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Safe infant feeding in the context of HIV

The impact of knowing that one is HIV positive must be exceedingly difficult to deal with, how much more so, when you are about to become a parent and you have to make vitally important decisions regarding your baby's future health.

How a mother should feed her baby is one of the most difficult decisions of all. However, every mother does have the right to the relevant information and to make her decision according to what she believes to be in the best interest of herself and her new baby. She also needs ongoing support and encouragement from friends, family and health care workers around her - regardless of the choices she makes.

The WHO HIV and Infant Feeding Technical Consultation was researched by
Zita Weise Prinze, (IFE Meeting, Oxford November 1st, 2006).
Her Geneva presentation, October 25-27, 2007 included:

1. New evidence on morbidity and mortality

• Early cessation of breastfeeding was associated with increased risk of infant morbidity (ill health) and mortality (death)
• Replacement feeding from birth had no additional benefit compared to short-duration breastfeeding in terms of preventing HIV infection or death.

2. 2/3rds of all breastfeeding-associated HIV transmission occurs after 6 months

3. Risk of death due to not breastfeeding declines substantially with infant age as illustrated by the graph below:

What Are Safe Feeding Options In The Face Of HIV?

It is clear that there are no simple answers. According to present research findings, the feeding options open to HIV+ mothers are:

1. Pasteurising Breastmilk
2. Exclusive Breastfeeding
3. Formula Feeding

1. Pasteurising Breastmilk

Vulnerable Babies
Probably the safest option for a HIV+ mother is to pasteurise her breastmilk. This means that she is able to offer her baby the advantages of breastfeeding, including the unique immune protective properties found in breastmilk, with minimal risk of her baby contracting HIV. (See table of comparison on Pasteurisation page)
For these reasons, mother's own pasteurised milk is a highly successful feeding option used in many Neonatal Intensive Care Units in South Africa, including Groote Schuur, Tygerberg and Kalafong Hospitals. Pasteurisation is also being used to an ever increasing extent in the private sector. Pasteurised human milk is preferable to any, even highly specialized, infant formulas. Should a mother for any reason be unable to provide her baby with breastmilk, pasteurised donor milk is always an option that can be used during the vulnerable period.
(See page on Starting a Milk Bank or Need Donor Milk?)

Well Babies
Pasteurised, mothers own breastmilk is also an easy, safe, cost effective feeding option that can be used at home. There is no time limit to how long a baby can be fed his mother's pasteurised breastmilk, even when introducing solids or weaning a baby onto other milk.
Unfortunately with the present lack of funds, facilities and donor milk, feeding donor bank milk to healthy babies is not an option at present.
However wet nursing remains a possibility, when offered under controlled conditions.
For instance if a baby is orphaned and another family member, whose HIV status is confirmed as negative, is breastfeeding her own child, it is possible for her to feed the orphaned baby as well. Her responsibility to remain HIV negative is obviously of paramount importance.

Increased Viral Load
Breastfeeding mothers, who are HIV+, need detailed information on exclusive breastfeeding. Mothers need to be educated on how to pasteurise their breastmilk in case they become ill or contract an infection such as mastitis.
Anybody whether HIV+ or HIV- needs to be educated on safe sex, but especially an HIV+ mother while breastfeeding.

Weaning
Another period when the risk of transmission is potentially increased, for a breastfeeding HIV+ mother, is when she weans her baby by introducing other foods or drink while still breastfeeding.
On the other hand, weaning overnight can also cause complications for a mother and her baby. The mother can become engorged and the baby might refuse to eat or drink other foods.
A solution to the dilemma does exist; she can pasteurise her breastmilk while weaning, and take all the time she needs to introduce solid foods into her baby's diet, or wean her baby onto formula. Pasteurising destroys the possible virus present in her breastmilk and mixed feeding can take place without the risk or transmission to her baby.
(See Pasteurisation methods on Pasteurisation page)

2. Exclusive Breastfeeding

Exclusive or only breastfeeding means that the mother gives her baby breastmilk only. This means that her baby gets no water, colic/wind medication, tea, juice, other milk or solid foods. Prescribed medication must however be given.

Exclusive breastfeeding is in fact the healthiest way to feed any baby, irrespective of his mother's HIV status. For an HIV+ mother exclusive breastfeeding decreases the risk of the transmission of HIV to her baby, but the risk increases as soon as anything other than breastmilk is fed to the baby.

According to the Zimbabwean Zvitambo study the risk of HIV transmission when exclusive breastfeeding is practiced for 6 months is 1.3%. The risk could be further reduced if mothers pasteurise their milk the moment that they suspect that they might have any kind of infection. Illness or infection increases the mother's viral load and therefore the risk of transmission to her baby is also increased.
(See Pasteurisation methods on Pasteurisation page)

3. Formula Feeding

The World Health Organisation (WHO), recommendation regarding infant feeding choices in the face of HIV is:
Exclusive breastfeeding is recommended for the first 6 months of life.

When replacement feeding is 'AFASS', avoidance of all breastfeeding by HIV infected mothers is recommended.

AFASS Interpreted in the South African context:

• Acceptable: Is formula feeding acceptable in her community, to her family, has she disclosed her status to her family?
• Feasible: Is formula feeding a feasible option for her? Where does she live, is she going to move to another district or province? Government sponsored free formula won't necessary continue to be available to her if she relocates.
• Affordable: She may receive 10 tins of free formula for 6 months, however does she have the necessary finance for taxi fares to the clinic, fuel to boil water, baby feeding utensils, extra milk should she run out and for when the 6 month cut off time arrives?
• Sustainable: Does she have a stable support structure? Are her circumstances likely to change?
• Safe: Does she have clean running water in her house? An indoor flush toilet?

When these 5 points are in place, formula feeding is an option for this mother and baby.

The utmost care must be taken that mothers know how to wash and sterilise their baby feeding equipment and know how to make formula correctly:

• Boiling is the recommended method of sterilizing baby feeding equipment.
• Formula made incorrectly, too weak or too strong, is extremely dangerous for babies.
• Incorrectly made formula leads to malnutrition.
• Mothers need to know when and how to increase the formula volume for their babies.
• Cup feeding is encouraged as this limits the chances of the milk being contaminated
• Brain growth is dependent on good nutrition.
• Mothers are to be encouraged to make one feed at a time,
• Half drunk formula not finished within 2 hours must be thrown away.
• Babies must not be left feeding alone with bottle propped.

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