food Microbiol. 2009 ; 136 : 185 – 188 . Google Scholar Crossref Search ADS PubMed 53 Killalea D , Ward LR , Roberts D , et al. . International epidemiological and microbiological study of outbreak of Salmonella Agona infection from a ready to eat savoury snack—I: England and Wales and the United States . BMJ. 1996 ; 313 : 1105 – 1107 . Google Scholar Crossref Search ADS PubMed 54 Rushdy AA , Stuart JM , Ward LR , et al. . National outbreak of Salmonella senftenberg associated with infant food . Epidemiol Infect. 1998 ; 120 : 125 – 128 . Google Scholar Crossref Search ADS PubMed 55 Sotir MJ , Ewald G , Kimura AC , et al. . Outbreak of Salmonella Wandsworth and Typhimurium infections in infants and toddlers traced to a commercial vegetable-coated snack food . Ped Infect Dis J . 2009 ; 28 : 1041 – 1046 . Google Scholar Crossref Search ADS 56 Koch J , Schrauder A , Alpers K , et al. . Salmonella Agona outbreak from contaminated aniseed, Germany . Emerg Infect Dis. 2005 ; 11 : 1124 – 1127 . Google Scholar Crossref Search ADS PubMed 57 Duc l. H , Dong TC , Logan NA , et al. . Cases of emesis associated with bacterial contamination of an infant breakfast cereal product . Int J Food Microbiol . 2005 ; 102 : 245 – 251 . Google Scholar Crossref Search ADS PubMed 58 Ilić S , Đurić P , Grego E. Salmonella senftenberg infections and fennel seed tea, Serbia . Emerg Infect Dis. 2010 ; 16 : 893 – 895 . Google Scholar Crossref Search ADS PubMed 59 Li Z , Ge W , Li K , et al. . Prevalence and characterization of Cronobacter sakazakii in retail milk-based infant and baby foods in Shaanxi, China . Foodborne Pathog Dis. 2016 ; 13 : 221 – 227 . Google Scholar Crossref Search ADS PubMed 60 Zhang Y , Chen J , Feng C , et al. . Quantitative prevalence, phenotypic and genotypic characteristics of Bacillus cereus isolated from retail infant foods in China . Foodborne Pathog Dis . 2017 ; 14 : 564 – 572 . Google Scholar Crossref Search ADS PubMed 61 Huang Y , Pang Y , Wang H , et al. . Occurrence and characterization of Cronobacter spp. in dehydrated rice powder from Chinese supermarket . PLoS One. 2015 ; 10 : e0131053 . doi:10.1371/journal.pone.0131053 Google Scholar Crossref Search ADS PubMed 62 Hwang JY , Park JH. Characteristics of enterotoxin distribution, hemolysis, lecithinase, and starch hydrolysis of Bacillus cereus isolated from infant formulas and ready-to-eat foods . J Dairy Sci. 2015 ; 98 : 1652 – 1660 . Google Scholar Crossref Search ADS PubMed 63 Wang X , Meng J , Zhang J , et al. . Characterization of Staphylococcus aureus isolated from powdered infant formula milk and infant rice cereal in China . Int J Food Microbiol . 2012 ; 153 : 142 – 147 . Google Scholar Crossref Search ADS PubMed 64 Shaker R , Osaili T , Al-Omary W , et al. . Isolation of Enterobacter sakazakii and other Enterobacter sp. from food and food production environments . Food Control . 2007 ; 18 : 1241 – 1245 . Google Scholar Crossref Search ADS 65 Jaradat ZW , Ababneh QO , Saadoun IM , et al. . Isolation of Cronobacter spp. (formerly Enterobacter sakazakii) from infant food, herbs and environmental samples and the subsequent identification and confirmation of the isolates using biochemical, chromogenic assays, PCR and 16S rRNA sequencing . BMC Microbiol. 2009 ; 9 : 225. doi:10.1186/1471-2180-9-225 Google Scholar Crossref Search ADS 66 Yacine Ware L , Durand N , Nikiema PA , et al. . Occurrence of mycotoxins in commercial infant formulas locally produced in Ouagadougou (Burkina Faso) . Food Control . 2017 ; 73 : 518 – 523 . Google Scholar Crossref Search ADS 67 Oluwafemi F , Ibeh IN. Microbial contamination of seven major weaning foods in Nigeria . J Health Popul Nutr . 2011 ; 29 : 415 – 419 . Google Scholar Crossref Search ADS PubMed 68 Cappozzo J , Jackson L , Lee HJ , et al. . Occurrence of ochratoxin A in infant Foods in the United States . J Food Prot. 2017 ; 80 : 251 – 256 . Google Scholar Crossref Search ADS PubMed 69 Lombaert GA , Pellaers P , Roscoe V , et al. . Mycotoxins in infant cereal foods from the Canadian retail market . Food Addit Contam. 2003 ; 20 : 494 – 504 . Google Scholar Crossref Search ADS PubMed 70 Aksenov IV , Sedova IB , Tutelyan VA. Cyrilli contamination of baby foods with ochratoxin A [in Russian] . Vopr Pitan. 2015 ; 84 : 76 – 81 . Google Scholar PubMed 71 Erkekoglu P , Sipahi H , Sahin G , Baydar T. A hidden danger in infant formulas and baby foods: Enterobacter sakazakii contamination . FABAD J Pharm Sci . 2009 ; 34 : 153 – 165 . 72 Abdullah Sani N , Hartantyo SH , Forsythe SJ. Microbiological assessment and evaluation of rehydration instructions on powdered infant formulas, follow-up formulas, and infant foods in Malaysia . J Dairy Sci. 2013 ; 96 : 1 – 8 . Google Scholar Crossref Search ADS PubMed 73 Al-Nabulsi AA , Osaili TM , Shaker RR , et al. . Survival of Cronobacter species in reconstituted herbal infant teas and their sensitivity to bovine lactoferrin . J Food Sci . 2009 ; 74 : M479 – M484 . Google Scholar Crossref Search ADS PubMed 74 Messelhausser U , Frenzel E , Blochinger C , et al. . Emetic Bacillus cereus are more volatile than thought: recent foodborne outbreaks and prevalence studies in Bavaria (2007–2013) . Biomed Res Int . 2014 ; 2014 : 465603 . doi:10.1155/2014/465603 Google Scholar Crossref Search ADS PubMed 75 World Health Organization, Food and Agriculture Organization of the United Nations . Safe Preparation, Storage and Handling of Powdered Infant Formula: Guidelines . Geneva, Switzerland : World Health Organization ; 2005 . 76 World Health Organization, United Nations Food and Agriculture Organization . How to Prepare Powdered Infant Formula in Care Settings . Geneva, Switzerland : World Health Organization ; 2007 . 77 World Health Organization, United Nations Food and Agriculture Organization . How to Prepare Formula for Cup-Feeding at Home . Geneva, Switzerland : World Health Organization ; 2007 . 78 World Health Organization . Basic Principles for the Preparation of Safe Food for Infants and Young Children. Geneva, Switzerland : World Health Organization ; 1996 . 79 Dewey K. Guiding Principles for Complementary Feeding of the Breastfed Child . Washington, DC : Pan American Health Organization ; 2003 . 80 Dewey K. Guiding Principles for Feeding Non-Breastfed Children 6–24 Months of Age . Geneva , Switzerland: World Health Organization ; 2005 . 81 US Department of Health and Human Services . Baby food and infant formula. Foodsafety.gov website. https://www.foodsafety.gov/keep/types/babyfood/index.html. Accessed January 1, 2018. © The Author(s) 2019. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Food safety considerations for commercial complementary foods from global operational guidance on infant and young child feeding in emergencies
JO - Nutrition Reviews
DO - 10.1093/nutrit/nuy065
DA - 2019-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/food-safety-considerations-for-commercial-complementary-foods-from-4SKJvsAv4T
SP - 350
VL - 77
IS - 5
DP - DeepDyve
ER -