Earthquakes are sudden natural disasters that affect individuals of all age groups. Nutrition is one of the most critical factors influencing infant and child health following such events(Reference Young, Borrel and Holland1–Reference Woodruff and Duffield3).
Feeding is a natural process that supports infant growth and development and continues in the aftermath of natural disasters(4). After events such as earthquakes, acute food shortages in the short term and gastrointestinal illnesses, malnutrition and inadequate or imbalanced nutrition in the longer term are frequently observed among infants and young children(Reference Young, Borrel and Holland1,Reference Felix, Kaniasty and You5) during disasters. Morbidity and mortality rates in infants and young children can increase by nearly two-fold, with malnutrition and nutritional deficiencies identified as major contributors to deaths(Reference Gözübüyük, Duras and Dağ2). Studies indicate that breast-feeding rates decline after disasters, whereas formula use and formula-related diarrhoea increase(Reference Dörnemann and Kelly6,Reference Hipgrave, Assefa and Winoto7) . Additionally, acute malnutrition and micronutrient deficiencies have been documented to be highly prevalent among infants and young children following disasters(Reference Young, Borrel and Holland1). Increases in wasting, stunting and underweight status in children have also been reported post-disaster(Reference Marshall, Lasco and Phaiyarom8). To mitigate these risks, the WHO’s International Code of Marketing of Breast-milk Substitutes (BMS Code) and Infant and Young Child Feeding in Emergencies guidelines provide essential directions(9). The BMS Code restricts inappropriate marketing and the use of breast milk substitutes, ensuring that they are provided only when medically indicated and under professional supervision. The Infant and Young Child Feeding in Emergencies guidelines recommend early initiation of breast-feeding, exclusive breast-feeding for the first six months, continued breast-feeding for two years or more and timely introduction of safe and appropriate complementary feeding(9,Reference Guan, Iellamo and Chase10) .
In emergency settings, these principles are implemented through the Infant and Young Child Feeding in Emergencies framework, which prioritises the protection, promotion and support of breast-feeding, while carefully regulating the use of breast milk substitutes to minimise health risks under compromised environmental conditions(Reference Guan, Iellamo and Chase10). Within this framework, emphasis is placed on the systematic assessment and monitoring of infant feeding practices and their associated factors in emergency contexts. Accordingly, assessing infant feeding practices and identifying factors influencing feeding behaviours in disaster-affected areas is recommended to support optimal infant health(Reference Woodruff and Duffield3).
The Centers for Disease Control and Prevention state that although general recommendations and guidelines for infant feeding and the transition to complementary foods remain unchanged during disasters, families may require additional support to learn how to safely feed their infants under such circumstances(4). Supporting infants and mothers during the complementary feeding transition, providing education and counselling, and monitoring the healthy growth and development of infants are among the primary roles and responsibilities of paediatric nurses(Reference Atwal11,Reference Bal Yılmaz, Bolışık, Conk, Başbakkal, Bal Yılmaz and Bolışık12) . Even after natural disasters, it is essential for paediatric nurses to fulfil these roles and responsibilities by assessing infants’ feeding and breast-feeding status as well as the factors that influence the transition to complementary feeding.
This study was conducted to examine infant feeding practices among infants aged 4–12 months living in container settlements in the earthquake-affected region and to identify factors influencing these practices during the post-earthquake period, particularly during the transition to complementary feeding.
Methods
This descriptive, cross-sectional study was conducted with mothers of infants aged 4–12 months living in container cities in the Antakya District of Hatay. Institutional approval for this study was obtained in November 2023. Because the earthquake occurred in February 2023, infant ages were adjusted accordingly, and only mothers of infants born on or after February 6, 2023, were included. Data were collected through face-to-face interviews conducted between November 2023 and June 2024.
Inclusion criteria:
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• Mothers of infants aged 4–12 months who had initiated complementary feeding.
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• Mothers who were literate, had no communication impairments and voluntarily agreed to participate.
Exclusion criteria:
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• Mothers and infants with chronic, neurological, congenital or metabolic disorders.
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• Infants with breast milk-related food allergies that required maternal dietary modification.
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• Mothers who did not complete the data collection forms.
The sample size was determined using a standard formula for populations of unknown size(Reference Esin, Erdoğan, Nahcivan and Esin13). The formula is as follows:
$n = {t^2}pq/{d^2}$
According to the formula;
t: Table value of the t-distribution of the confidence level (1·96 for 95 % confidence level).
p: 0·5 Frequency (probability) of the event under investigation
q: 0·5 Frequency (probability) non-occurrence of the event
d: Sampling error (0·05 for 95 % confidence level)
The required sample size was 384(Reference Esin, Erdoğan, Nahcivan and Esin13). To account for potential sample loss, 396 mothers were recruited for this study.
Data collection tools
Data were collected using the Family Introduction Form and Complementary Feeding Transition Questionnaire, developed based on the literature.
Family introduction form
This form, developed based on relevant literature, includes items assessing the sociodemographic characteristics of the participating mothers and their infants (e.g. household size, number of individuals living in the container, age, gender, occupation, educational level, number of children, the infant’s gender and age in months, experience of first-degree losses during the earthquake and the infant’s health status)(Reference Kahraman, Gümüş and Binay Yaz14,Reference Pallewaththa, Agampodi and Agampodi15) .
Complementary feeding transition questionnaire
This form, also developed based on the literature, includes questions regarding the infant’s transition to complementary feeding (e.g. breast-feeding status, duration of breast-feeding, changes in sucking behaviour after the earthquake, perceived changes in breast milk quantity, use of supplemental formula, initiation of complementary foods after the earthquake, types of complementary foods, feeding frequency, mother’s feeding methods, preparation of individualised complementary foods, feeding routines after the earthquake, use of pacifiers or bottles and any loss of appetite or weight reported after the earthquake)(Reference Kahraman, Gümüş and Binay Yaz14–Reference Martí-Solsona, González-Chordá and Andreu-Pejo16).
Data analyses
Statistical analyses were conducted using IBM SPSS version 25.0. Numerical variables were summarised using the mean, SD, and minimum and maximum values, whereas categorical variables were presented as frequencies and percentages. The normality of the data distribution was assessed using the Kolmogorov–Smirnov test.
The Pearson χ 2 test was used to evaluate categorical variables related to infant feeding practices, associated factors and transition to complementary feeding. A significance level of 0·05 was adopted for all analyses.
Results
Sociodemographic characteristics of the families are presented in Table 1. Among the mothers, 43·9 % were between 25 and 29 years of age, while 33·1 % of fathers were 30–34. Additionally, 60·7 % of the mothers were housewives and 40·7 % of the fathers were self-employed.
Sociodemographic features of families
Table 1. Long description
The table presents sociodemographic features of families, focusing on household size, mother’s age, father’s age, number of children, infants’ age, and infants’ gender. It includes data on households with 2-3 people, 4-5 people, and 6-7 people, with percentages of 37.9%, 49.2%, and 12.8% respectively. The age distribution of mothers shows 17.9% are 19-24 years old, 43.9% are 25-29 years old, 21.5% are 30-34 years old, 9.8% are 35-39 years old, and 6.9% are 40 and older. Fathers’ age distribution includes 3.3% aged 19-24, 24.7% aged 25-29, 33.1% aged 30-34, 15.9% aged 35-39, and 23% aged 40 and older. The number of children per family is divided into 36.4% with one child, 29.5% with two children, 21.2% with three children, and 12.9% with more than four children. Infants’ age is categorized into 6.8% aged 4-6 months, 43.2% aged 7-9 months, and 50% aged 10-12 months. The gender of infants shows 38.4% are girls and 61.6% are boys. The table provides a comprehensive overview of the sociodemographic characteristics of the families surveyed.
n: number; %: percentage.
Overall, 55·8 % of the infants were delivered via caesarean section and 80·3 % were born at full term. All mothers reported that their homes were damaged during the earthquake: 66·2 % experienced severe damage or complete destruction, while 33·8 % reported moderate damage. All mothers lived in container cities at the time of data collection. Additionally, 6·3 % of the mothers were hospitalised following the earthquake. It was also determined that 17·2 % of the mothers had lost a first-degree relative during the earthquake, and among them, 73·5 % had lost a sibling (Table 2).
Earthquake experiences
Table 2. Long description
The table presents data on various experiences of an earthquake, focusing on rescue efforts, injuries, relocations, and health impacts on infants. It includes columns for the type of experience, the number of occurrences (n), and the corresponding percentage (%). Key data points include how individuals were rescued, whether they were injured, injury to first-degree relatives, loss of first-degree relatives, relocation frequency, and the impact of relocations on breastfeeding. Additionally, it details the effects on the mother’s ability to breastfeed and the health problems of babies after the earthquake, including specific issues like diarrhea, upper respiratory tract infections (URTI), lower respiratory tract infections (LRTI), and other health problems.
URTI: Upper respiratory tract infection, LRTI: Lower respiratory tract infection, n: number; %: percentage.
52·5 of the families relocated to 3–4 times, whereas 31·8 % relocated five or more times. A total of 63·6 % indicated that relocation affected their infants’ nutritional status, with 40·4 % reporting a decrease in milk supply and 42·1 % attributed to the lack of a suitable environment for breast-feeding and feeding (Table 2).
In the earthquake-affected region, 50·8 % of mothers did not continue breast-feeding after the event, and 59·6 % of infants under one year of age were not breastfed. Additionally, 19·2 % of the infants were exclusively breastfed during the first six months, while 58·6 % received formula supplementation. Among the infants included in the study, 58·3 % transitioned to complementary foods before six months of age and 49·0 % initiated complementary feeding with jarred baby foods (Table 3). Mothers reported that 73·7 % of their infants used pacifiers and 75·8 % used bottles.
Infant feeding practices
Table 3. Long description
The table presents data on infant feeding practices in an earthquake-affected region. It includes variables such as continuing breast-feeding after the earthquake, exclusive breast-feeding duration, decrease in milk quantity, formula supplement status, time to start complementary feeding, types of complementary foods introduced, feeding methods, ability to prepare additional food, use of distractions, and distraction methods. The table has 13 rows and 3 columns, with column headers labeled Variables, n, and percentage. Notable trends include a significant decrease in breast-feeding after the earthquake, with 50.8 percent of mothers not continuing, and 59.6 percent of infants under one year of age not being breastfed. Additionally, 19.2 percent of infants were exclusively breastfed for six months, while 58.6 percent received formula supplementation. Complementary foods were introduced before six months for 58.3 percent of infants, with jarred baby foods being the most common initial food. Mothers reported using pacifiers for 73.7 percent of infants and bottles for 75.8 percent.
BLW: Bay led weaning; n: number; %: percentage.
Additionally, 62·4 % of mothers stated that they could prepare complementary foods in their container homes, with 48·2 % preparing soups, and 51·8 % preparing fruit purees. Furthermore, 98·2 % of the mothers indicated that they did not obtain complementary food from the field kitchens.
64·4 of the mothers, 64·4 % reported having knowledge about the transition to complementary feeding, with 42·1 % indicating that the internet was their primary source of information. However, 72·9 % of those with such knowledge stated that they were unable to apply it under post-earthquake conditions. It was found that 56·3 % of the mothers required information, education and counselling on breast-feeding and complementary feeding. Additionally, 72·2 % reported having various needs related to complementary feeding, of which 41·5 % required ready-made formulas, 58·5 % needed food packages or ready-to-eat meals and 40·4 % needed items such as high chairs, bibs and child-friendly utensils.
An analysis of sociodemographic factors affecting feeding revealed no statistically significant differences between maternal age, educational level, number of children and continuation of breast-feeding or exclusive breast-feeding (P > 0·05).
All the families in the study were relocated. A statistically significant association was found between the number of relocations and the continuation of breast-feeding, with increasing relocations corresponding to higher rates of breast-feeding cessation (P = 0·016). Similarly, a significant relationship was identified between the number of relocations and decreased breast milk supply, with more frequent relocations being associated with greater reductions in milk production (P < 0·001) (Table 4).
Relationship between feeding practices and earthquake experiences
Table 4. Long description
The table presents data on the relationship between feeding practices and earthquake experiences, focusing on the decrease in the amount of breast milk and the transition to complementary feeding. It includes information on relocations and loss in an earthquake. The table has four main sections: relocations (1-2 times, 3-4 times, 5 and above), and loss in an earthquake (yes, no). Each section is divided into columns for yes or no responses regarding the decrease in breast milk and transition to complementary feeding, with corresponding numbers and percentages. Notable trends include higher percentages of decreased breast milk and transition to complementary feeding with increased relocations and loss in an earthquake. Statistical analysis using Pearson’s chi-squared test shows significant relationships for some variables.
n: number; %: percentage.
* Pearson’s χ 2d test.
A statistically significant association was identified between experiencing loss during the earthquake and continuation of breast-feeding, with mothers who experienced such losses being more likely to discontinue breast-feeding (P < 0·001). A significant relationship was also found between experiencing loss and reduced breast milk supply, as mothers who experienced losses reported greater decline in milk production (P < 0·001). However, no statistically significant differences were observed between the number of relocations or loss and the use of formula or the timing of the transition to complementary feeding (P > 0·05).
Discussion
The WHO and the American Academy of Pediatrics recommend exclusive breast-feeding for the first six months, followed by the introduction of appropriate complementary foods after six months (after 180 d), while continuing breast-feeding up to two years of age and beyond(Reference Martí-Solsona, González-Chordá and Andreu-Pejo16–Reference Meek and Noble18). In this study, more than half of the mothers did not continue breast-feeding after the earthquake, only 19·2 % of the infants were exclusively breastfed for the first six months, and approximately 60 % of infants under one year were not breastfed. However, according to the 2018 Türkiye Demographic and Health Survey, the rate of exclusive breast-feeding for the first six months in Türkiye was 41 %, the rate of breast-feeding up to one year was 66 %, and the rate of breast-feeding up to two years was 34 %(19). Previous studies have similarly reported exclusive breast-feeding rates of 33·3 %(Reference Yakar, Azakoglu Karaca and Tanriover20) and 55 %(Reference Göktepe and Öztürk21). Although research investigating the effects of disasters on infant feeding practices remains limited, existing evidence demonstrates consistency across studies. Following the 2016 Japan earthquake and the Fukushima nuclear power plant accident, breast-feeding rates were reported to be lower than expected when compared with national statistics(Reference Ishii, Goto and Ota22) Similarly, after the 2018 Haiti earthquake, disruptions in both the quality and quantity of maternal breast milk were identified(Reference Dörnemann and Kelly6). In a study conducted after the Indian Ocean tsunami involving 100 mothers and 176 children, more than two-thirds of the mothers reported that their breast-feeding practices had been adversely affected, and nearly three-quarters stated that their infants were fed formula(Reference Adhisivam, Srinivasan and Soudarssanane23). Parallel findings were observed following wildfires in Canada, where a decline in the maternal milk supply was documented(Reference DeYoung, Chase and Branco24). Importantly, achieving these targets requires systematic integration of breast-feeding support strategies into disaster preparedness, response and recovery plans.
In the present study, more than half of the mothers reported supplementing their infant diets with formulas. The Operational Guidance on Infant and Young Child Feeding in Emergencies and the International Code of Marketing of BMS are essential frameworks for protecting and promoting breast-feeding and for preventing inappropriate and unnecessary use of formula during emergencies(9,Reference Guan, Iellamo and Chase10) . In Türkiye, the WHO’s International Code of Marketing of BMS is implemented through national regulations enforced by the Ministry of Health of Turkey, which restrict the promotion and inappropriate use of breast milk substitutes(Reference Çaylan, Yalçın and Karabayır25,26) . Concurrently, infant and young child feeding practices are guided by recommendations from the WHO and UNICEF to promote optimal breast-feeding and appropriate complementary feeding(26).
In emergency contexts, such as earthquakes, these frameworks are further reinforced through the Infant and Young Child Feeding in Emergencies approach, which emphasises the protection and support of breast-feeding while ensuring that the use of breast milk substitutes remains strictly controlled, needs-based and supervised by health professionals(26,Reference Bilgin and Karabayır27) . In addition to these regulatory frameworks, national programmes such as breast-feeding promotion initiatives and Baby-Friendly Hospital practices implemented in collaboration with UNICEF play a key role in improving infant and young child feeding practices(Reference Çaylan, Yalçın and Karabayır25). However, an observational study conducted in Türkiye following the recent earthquake documented systematic violations of the code by formula companies. These companies donated substantial quantities of formula and feeding equipment to the Turkish Red Crescent, governmental bodies and disaster relief coordinators responsible for infant and young child feeding, thereby disregarding Operational Guidance on Infant and Young Child Feeding in Emergencies recommendations(Reference Guan, Iellamo and Chase10). The elevated prevalence of formula use identified in the current study was consistent with the findings of this observational study. Comparable patterns were observed in other disaster contexts. Following the earthquake in Indonesia, uncontrolled and widespread formula distribution resulted in 89 % of infants receiving formula, with the proportion of formula-fed infants increasing from 32 % before the disaster to 43 % afterward(Reference Hipgrave, Assefa and Winoto7). It is essential to prioritise breast-feeding over formula feeding in the aftermath of earthquakes, provide comprehensive relief support for mothers who have reduced or discontinued lactation and ensure that infants receive breast milk whenever possible(Reference Bilgin and Karabayır27,Reference Ayoya, Golden and Ngnie-Teta28) . Accordingly, post-disaster management plans should prioritise robust breast-feeding support systems, as maintaining and strengthening breast-feeding practices constitutes a central strategy for protecting infant health in emergencies.
In the present study, frequent maternal relocation significantly affected breast-feeding practices and lactation. An increase in the number of relocations was associated with higher rates of breast-feeding cessation and greater reduction in milk supply. Mothers frequently reported that repeated relocation prevented them from accessing suitable environments for breast-feeding. Consistent with these findings, previous research examining barriers to infant feeding in post-disaster settings has identified inadequate privacy or breast-feeding-friendly spaces, insufficient fluid and energy intake, psychological stress and physical fatigue as major impediments to breast-feeding(Reference Hwang, Iellamo and Ververs29). A study investigating the perspectives and resilience of women affected by the Kumamoto earthquake reported that postpartum women experienced malnutrition, required additional support for infant care, lacked appropriate environments for breast-feeding and childcare, and expressed heightened anxiety regarding the well-being of their infants and other children(Reference Suzuki, Sato and Miyazaki30). Similarly, research conducted in provinces impacted by the 2023 Türkiye earthquake identified several factors that adversely affected infant feeding practices, including overcrowded and unsuitable breast-feeding environments, elevated stress and fear, diminished breast-feeding support resulting from disruptions in social relationships, challenges in meeting basic physiological needs and shortages of professional healthcare personnel within the disaster zone(Reference Mizrak Sahin and Kabakci31–33). Successful models for post-disaster breast-feeding support have been documented. For example, following the 2010 Haiti earthquake, ‘baby tents’ were rapidly established to provide safe private spaces where mothers could breastfeed and receive assistance from trained counsellors and peer supporters, enabling the continuation of breast-feeding under emergency conditions(Reference Ayoya, Golden and Ngnie-Teta28). The prompt organisation of such support systems, provision of appropriate environments for breast-feeding and complementary feeding and timely identification and response to maternal–infant needs constitute essential responsibilities of health authorities, local governments and healthcare professionals. Fulfilling these responsibilities with adequate awareness and preparedness has the potential to improve the continuation and duration of breast-feeding in disaster settings.
In the present study, complementary feeding was initiated before the sixth month in the majority of infants, and approximately half of the infants transitioned to complementary feeding with jarred baby food. Yogurt is the second most commonly used complementary food. Although initial complementary feeding practices vary across cultures, the Ministry of Health of Türkiye recommends yogurt as the primary complementary food(34). Consistent with these findings, studies conducted in Türkiye have reported that commonly preferred first foods include fruit juice, yogurt, dairy products and vegetable-based soups(Reference Kahraman, Gümüş and Binay Yaz14,Reference Kahraman, Sönmez Düzkaya, Karakul, Sade and Sönmez35–Reference Uçar and Şahin38) .
Studies examining complementary feeding practices in the aftermath of disasters are limited. Following the earthquake in Indonesia, 76 % of infants were reported to have been fed commercial oatmeal and 49 % powdered milk(Reference Hipgrave, Assefa and Winoto7). These findings indicate that mothers frequently rely on commercially prepared food after disasters. Limited access to fresh fruits and vegetables, inadequate materials and environments for preparing homemade complementary foods and the widespread distribution of donated formula and jarred baby foods are likely contributors to the increased use of ready-made products for complementary feeding.
Strengths and limitations
A key strength of this study is that the data were collected through face-to-face interviews in Hatay, one of the provinces most severely affected by the earthquake. However, this study had several limitations. As a cross-sectional study, causal relationships could not be established; therefore, infant feeding practices and nutritional status could not be compared before and after the earthquake. The findings were based on maternal reports. Additionally, anthropometric measurements, which are an important component for evaluating nutritional status, were not included. Despite these limitations, this study provides valuable baseline evidence to inform future research and to guide the development of intervention programmes.
Conclusion
This study demonstrated that breast-feeding practices were significantly disrupted following the earthquake, with many mothers experiencing a reduction in milk supply. Relocation and the loss of first-degree relatives emerged as the most significant factors associated with these outcomes. These findings underscore the importance of health professionals closely monitoring infants’ nutritional status and growth after disasters, identifying the determinants of feeding difficulties and evaluating the adequacy and balance of dietary intake to support optimal growth and development. Establishing supportive environments that facilitate breast-feeding is essential in disaster-affected areas. In addition, dedicated spaces within field kitchens should be provided to promote appropriate infant feeding practices. Furthermore, strengthening the implementation of the WHO’s International Code of Marketing of BMS in disaster settings in Türkiye, along with enhancing breast-feeding counselling and mother–baby friendly support services, may help mothers maintain breast-feeding during and after disasters. To minimise the adverse effects of disaster-related nutritional disruptions on infant and child health, mothers should also be provided with regular and structured education and counselling on breast-feeding and complementary feeding practices.
Acknowledgements
The authors would like to thank all participants in this study.
No financial support provided.
A. K. and E. Ç. designed this study. E. Ç. contributed to the data acquisition. A. K., E. Ç., M. G., and D. K. contributed to data analysis and interpretation. A. K. and E. Ç. performed statistical analysis. A. K., E. Ç., M. G. and D. K. contributed to drafting and revising the manuscript critically for important intellectual content of the manuscript together. All authors have read and approved the final manuscript.
The authors (s) declare no potential conflicts of interest with respect to the research, authorship or publication of this article.
Ethical approval for the study was obtained from the Hatay Mustafa Kemal University Non-Interventional Clinical Research Ethics Committee on October 12, 2023 (Decision No. 07). Written and verbal permission was obtained from tent city and container city administrations, and written permission was granted by the Governorship of Hatay on November 6, 2023 (No. E-72174601). Prior to data collection, all participating mothers were informed of the study and provided written informed consent. All procedures performed in this study adhered to the ethical standards of the institutional and national research committees and to the principles of the 1964 Declaration of Helsinki and its subsequent amendments or comparable ethical standards for research involving human participants.
