Identifying Countries at High Risk of Infant and Young Child Feeding Challenges Post- Earthquake

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Using secondary data from the Global Earthquake Model Foundation, we analyzed estimated average annual fatalities and average annual area damaged due to earthquakes to identify the top 20 countries globally with the highest value for each indicator. We then assessed these countries’ vulnerability to infant feeding disruptions by examining their exclusive breastfeeding rates. Countries with low exclusive breastfeeding rates face heightened challenges in safely feeding infants during natural disasters due to their heavy reliance on substantial resources needed for artificial feeding. Additionally, countries with high annual average fatalities require robust preparedness plans and support systems to ensure continued care and immediate nutrition for infants, breastfed and non-breastfed alike, in the event of caregiver loss. In contrast, countries with a high risk of significant infrastructure damage are particularly susceptible to food safety and access challenges even when caregivers remain with their infants. Out of 198 countries assessed, the findings identify 24 countries with either the highest average annual fatalities or the highest average annual area damaged values from earthquakes, and a cohort of 16 countries appears in both categories. Strengthening breastfeeding promotion, providing lactation support, and establishing emergency preparedness plans for infant feeding are critical for reducing mortality in the identified countries. Integrating the Operational Guidance for Infant Feeding in Emergencies (Operational Guidance) into national disaster response plans will improve preparedness, especially if it is available in the national languages of these countries (especially Mandarin, Farsi, and Urdu). We strongly encourage all identified countries to prioritize integrating infant feeding strategies into their earthquake preparedness plans to protect and promote the well-being of infants. Infant Feeding Earthquakes Emergency Preparedness Breastfeeding Child Nutrition Figures Figure 1 Introduction Ensuring safe and appropriate infant feeding practices supports optimal growth, development, and positive health outcomes in young children, particularly during natural disasters such as earthquakes. The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) recommend exclusive breastfeeding for the first six months of life, followed by the introduction of safe and nutritionally adequate complementary foods while continuing breastfeeding for up to two years or beyond (World Health Organization 2020a ). Exclusive breastfeeding (EBF) is critical for an infant’s health and survival, even more so in disaster settings. (Kramer et al., 2008 ; Jordin et al., 2021). Breastmilk is safe and readily available. It provides essential nutrients and antibodies to protect infants from common childhood illnesses like diarrhea and respiratory illnesses, which are significant causes of child mortality (World Health Organization 2020a ; World Health Organization 2020b ). In situations where the mother’s breastmilk is not available, such as maternal death, absence, serious illness, or where they are otherwise unable to breastfeed, alternative feeding methods can be used, such as breastfeeding by another healthy woman or use of donor human milk. In situations where a mother is partially breastfeeding her infant or where the infant is not breastfed, and no alternate source of human milk is available, infants < 6 months of age will be dependent on Breastmilk Substitutes (BMS). Two options for BMS for infants include powdered infant formula or ready-to-use infant formula. Earthquakes pose significant challenges for safe infant feeding practices, regardless of feeding methods. For example, during earthquakes, mothers who practice EBF may die, be trapped, be injured, become separated from their infants, or have other reasons preventing breastfeeding. In these circumstances, immediate alternatives need to be sought as an infant requires feeding every few hours. The destruction of infrastructure, including supplies, displacement of families, lack of clean water, fuel, or electricity, and sanitation facilities, creates a challenging environment that is magnified in countries with low EBF rates and many non-breastfed infants. The risk of contamination and incorrect preparation of infant formula is extremely high in these contexts (Gribble & Berry, 2011 ). Powdered infant formula is the most risky feeding method in such disaster settings due to the extensive resources required for its safe preparation, including clean water, proper utensils, and fuel for heating water for safe preparation as well as sterilizing utensils. Despite being bulkier and pricier, ready-to-use infant formula (RUIF) is preferred as it requires significantly less preparation and minimizes the risk of contamination, making it safer and more practical for infants during emergencies (IFE Core Group, 2017 ; Emergency Nutrition Network, 2019). However, context-appropriate BMS, especially RUIF, might not be available or accessible in an earthquake setting because of the destruction of infrastructure. Studies have identified infant and breastfeeding challenges during post-earthquake responses in Russia, New Zealand, Indonesia, Türkiye, and Italy (Beinin, 1981 ; Gribble et al., 2019; Hwang et al., 2021 ; Giusti, 2022; Suzan et al., 2025 ), including the lack of availability or utilization of infant feeding experts and insufficient support from aid organizations or government agencies. These shortcomings contributed to increased post-disaster morbidity and mortality among infants from malnutrition and infectious diseases. In Japan, research on the post-disaster feeding outcomes after the Great East Japanese Earthquake in 2011 determined that effective guidance is important to protect breastfeeding exclusivity and prevent replacement feeding with BMS (Kyozuka et al., 2016 ). To protect and promote infant and young child feeding (IYCF) practices in emergencies, the Infant Feeding in Emergencies Core Group under the Global Nutrition Cluster developed the Operational Guidance for Infant and Young Child Feeding in Emergencies (Operational Guidance) to guide governments, NGOs, UN agencies, and others in preparedness plans. This evidence-based guidance was affirmed by the 2010 World Health Assembly Resolution 63.23, and Member States are called to align their national preparedness plans to support infant feeding during emergencies (IFE Core Group, 2017 ; World Health Assembly, 2010 ). This study aims to identify countries that are likely to have a relatively large number of fatalities and/or destroyed infrastructure to inform them of the necessity of infant feeding preparedness efforts and encourage the integration of infant feeding measures into earthquake response plans. The study also aims to identify languages in which the Operational Guidance has not yet been translated, and which countries are at high risk of infant feeding challenges following major earthquakes. Methods We conducted an analysis of the potential impact of earthquakes on infant feeding practices, considering factors such as average annual fatalities, damaged infrastructure, and preparedness measures. Our analysis aimed to identify areas where enhanced preparedness and guidance implementation could mitigate the earthquake's impact on infant feeding practices. The Global Seismic Risk Model (GSRM), developed and maintained by the Global Earthquake Model (GEM) Foundation (Silva et al., 2020 ), uses a probabilistic method to evaluate seismic risk and estimate the potential impacts of earthquakes on buildings and people. It has three components: (1) a seismic hazard model (Pagani et al., 2020 ), which predicts the ground shaking for specific earthquakes; (2) an exposure model (Yepes-Estrada et al., 2023 ), which maps the locations and key features of buildings; and (3) a vulnerability model (Martins & Silva, 2021 ), which estimates how likely buildings are to be damaged by shaking. These components are analyzed using the Open Quake engine (Pagani et al., 2014) developed by the GEM Foundation. The model simulates potential earthquakes over a long period and calculates each earthquake’s impact by combining ground shaking intensity, building exposure, and vulnerability. Metrics such as economic loss, fatalities, and damaged/collapsed buildings are averaged over time to give annualized results, which can then be used to compare seismic risks across regions. We obtained data on Average Annual Fatalities (AAF) and Average Annual Area Damaged (AAA) from the country-level outputs of the 2023 GSRM report (Silva et al., 2023 ) database, which comprises 198 countries or territories. The AAF reflects the estimated yearly human deaths from earthquake-induced building collapses, including maternal/caregiver deaths, which may disrupt infant feeding practices and increase risks for growth faltering, malnutrition, and infectious disease morbidity. We considered countries with the highest AAFs to be those that would face the greatest challenges for infant feeding, in any form, post-earthquake. The AAA reflects the estimated annual area of buildings in square kilometers that need repair or replacement, caused by the impact of earthquakes, and is used herein as a proxy measure for the overall potential of earthquake-related destruction. Countries/territories with high AAA values were considered to face challenges for safe feeding of non-breastfed infants, given the potential reduction in access to essential resources like clean water, sanitation, BMS, and healthcare services, which could impact safe and hygienic infant feeding practices. Additionally, EBF rates for each country were analyzed to identify further risks to infant feeding post-earthquake. We assumed that countries with EBF rates lower than 50% would face more significant challenges for safe infant feeding of non-breastfed infants. We selected the 20 top countries with the highest AAF values and the countries with the highest AAA values. We then identified countries ranked in the top 20 for both measures. These countries experienced high fatality levels and damage to infrastructure and were considered most likely to face substantial challenges in maintaining safe infant feeding practices following an earthquake. Next, we reviewed the EBF rates of the top 20 countries for each measure to identify countries with relatively lower breastfeeding rates and higher dependency on BMS. Subsequently, we evaluated the availability of the Operational Guidance in the corresponding national languages of the top 20 AAF and AAA countries (IFE Core Group 2017 ). We assumed that the absence of guidance in the local language may affect a country's preparedness to handle infant feeding challenges in an earthquake context. Results The study analyzed data on the risk of infant feeding disruptions due to earthquakes by examining indicators separately: Average Annual Fatalities (AAF), Average Annual Area Damaged (AAA), Exclusive Breastfeeding (EBF) rates, and the availability of Operational Guidance in national languages. Table 1 presents each indicator and its respective values. Twenty-four countries ranked in the top 20 for either AAF or AAA values, with sixteen of these appearing on both lists: Afghanistan, Algeria, Bangladesh, China, Guatemala, India, Indonesia, Iran, Italy, Mexico, Pakistan, Peru, the Philippines, Romania, Taiwan, and Türkiye. These countries face the highest overall risk for infant feeding disruptions post-earthquake. Additionally, Ecuador, Colombia, Japan, and the USA were in the top 20 for AAF but not AAA, while El Salvador, Haiti, Nepal, and Uzbekistan ranked in the top 20 for AAA but not AAF. As shown in Fig. 1 , China (AAF 3,979), Pakistan (AAF 2,615), Türkiye (AAF 2,237), India (AAF 1,940), and Iran (AAF 1,900) exhibited the highest AAF values, indicating significant human losses, including caregivers. Afghanistan (AAF 1,418), Bangladesh (AAF 477), and Peru (AAF 543) also reported high AAF values, which could disrupt breastfeeding continuity due to maternal fatalities. In contrast, Colombia (AAF 176), Taiwan (AAF 182), and Italy (AAF 181) ranked lower but remain at risk due to infrastructure damage and varying EBF rates. The highest AAA values were observed in China (13.79 km²), Pakistan (8.73 km²), India (8.57 km²), Türkiye (8.27 km²), and Iran (6.35 km²), highlighting the potential for widespread destruction of infrastructure essential for safe infant feeding practices (Fig. 1 ). Japan (AAA 7.00 km²), Mexico (AAA 3.45 km²), and the USA (AAA 3.85 km²) also exhibited significant infrastructure damage, which could hinder access to clean water and infant feeding supplies. Countries such as Colombia (AAA 2.87 km²) and Taiwan (AAA 2.95 km²) had moderate AAA values, but their reliance on non-breastmilk alternatives could still present challenges in emergency settings. EBF rates varied across high-risk countries. Afghanistan (EBF 63.3%), Bangladesh (EBF 62.6%), India (EBF 64%), and Peru (EBF 66.9%) demonstrated relatively high EBF rates, suggesting a stronger baseline for sustaining breastfeeding post-disaster. In contrast, China (EBF 35.1%), Japan (EBF 37.4%), Italy (EBF 30.0%), and Algeria (EBF 28.6%)reported lower EBF rates, indicating greater reliance on BMS and heightened vulnerability to unsafe infant feeding practices and supply chain disruptions. Romania (EBF 15.8%) and the USA (EBF 25.8%) also had low EBF rates, necessitating contingency plans for artificial feeding. Operational Guidance for Infant Feeding in Emergencies is available in the local language of some high-risk countries, including Algeria, Bangladesh, Colombia, Ecuador, Guatemala, India, Indonesia, Italy, Mexico, Peru, and Türkiye. If the guidance is effectively implemented, these countries may have a stronger preparedness capacity. However, Afghanistan, China, Iran, Nepal, Pakistan, the Philippines, Romania, Taiwan, and Uzbekistan lacked translated guidance, presenting a critical gap in emergency response planning. These findings highlight the varying risks faced by high-exposure countries. Some experience greater caregiver losses, others face significant infrastructure damage, and many struggle with low breastfeeding rates. The combination of these factors influences the overall risk of infant feeding disruptions in the aftermath of earthquakes. Table 1 High-Risk Earthquake Countries falling in the top 20 with the highest AAF values and/or AAA values listed with EBF Rates and the absence or presence of Operational Guidance in their respective national languages. Countries Exclusive Breastfeeding (EBF) rate (%) ABCD Average Annual Fatalities (AAF) Silva et al. (2023) Average Annual Area Damaged in km² (AAA) Silva et al. (2023) Operational Guidance in National Language IFE Core Group. (2017) . 1 Afghanistan 63.3 (a) 1418 1.69 No 2 Algeria 28.6 (a) 654 1.11 Yes 3 Bangladesh 62.6 (a) 477 1.79 Yes 4 China 35.1 (a) 3979 13.79 No 5 Colombia 36.7 (a) 176 2.87 Yes 6 Ecuador 39.6 (a) 180 1.59 Yes 7 El Salvador 46.7 (a) 185 0.79 Yes 8 Guatemala 53.2 (a) 478 1.56 Yes 9 Haiti 39.9 (a) 254 0.39 Yes 10 India 64.01 (b) 1940 8.57 Yes 11 Indonesia 50.7 (a) 735 5.38 Yes 12 Iran 47.4 (a) 1900 6.35 No 13 Italy 30.0 (d) 181 2.54 Yes 14 Japan 37.4 (e) 86 7.00 Yes 15 Mexico 35.9 (a) 352 3.45 Yes 16 Nepal 56.4 (a) 600 1.04 No 17 Pakistan 47.8 (a) 2615 8.73 No 18 Peru 66.9 (a) 543 2.30 Yes 19 Philippines 40.9 (a) 477 3.89 No 20 Romania 15.8 (a) 302 1.47 No 21 Taiwan 30.9 (c) 182 2.95 No 22 Türkiye 40.7 (a) 2237 8.27 Yes 23 USA 25.8 (a) 36 3.85 Yes 24 Uzbekistan 49.5 (a) 291 0.96 No a (UNICEF, 2021 ); b (Ramnika Aggarwal, Priyanka Garg & Madhur Verma, 2024); c (Chen, T.-L., Chen, L.-L., & Gau, M.-L. (2024).); d (Pizzi, E., Salvatore, M.A., Giusti, A., et al. (2025)); e (Inano et al., 2021 ) Discussion This study provides critical insights into the impact of earthquakes on infant and young child feeding (IYCF) by examining key risk factors, including Average Annual Fatalities (AAF), Average Annual Area Damaged (AAA), exclusive breastfeeding (EBF) rates, and the availability of Operational Guidance in national languages. The findings underscore how different vulnerabilities contribute to potential disruptions in infant feeding practices post-earthquake, aligning with prior research on emergency nutrition and disaster response (Silva et al., 2023 ; IFE Core Group, 2017 ). The analysis of AAF reveals that the loss of caregivers, particularly mothers, may significantly affect breastfeeding continuity, posing serious risks to infant nutrition. Studies have documented that maternal morbidity and mortality during earthquakes can interrupt breastfeeding and lead to an increased reliance on artificial feeding, which may be challenging in emergency contexts due to resource limitations (Alexander & Magni, 2013 ; CARE Afghanistan, 2024 ). In Afghanistan, for instance, the 2023 earthquake resulted in disproportionately high female and child fatalities, exacerbating the risks associated with infant feeding (UN Women, 2023 ). Similar patterns have been observed in earthquakes in Italy, Japan, and Pakistan, where mortality rates among women of reproductive age were elevated due to household occupancy trends and physical structural vulnerabilities (Ardagh et al., 2016 ; Beinin, 1981 ). These factors suggest that caregiver loss is critical in shaping IYCF challenges in disaster settings. Infants depend entirely on their caregivers for nutrition and care and will rapidly deteriorate without many foods over a 24-hour period, making them particularly vulnerable in these circumstances. The potential disruption in feeding practices can have long-term consequences on child health and development, as inadequate nutrition in the early stages of life is linked to increased risks of malnutrition, stunted growth, and weakened immune function (World Health Organization, 2020). Countries with high AAA values present a distinct challenge, as infrastructure damage can severely limit access to clean water, sanitation, and essential feeding resources. The results indicate that non-breastfed infants in these regions may be particularly susceptible to feeding-related health risks, including malnutrition and increased infection rates due to lack of immune protection from breastfeeding, coupled with unsafe preparation of breastmilk substitutes (BMS). Violations of international codes and challenges in ensuring safe infant nutrition have been documented with critical impact on infant feeding practices (Guan et al., 2024 ; Hwang et al., 2021 ; DeYoung et al., 2018). In middle- and high-income countries, where there is often a higher prevalence ofBMS-dependent infants, earthquakes can severely disrupt supply chains and healthcare services, compromising access to safe infant feeding options. For instance, during the 2011 Christchurch earthquake in New Zealand, infrastructure disruptions affected the distribution of essential supplies and caregivers’ ability to access healthcare support for infant feeding (Hargest-Slade & Gribble, 2015 ). Similarly, in the aftermath of the 2011 Great East Japan Earthquake, evacuation shelters faced significant challenges in providing adequate nutrition, particularly for formula-fed infants. A study analyzing dietary conditions in these shelters found that many lacked the facilities and resources necessary for preparing balanced meals, including infant formula. The absence of cooking equipment and disruptions to gas supplies further impeded the ability to provide appropriate nutrition to evacuees (Tsuboyama-Kasaoka, Hoshi, Onodera, Mizuno, & Sako, 2014 ). Identical challenges were identified in the 2023 Türkiye earthquake, where mothers reported problems regarding information, support, equipment, appropriate space, and food supply related to infant feeding. A lack of attention to the post-disaster nutritional needs of breastfeeding mothers was also identified (Suzan et al., 2025 ). The case of Haiti’s 2010 earthquake illustrates how structured feeding support interventions, including lactation counseling and controlled BMS distribution, have contributed to mitigating post-disaster nutrition risks (Ayoya et al., 2013 ). The destruction of critical infrastructure also affects food distribution channels, reducing access to both maternal nutrition and infant feeding supplies. Countries where infrastructure fragility is already a concern before an earthquake may experience prolonged disruptions in essential services, further exacerbating health and nutrition disparities among vulnerable populations (Emergency Nutrition Network, 2019). These findings align with previous research suggesting that long-term recovery efforts must account for the restoration of maternal and child health services, as delays in access to nutritional support can have cascading effects on infant survival and development (Silva et al., 2023 ). Another important factor emerging from this study is the availability of translated Operational Guidance in national languages. The findings show that several high-risk countries lack access to these guidelines in their national language, which may influence the effectiveness of emergency response strategies. Prior research suggests that the availability of translated guidance enhances coordination among responders and facilitates the implementation of best practices in IYCF support (IFE Core Group, 2017 ). In regions such as China, Iran, and Pakistan, where earthquake-related fatalities and infrastructure damage are substantial, translation efforts can contribute to enhancing preparedness and response efficiency. Additionally, studies on emergency response effectiveness indicate that training initiatives based on standardized guidance can improve adherence to recommended feeding practices, further supporting the role of translated materials in preparedness planning (World Health Assembly, 2010 ). Ensuring that such guidance is translated, widely disseminated, and integrated into national disaster preparedness strategies may contribute to more effective implementation in emergency settings. Additionally, the existence of translated guidance alone does not guarantee its utility; effective implementation requires coordinated efforts across governmental agencies, non-governmental organizations, and international aid partners to incorporate these guidelines into on-the-ground response mechanisms (Jordyn et al., 2021 ). This study contributes to the broader understanding of the interplay between caregiver loss, infrastructure damage, and IYCF preparedness in earthquake-prone regions. The findings align with existing literature on disaster nutrition and risk mitigation strategies by identifying patterns across AAF, AAA, EBF rates, and policy implementation gaps. The results suggest that further research into the relationships between gendered mortality patterns, infrastructure resilience, and emergency feeding strategies may provide additional perspectives on improving infant nutrition outcomes in post-earthquake settings. Expanding these analyses across diverse geographic contexts will be valuable in strengthening IYCF resilience in high-risk regions. Moreover, future research could examine the role of community-based support systems in sustaining appropriate infant feeding practices in disaster settings. Interventions providing privacy, counselling (face-to-face or telehealth), and facilitating support such as baby-friendly spaces, also known as mother-baby tents, and access to mother-to-mother support networks have been reported to enhance breastfeeding rates and improve maternal confidence in emergencies (Basibuyuk et al., 2025 ; Mudiyanselage et al., 2022; Dozio et al., 2020; Gribble & Berry, 2011 ; Ayoya et al., 2013 ). Understanding the interaction between policy, community engagement, disaster preparedness, and response effectiveness could provide further insights into strengthening IYCF frameworks in earthquake-prone regions. Limitations This study has a few limitations. First, the impact of earthquakes on infant feeding practices may differ significantly between urban and rural areas. Urban areas often have more robust infrastructure and better access to emergency services and resources, whereas rural areas may be more isolated and face greater challenges in disaster response. However, urban structures could also potentially endure more damage. Second, the study relies on secondary data, which may not capture all nuances of local conditions or recent changes in infrastructure and health practices. We assumed that average EBF rates were the same throughout each individual country. However, EBF rates may differ across earthquake-affected geographical areas within a country. Moreover, EBF rates and other indicators may have changed since the data was collected, influencing the current risk assessment. Third, the AAA and AAF data do not account for the differentiation of age and gender in the estimates of earthquake impact. Finally, the study does not account for a country's resilience to earthquakes, such as emergency preparedness measures, healthcare system strength, or community support networks, as these factors are difficult to measure comprehensively. Conclusion This study underscores the need for targeted preparedness measures to mitigate the impact of earthquakes on infant feeding practices in high-risk countries. Countries with high AAF require robust disaster preparedness plans to safeguard breastfeeding and ensure alternative feeding methods are available if breastfeeding mothers are incapacitated. In contrast, countries with high AAA must prioritize infrastructure resilience and adopt mitigating guidance to maintain safe feeding practices, particularly if there were previously many non-breastfed infants who rely on BMS that require substantial resources for safe consumption. Regardless of AAF and AAA values, countries with low EBF rates may face heightened risks after earthquakes because of the number of infants dependent on BMS. Countries with high AAF and AAA values and low EBF rates are at greater risk. Strengthening breastfeeding promotion, providing lactation support, psycho-social support and establishing emergency preparedness plans for infant feeding are essential steps for these countries. Integrating Operational Guidance into disaster response plans and translating it into additional languages will strengthen preparedness efforts. High-risk countries can build resilience in their infant feeding practices by addressing these vulnerabilities and better protecting infants during and after earthquakes. The focus of support should be on keeping good practice going (interrupting breastfeeding as little as possible) and mitigating risks of artificial feeding. Integrating infant feeding strategies into national disaster management plans, potentially coupled with international support, will be key to safeguarding the health and nutrition of infants, especially because they cannot wait 24 hours to be fed. Declarations Ethics approval and consent to participate Not applicable. This study involved only publicly available secondary data and did not include human participants or personal data. Consent for publication Not applicable. Availability of data and materials All data used in this study are publicly available and referenced accordingly in the manuscript. The seismic risk data was obtained from the Global Earthquake Model Foundation database, and breastfeeding rates were retrieved from UNICEF and national health reports. Competing interests The authors declare that they have no known competing interests. Funding This research received no external funding. Authors' contributions Aly Drame : Conceptualization, Methodology, Writing – Original Draft, Data Analysis Andrés Abarca : Seismic Risk Data Acquisition and Interpretation, Review & Editing Jodine Chase : Infant Feeding in Emergencies Expertise, Critical Review Mija Ververs : Supervision, Conceptualization, Methodology, Review, and Guidance on Humanitarian Health Frameworks All authors have read and approved the final manuscript. 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Earthquake Spectra . 2020;36(1_suppl):226-251. doi:10.1177/8755293020931866 Pagani, M., Monelli, D., Weatherill, G., Danciu, L., Crowley, H., Silva, V., Henshaw, P., Butler, L., Nastasi, M., Panzeri, L., Simionato, M. and Vigano, D., [2014] “OpenQuake Engine: An open hazard (and risk) software for the Global Earthquake Model,” Seismological Research Letters, Vol. 85, No. 3, pp 692-702. doi: https://doi.org/10.1785/0220130087 Pizzi, E., Salvatore, M.A., Giusti, A., et al. (2025). Monitoring prevalence of breastfeeding and associated factors: results of the 2022 data collection of the Italian surveillance of children aged 0–2 years . Annali dell’Istituto Superiore di Sanità, 61(1): 3–12. DOI: 10.4415/ANN_25_01_02 Silva, A. Calderon, M. Caruso, C. Costa, J. Dabbeek, M.C. Hoyos, Z. Karimzadeh, L. Martins, N. Paul, A. Rao, M. Simionato, C. Yepes-Estrada, H. Crowley, K. Jaiswal (2023), Country/Territory Seismic Risk Profiles of the GEM Foundation, GitHub. https://github.com/gem/risk-profiles/ DOI: https://doi.org/10.5281/zenodo.8431824 Silva V, Amo-Oduro D, Calderon A, et al. Development of a global seismic risk model. Earthquake Spectra . 2020;36(1_suppl):372-394. doi:10.1177/8755293019899953 Suzan, ÖK., Topal, S., Çaka, SY., Çınar, N. (2025). Investigation of the sustainability of breastfeeding and infant nutrition in the earthquake region based on mothers' experiences: a qualitative study. BMC Public Health ., 25(1):953. doi: 10.1186/s12889-025-22137-0 Swansea Bay Maternity. (2019). Feeding Guideline for Alternative Methods in the Full Term Breastfed Infant (including cup feeding, syringe feeding and bottle feeding) . WISDOM. Retrieved from https://wisdom.nhs.wales/health-board-guidelines/swansea-bay-maternity-file/ Tsuboyama-Kasaoka, N., Hoshi, Y., Onodera, K., Mizuno, S., & Sako, K. (2014). What factors were important for dietary improvement in emergency shelters after the Great East Japan Earthquake? Asia Pacific Journal of Clinical Nutrition, 23 (1), 159–166. https://doi.org/10.6133/apjcn.2014.23.1.17 UN Women. (2023). Trapped in their homes: Women and girls comprise majority of earthquake casualties in Afghanistan . Retrieved from https://www.unwomen.org/en/news-stories/feature-story/2023/10/trapped-in-their-homes-women-and-girls-comprise-majority-of-earthquake-casualties-in-afghanistan UNICEF. (2021). Breastfeeding. UNICEF DATA. September 2021, from https://data.unicef.org/resources/dataset/breastfeeding/ (Accessed November 13, 2024) World Health Organization. (2020a). Infant and young child feeding. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding . (Accessed November 13, \ 2024) World Health Organization. (2020b). Breastfeeding. https://www.who.int/health-topics/breastfeeding#tab=tab_1 . (Accessed November 13 2024) World Population Review. (WPR) (2024). Taiwan Population. https://worldpopulationreview.com/countries/taiwan-population. (Accessed November 13, 2024) World Bank (WB) (2024). Total Population https://data.worldbank.org/indicator/SP.POP.TOTL. (Accessed November 13, 2024) World Health Assembly. (2010). WHA63.23: Infant and Young Child Nutrition . Geneva: World Health Organization. Retrieved from https://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R23-en.pdf . (Accessed November 13, 2024) World Health Organization. (1981). International code of marketing of breast-milk substitutes (WHO/NMH/NHD/17.1). World Health Organization. https://iris.who.int/bitstream/handle/10665/254911/WHO-NMH-NHD-17.1-eng.pdf (Accessed October 15, 2024) Yepes-Estrada C, Calderon A, Costa C, et al. Global building exposure model for earthquake risk assessment. Earthquake Spectra . 2023;39(4):2212-2235. doi:10.1177/87552930231194048 Additional Declarations No competing interests reported. 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The World Health Organization (WHO) and the United Nations Children\u0026rsquo;s Fund (UNICEF) recommend exclusive breastfeeding for the first six months of life, followed by the introduction of safe and nutritionally adequate complementary foods while continuing breastfeeding for up to two years or beyond (World Health Organization \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020a\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExclusive breastfeeding (EBF) is critical for an infant\u0026rsquo;s health and survival, even more so in disaster settings. (Kramer et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Jordin et al., 2021). Breastmilk is safe and readily available. It provides essential nutrients and antibodies to protect infants from common childhood illnesses like diarrhea and respiratory illnesses, which are significant causes of child mortality (World Health Organization \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020a\u003c/span\u003e; World Health Organization \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020b\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn situations where the mother\u0026rsquo;s breastmilk is not available, such as maternal death, absence, serious illness, or where they are otherwise unable to breastfeed, alternative feeding methods can be used, such as breastfeeding by another healthy woman or use of donor human milk. In situations where a mother is partially breastfeeding her infant or where the infant is not breastfed, and no alternate source of human milk is available, infants\u0026thinsp;\u0026lt;\u0026thinsp;6 months of age will be dependent on Breastmilk Substitutes (BMS). Two options for BMS for infants include powdered infant formula or ready-to-use infant formula.\u003c/p\u003e\u003cp\u003eEarthquakes pose significant challenges for safe infant feeding practices, regardless of feeding methods. For example, during earthquakes, mothers who practice EBF may die, be trapped, be injured, become separated from their infants, or have other reasons preventing breastfeeding. In these circumstances, immediate alternatives need to be sought as an infant requires feeding every few hours. The destruction of infrastructure, including supplies, displacement of families, lack of clean water, fuel, or electricity, and sanitation facilities, creates a challenging environment that is magnified in countries with low EBF rates and many non-breastfed infants. The risk of contamination and incorrect preparation of infant formula is extremely high in these contexts (Gribble \u0026amp; Berry, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Powdered infant formula is the most risky feeding method in such disaster settings due to the extensive resources required for its safe preparation, including clean water, proper utensils, and fuel for heating water for safe preparation as well as sterilizing utensils. Despite being bulkier and pricier, ready-to-use infant formula (RUIF) is preferred as it requires significantly less preparation and minimizes the risk of contamination, making it safer and more practical for infants during emergencies (IFE Core Group, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Emergency Nutrition Network, 2019). However, context-appropriate BMS, especially RUIF, might not be available or accessible in an earthquake setting because of the destruction of infrastructure.\u003c/p\u003e\u003cp\u003eStudies have identified infant and breastfeeding challenges during post-earthquake responses in Russia, New Zealand, Indonesia, T\u0026uuml;rkiye, and Italy (Beinin, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1981\u003c/span\u003e; Gribble et al., 2019; Hwang et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Giusti, 2022; Suzan et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), including the lack of availability or utilization of infant feeding experts and insufficient support from aid organizations or government agencies. These shortcomings contributed to increased post-disaster morbidity and mortality among infants from malnutrition and infectious diseases. In Japan, research on the post-disaster feeding outcomes after the Great East Japanese Earthquake in 2011 determined that effective guidance is important to protect breastfeeding exclusivity and prevent replacement feeding with BMS (Kyozuka et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). To protect and promote infant and young child feeding (IYCF) practices in emergencies, the Infant Feeding in Emergencies Core Group under the Global Nutrition Cluster developed the Operational Guidance for Infant and Young Child Feeding in Emergencies (Operational Guidance) to guide governments, NGOs, UN agencies, and others in preparedness plans. This evidence-based guidance was affirmed by the 2010 World Health Assembly Resolution 63.23, and Member States are called to align their national preparedness plans to support infant feeding during emergencies (IFE Core Group, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; World Health Assembly, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study aims to identify countries that are likely to have a relatively large number of fatalities and/or destroyed infrastructure to inform them of the necessity of infant feeding preparedness efforts and encourage the integration of infant feeding measures into earthquake response plans. The study also aims to identify languages in which the Operational Guidance has not yet been translated, and which countries are at high risk of infant feeding challenges following major earthquakes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted an analysis of the potential impact of earthquakes on infant feeding practices, considering factors such as average annual fatalities, damaged infrastructure, and preparedness measures. Our analysis aimed to identify areas where enhanced preparedness and guidance implementation could mitigate the earthquake's impact on infant feeding practices.\u003c/p\u003e\u003cp\u003eThe Global Seismic Risk Model (GSRM), developed and maintained by the Global Earthquake Model (GEM) Foundation (Silva et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), uses a probabilistic method to evaluate seismic risk and estimate the potential impacts of earthquakes on buildings and people. It has three components: (1) a seismic hazard model (Pagani et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), which predicts the ground shaking for specific earthquakes; (2) an exposure model (Yepes-Estrada et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), which maps the locations and key features of buildings; and (3) a vulnerability model (Martins \u0026amp; Silva, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), which estimates how likely buildings are to be damaged by shaking. These components are analyzed using the Open Quake engine (Pagani et al., 2014) developed by the GEM Foundation.\u003c/p\u003e\u003cp\u003eThe model simulates potential earthquakes over a long period and calculates each earthquake\u0026rsquo;s impact by combining ground shaking intensity, building exposure, and vulnerability. Metrics such as economic loss, fatalities, and damaged/collapsed buildings are averaged over time to give annualized results, which can then be used to compare seismic risks across regions. We obtained data on Average Annual Fatalities (AAF) and Average Annual Area Damaged (AAA) from the country-level outputs of the 2023 GSRM report (Silva et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) database, which comprises 198 countries or territories. The AAF reflects the estimated yearly human deaths from earthquake-induced building collapses, including maternal/caregiver deaths, which may disrupt infant feeding practices and increase risks for growth faltering, malnutrition, and infectious disease morbidity. We considered countries with the highest AAFs to be those that would face the greatest challenges for infant feeding, in any form, post-earthquake.\u003c/p\u003e\u003cp\u003eThe AAA reflects the estimated annual area of buildings in square kilometers that need repair or replacement, caused by the impact of earthquakes, and is used herein as a proxy measure for the overall potential of earthquake-related destruction. Countries/territories with high AAA values were considered to face challenges for safe feeding of non-breastfed infants, given the potential reduction in access to essential resources like clean water, sanitation, BMS, and healthcare services, which could impact safe and hygienic infant feeding practices.\u003c/p\u003e\u003cp\u003eAdditionally, EBF rates for each country were analyzed to identify further risks to infant feeding post-earthquake. We assumed that countries with EBF rates lower than 50% would face more significant challenges for safe infant feeding of non-breastfed infants.\u003c/p\u003e\u003cp\u003eWe selected the 20 top countries with the highest AAF values and the countries with the highest AAA values. We then identified countries ranked in the top 20 for both measures. These countries experienced high fatality levels and damage to infrastructure and were considered most likely to face substantial challenges in maintaining safe infant feeding practices following an earthquake. Next, we reviewed the EBF rates of the top 20 countries for each measure to identify countries with relatively lower breastfeeding rates and higher dependency on BMS.\u003c/p\u003e\u003cp\u003eSubsequently, we evaluated the availability of the Operational Guidance in the corresponding national languages of the top 20 AAF and AAA countries (IFE Core Group \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). We assumed that the absence of guidance in the local language may affect a country's preparedness to handle infant feeding challenges in an earthquake context.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study analyzed data on the risk of infant feeding disruptions due to earthquakes by examining indicators separately: Average Annual Fatalities (AAF), Average Annual Area Damaged (AAA), Exclusive Breastfeeding (EBF) rates, and the availability of Operational Guidance in national languages. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents each indicator and its respective values. Twenty-four countries ranked in the top 20 for either AAF or AAA values, with sixteen of these appearing on both lists: Afghanistan, Algeria, Bangladesh, China, Guatemala, India, Indonesia, Iran, Italy, Mexico, Pakistan, Peru, the Philippines, Romania, Taiwan, and T\u0026uuml;rkiye. These countries face the highest overall risk for infant feeding disruptions post-earthquake. Additionally, Ecuador, Colombia, Japan, and the USA were in the top 20 for AAF but not AAA, while El Salvador, Haiti, Nepal, and Uzbekistan ranked in the top 20 for AAA but not AAF.\u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, China (AAF 3,979), Pakistan (AAF 2,615), T\u0026uuml;rkiye (AAF 2,237), India (AAF 1,940), and Iran (AAF 1,900) exhibited the highest AAF values, indicating significant human losses, including caregivers. Afghanistan (AAF 1,418), Bangladesh (AAF 477), and Peru (AAF 543) also reported high AAF values, which could disrupt breastfeeding continuity due to maternal fatalities. In contrast, Colombia (AAF 176), Taiwan (AAF 182), and Italy (AAF 181) ranked lower but remain at risk due to infrastructure damage and varying EBF rates.\u003c/p\u003e\u003cp\u003eThe highest AAA values were observed in China (13.79 km\u0026sup2;), Pakistan (8.73 km\u0026sup2;), India (8.57 km\u0026sup2;), T\u0026uuml;rkiye (8.27 km\u0026sup2;), and Iran (6.35 km\u0026sup2;), highlighting the potential for widespread destruction of infrastructure essential for safe infant feeding practices (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Japan (AAA 7.00 km\u0026sup2;), Mexico (AAA 3.45 km\u0026sup2;), and the USA (AAA 3.85 km\u0026sup2;) also exhibited significant infrastructure damage, which could hinder access to clean water and infant feeding supplies. Countries such as Colombia (AAA 2.87 km\u0026sup2;) and Taiwan (AAA 2.95 km\u0026sup2;) had moderate AAA values, but their reliance on non-breastmilk alternatives could still present challenges in emergency settings.\u003c/p\u003e\u003cp\u003eEBF rates varied across high-risk countries. Afghanistan (EBF 63.3%), Bangladesh (EBF 62.6%), India (EBF 64%), and Peru (EBF 66.9%) demonstrated relatively high EBF rates, suggesting a stronger baseline for sustaining breastfeeding post-disaster. In contrast, China (EBF 35.1%), Japan (EBF 37.4%), Italy (EBF 30.0%), and Algeria (EBF 28.6%)reported lower EBF rates, indicating greater reliance on BMS and heightened vulnerability to unsafe infant feeding practices and supply chain disruptions. Romania (EBF 15.8%) and the USA (EBF 25.8%) also had low EBF rates, necessitating contingency plans for artificial feeding.\u003c/p\u003e\u003cp\u003eOperational Guidance for Infant Feeding in Emergencies is available in the local language of some high-risk countries, including Algeria, Bangladesh, Colombia, Ecuador, Guatemala, India, Indonesia, Italy, Mexico, Peru, and T\u0026uuml;rkiye. If the guidance is effectively implemented, these countries may have a stronger preparedness capacity. However, Afghanistan, China, Iran, Nepal, Pakistan, the Philippines, Romania, Taiwan, and Uzbekistan lacked translated guidance, presenting a critical gap in emergency response planning.\u003c/p\u003e\u003cp\u003eThese findings highlight the varying risks faced by high-exposure countries. Some experience greater caregiver losses, others face significant infrastructure damage, and many struggle with low breastfeeding rates. The combination of these factors influences the overall risk of infant feeding disruptions in the aftermath of earthquakes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHigh-Risk Earthquake Countries falling in the top 20 with the highest AAF values and/or AAA values listed with EBF Rates and the absence or presence of Operational Guidance in their respective national languages.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCountries\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExclusive Breastfeeding (EBF) rate (%) \u003csup\u003eABCD\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAverage Annual Fatalities (AAF) \u003csup\u003eSilva et al. (2023)\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAverage Annual Area Damaged in km\u0026sup2; (AAA)\u003c/p\u003e\u003cp\u003e\u003csup\u003eSilva et al. (2023)\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOperational Guidance in National Language\u003c/p\u003e\u003cp\u003e\u003csup\u003eIFE Core Group. (2017)\u003c/sup\u003e.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfghanistan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.3 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1418\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlgeria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.6 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e654\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBangladesh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.6 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e477\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChina\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.1 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3979\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColombia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.7 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEcuador\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.6 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEl Salvador\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.7 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e185\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGuatemala\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.2 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e478\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHaiti\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.9 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e254\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.01\u003csup\u003e(b)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1940\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndonesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.7 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e735\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIran\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.4 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.0 \u003csup\u003e(d)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e181\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJapan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.4 \u003csup\u003e(e)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMexico\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.9 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNepal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.4 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e600\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePakistan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.8 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeru\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.9 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e543\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhilippines\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.9 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e477\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRomania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.8 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTaiwan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.9 \u003csup\u003e(c)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eT\u0026uuml;rkiye\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.7 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2237\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.8 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUzbekistan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.5 \u003csup\u003e(a)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e291\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003ea\u003c/sup\u003e(UNICEF, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e);\u003csup\u003eb\u003c/sup\u003e(Ramnika Aggarwal, Priyanka Garg \u0026amp; Madhur Verma, 2024); \u003csup\u003ec\u003c/sup\u003e(Chen, T.-L., Chen, L.-L., \u0026amp; Gau, M.-L. (2024).); \u003csup\u003ed\u003c/sup\u003e(Pizzi, E., Salvatore, M.A., Giusti, A., et al. (2025)); \u003csup\u003ee\u003c/sup\u003e(Inano et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides critical insights into the impact of earthquakes on infant and young child feeding (IYCF) by examining key risk factors, including Average Annual Fatalities (AAF), Average Annual Area Damaged (AAA), exclusive breastfeeding (EBF) rates, and the availability of Operational Guidance in national languages. The findings underscore how different vulnerabilities contribute to potential disruptions in infant feeding practices post-earthquake, aligning with prior research on emergency nutrition and disaster response (Silva et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; IFE Core Group, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe analysis of AAF reveals that the loss of caregivers, particularly mothers, may significantly affect breastfeeding continuity, posing serious risks to infant nutrition. Studies have documented that maternal morbidity and mortality during earthquakes can interrupt breastfeeding and lead to an increased reliance on artificial feeding, which may be challenging in emergency contexts due to resource limitations (Alexander \u0026amp; Magni, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; CARE Afghanistan, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In Afghanistan, for instance, the 2023 earthquake resulted in disproportionately high female and child fatalities, exacerbating the risks associated with infant feeding (UN Women, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Similar patterns have been observed in earthquakes in Italy, Japan, and Pakistan, where mortality rates among women of reproductive age were elevated due to household occupancy trends and physical structural vulnerabilities (Ardagh et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Beinin, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1981\u003c/span\u003e). These factors suggest that caregiver loss is critical in shaping IYCF challenges in disaster settings. Infants depend entirely on their caregivers for nutrition and care and will rapidly deteriorate without many foods over a 24-hour period, making them particularly vulnerable in these circumstances. The potential disruption in feeding practices can have long-term consequences on child health and development, as inadequate nutrition in the early stages of life is linked to increased risks of malnutrition, stunted growth, and weakened immune function (World Health Organization, 2020).\u003c/p\u003e\u003cp\u003eCountries with high AAA values present a distinct challenge, as infrastructure damage can severely limit access to clean water, sanitation, and essential feeding resources. The results indicate that non-breastfed infants in these regions may be particularly susceptible to feeding-related health risks, including malnutrition and increased infection rates due to lack of immune protection from breastfeeding, coupled with unsafe preparation of breastmilk substitutes (BMS). Violations of international codes and challenges in ensuring safe infant nutrition have been documented with critical impact on infant feeding practices (Guan et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Hwang et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; DeYoung et al., 2018). In middle- and high-income countries, where there is often a higher prevalence ofBMS-dependent infants, earthquakes can severely disrupt supply chains and healthcare services, compromising access to safe infant feeding options. For instance, during the 2011 Christchurch earthquake in New Zealand, infrastructure disruptions affected the distribution of essential supplies and caregivers\u0026rsquo; ability to access healthcare support for infant feeding (Hargest-Slade \u0026amp; Gribble, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Similarly, in the aftermath of the 2011 Great East Japan Earthquake, evacuation shelters faced significant challenges in providing adequate nutrition, particularly for formula-fed infants. A study analyzing dietary conditions in these shelters found that many lacked the facilities and resources necessary for preparing balanced meals, including infant formula. The absence of cooking equipment and disruptions to gas supplies further impeded the ability to provide appropriate nutrition to evacuees (Tsuboyama-Kasaoka, Hoshi, Onodera, Mizuno, \u0026amp; Sako, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Identical challenges were identified in the 2023 T\u0026uuml;rkiye earthquake, where mothers reported problems regarding information, support, equipment, appropriate space, and food supply related to infant feeding. A lack of attention to the post-disaster nutritional needs of breastfeeding mothers was also identified (Suzan et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The case of Haiti\u0026rsquo;s 2010 earthquake illustrates how structured feeding support interventions, including lactation counseling and controlled BMS distribution, have contributed to mitigating post-disaster nutrition risks (Ayoya et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The destruction of critical infrastructure also affects food distribution channels, reducing access to both maternal nutrition and infant feeding supplies. Countries where infrastructure fragility is already a concern before an earthquake may experience prolonged disruptions in essential services, further exacerbating health and nutrition disparities among vulnerable populations (Emergency Nutrition Network, 2019). These findings align with previous research suggesting that long-term recovery efforts must account for the restoration of maternal and child health services, as delays in access to nutritional support can have cascading effects on infant survival and development (Silva et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother important factor emerging from this study is the availability of translated Operational Guidance in national languages. The findings show that several high-risk countries lack access to these guidelines in their national language, which may influence the effectiveness of emergency response strategies. Prior research suggests that the availability of translated guidance enhances coordination among responders and facilitates the implementation of best practices in IYCF support (IFE Core Group, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In regions such as China, Iran, and Pakistan, where earthquake-related fatalities and infrastructure damage are substantial, translation efforts can contribute to enhancing preparedness and response efficiency. Additionally, studies on emergency response effectiveness indicate that training initiatives based on standardized guidance can improve adherence to recommended feeding practices, further supporting the role of translated materials in preparedness planning (World Health Assembly, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Ensuring that such guidance is translated, widely disseminated, and integrated into national disaster preparedness strategies may contribute to more effective implementation in emergency settings. Additionally, the existence of translated guidance alone does not guarantee its utility; effective implementation requires coordinated efforts across governmental agencies, non-governmental organizations, and international aid partners to incorporate these guidelines into on-the-ground response mechanisms (Jordyn et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study contributes to the broader understanding of the interplay between caregiver loss, infrastructure damage, and IYCF preparedness in earthquake-prone regions. The findings align with existing literature on disaster nutrition and risk mitigation strategies by identifying patterns across AAF, AAA, EBF rates, and policy implementation gaps. The results suggest that further research into the relationships between gendered mortality patterns, infrastructure resilience, and emergency feeding strategies may provide additional perspectives on improving infant nutrition outcomes in post-earthquake settings. Expanding these analyses across diverse geographic contexts will be valuable in strengthening IYCF resilience in high-risk regions. Moreover, future research could examine the role of community-based support systems in sustaining appropriate infant feeding practices in disaster settings. Interventions providing privacy, counselling (face-to-face or telehealth), and facilitating support such as baby-friendly spaces, also known as mother-baby tents, and access to mother-to-mother support networks have been reported to enhance breastfeeding rates and improve maternal confidence in emergencies (Basibuyuk et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Mudiyanselage et al., 2022; Dozio et al., 2020; Gribble \u0026amp; Berry, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Ayoya et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e ). Understanding the interaction between policy, community engagement, disaster preparedness, and response effectiveness could provide further insights into strengthening IYCF frameworks in earthquake-prone regions.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study has a few limitations. First, the impact of earthquakes on infant feeding practices may differ significantly between urban and rural areas. Urban areas often have more robust infrastructure and better access to emergency services and resources, whereas rural areas may be more isolated and face greater challenges in disaster response. However, urban structures could also potentially endure more damage. Second, the study relies on secondary data, which may not capture all nuances of local conditions or recent changes in infrastructure and health practices. We assumed that average EBF rates were the same throughout each individual country. However, EBF rates may differ across earthquake-affected geographical areas within a country. Moreover, EBF rates and other indicators may have changed since the data was collected, influencing the current risk assessment. Third, the AAA and AAF data do not account for the differentiation of age and gender in the estimates of earthquake impact. Finally, the study does not account for a country's resilience to earthquakes, such as emergency preparedness measures, healthcare system strength, or community support networks, as these factors are difficult to measure comprehensively.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the need for targeted preparedness measures to mitigate the impact of earthquakes on infant feeding practices in high-risk countries. Countries with high AAF require robust disaster preparedness plans to safeguard breastfeeding and ensure alternative feeding methods are available if breastfeeding mothers are incapacitated. In contrast, countries with high AAA must prioritize infrastructure resilience and adopt mitigating guidance to maintain safe feeding practices, particularly if there were previously many non-breastfed infants who rely on BMS that require substantial resources for safe consumption.\u003c/p\u003e\u003cp\u003eRegardless of AAF and AAA values, countries with low EBF rates may face heightened risks after earthquakes because of the number of infants dependent on BMS. Countries with high AAF and AAA values and low EBF rates are at greater risk. Strengthening breastfeeding promotion, providing lactation support, psycho-social support and establishing emergency preparedness plans for infant feeding are essential steps for these countries. Integrating Operational Guidance into disaster response plans and translating it into additional languages will strengthen preparedness efforts.\u003c/p\u003e\u003cp\u003eHigh-risk countries can build resilience in their infant feeding practices by addressing these vulnerabilities and better protecting infants during and after earthquakes. The focus of support should be on keeping good practice going (interrupting breastfeeding as little as possible) and mitigating risks of artificial feeding. Integrating infant feeding strategies into national disaster management plans, potentially coupled with international support, will be key to safeguarding the health and nutrition of infants, especially because they cannot wait 24 hours to be fed.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable. This study involved only publicly available secondary data and did not include human participants or personal data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All data used in this study are publicly available and referenced accordingly in the manuscript. The seismic risk data was obtained from the Global Earthquake Model Foundation database, and breastfeeding rates were retrieved from UNICEF and national health reports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no known competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cem\u003eAly Drame\u003c/em\u003e: Conceptualization, Methodology, Writing – Original Draft, Data Analysis\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eAndrés Abarca\u003c/em\u003e: Seismic Risk Data Acquisition and Interpretation, Review \u0026amp; Editing\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eJodine Chase\u003c/em\u003e: Infant Feeding in Emergencies Expertise, Critical Review\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eMija Ververs\u003c/em\u003e: Supervision, Conceptualization, Methodology, Review, and Guidance on Humanitarian Health Frameworks\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors would like to acknowledge the contributions of the Global Earthquake Model Foundation, which made its data available, and the Infant Feeding in Emergencies (IFE) Core Group, which led to the development of the Operational Guidance used in this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAfghanaid. 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World Health Organization. https://iris.who.int/bitstream/handle/10665/254911/WHO-NMH-NHD-17.1-eng.pdf \u003cu\u003e(Accessed October 15, 2024)\u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eYepes-Estrada C, Calderon A, Costa C, et al. Global building exposure model for earthquake risk assessment. \u003cem\u003eEarthquake Spectra\u003c/em\u003e. 2023;39(4):2212-2235. doi:10.1177/87552930231194048\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Infant Feeding, Earthquakes, Emergency Preparedness, Breastfeeding, Child Nutrition","lastPublishedDoi":"10.21203/rs.3.rs-6636415/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6636415/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study examines the potential risks to infant feeding practices following earthquakes in countries at high risk of fatality and/or infrastructure damage. Using secondary data from the Global Earthquake Model Foundation, we analyzed estimated average annual fatalities and average annual area damaged due to earthquakes to identify the top 20 countries globally with the highest value for each indicator. We then assessed these countries\u0026rsquo; vulnerability to infant feeding disruptions by examining their exclusive breastfeeding rates. Countries with low exclusive breastfeeding rates face heightened challenges in safely feeding infants during natural disasters due to their heavy reliance on substantial resources needed for artificial feeding. Additionally, countries with high annual average fatalities require robust preparedness plans and support systems to ensure continued care and immediate nutrition for infants, breastfed and non-breastfed alike, in the event of caregiver loss. In contrast, countries with a high risk of significant infrastructure damage are particularly susceptible to food safety and access challenges even when caregivers remain with their infants. Out of 198 countries assessed, the findings identify 24 countries with either the highest average annual fatalities or the highest average annual area damaged values from earthquakes, and a cohort of 16 countries appears in both categories. Strengthening breastfeeding promotion, providing lactation support, and establishing emergency preparedness plans for infant feeding are critical for reducing mortality in the identified countries. Integrating the Operational Guidance for Infant Feeding in Emergencies (Operational Guidance) into national disaster response plans will improve preparedness, especially if it is available in the national languages of these countries (especially Mandarin, Farsi, and Urdu). We strongly encourage all identified countries to prioritize integrating infant feeding strategies into their earthquake preparedness plans to protect and promote the well-being of infants.\u003c/p\u003e","manuscriptTitle":"Identifying Countries at High Risk of Infant and Young Child Feeding Challenges Post- Earthquake","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:29:33","doi":"10.21203/rs.3.rs-6636415/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9aaa5a07-9013-43d8-9637-db385e4a751a","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T14:52:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:29:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6636415","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6636415","identity":"rs-6636415","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}