Medical staff at the Matero Clinic in Lusaka, the capital of Zambia, are making strides in the prevention of mother to child transmission (PMTCT) of HIV by encouraging exclusive breastfeeding for six months.Unlike in Guyana, where HIV-infected mothers are encouraged not to breastfeed their babies, the mothers in Lusaka and other parts of Zambia are encouraged to breastfeed exclusively for about six months and then to stop completely, when they are advised to do so by health care workers. This has resulted in fewer babies testing HIV positive.Clinical Director of the Centre for Infectious Disease Research in Zambia (CIDRZ) Dr Caroline Bolton said the decision to go the route of exclusive breastfeeding was taken some time ago after it was realised that it was too expensive for mothers to feed their babies using formula. It was also discovered that among formula-fed babies there was a high incidence of death from diarrhoeal and other water-borne diseases as access to clean water in some communities is almost non-existent. The rate of HIV infection among these babies was also still high.Physician Dr Mannasseh Phiri, who is also an AIDS activist, explained that it was difficult for the mothers to find money to purchase the coals to boil water to make safe feed for their babies. “They would prefer to keep the coals to cook food,” he said. Both doctors explained too that since in the past it was known that HIV positive mothers could not breastfeed, women who did not want their status known, would give the formula, but still breastfeed in public.”So they would breastfeed and bottle feed the baby. But feeding the baby with cold and sometimes tainted formula would cause the baby’s insides [or mouths] to become sore [bruised], making it easier for the child to be come infected,” Dr Phiri explained. Adherence However, adherence by the HIV positive mothers has been admirable, the doctors said. One example is Lillian Mukuka, an HIV positive widow, who had not heard about HIV prior to 2005. She did not even suspect that she was carrying the virus.Mukuka is the mother of four children. She said her husband died last year, after having suffered several bouts of illness.”My husband died last year when I was pregnant with my daughter. I didn’t even know about HIV. He was very sick,” she said. “I discovered that I was positive when I went to the clinic for ante-natal services. I didn’t know I had the disease.”

Mukuka said she did not know much about HIV and accepted her status. She said she was advised to take Nevirapine to reduce the chances of her child contracting the disease.

“Before my daughter was born I was given Nevirapine and when my daughter was born she was given Septrin,” she said.

She said she was advised by the doctor to exclusively breastfeed her daughter until she was five months and three weeks old.

“It was very difficult for me because she was hungry all the time and she used to cry a lot.

The doctor advised me not to give her any solid food or other liquids, not even water,” she said. “I followed the doctor’s instructions and my daughter has had no problems.”

Mukuka stopped breastfeeding her baby in October on the doctor’s advice. “The problem I had was to buy milk for my child, I did not have any money,” she said, so that doctor gave me a letter to take to Chipata clinic, where they linked me with an organisation called Chipo which gives me milk for Natasha.”

Natasha has accepted solid food, eats a lot more and is less irritable.

“Up to now she has not had any problems, she can sit, she can walk, just like any other baby. Now I am just waiting for her to be tested for HIV when she is one year and six months, to see if the treatment worked,” Mukuka said. “She didn’t have sores in her mouth, and has not been sick since she was born.”

Mukuka says it is important for parents and guardians to ensure they take an HIV test and have their children tested as well.

“HIV is a very serious disease, if you just keep staying at home or keep your children at home, they can die,” she said.

Mukuka is not yet on anti-retroviral treatment because her CD4 count is still high.

Dr Bolton said making breastfeeding safer was an emerging challenge in prevention of mother to child transmission of HIV.

She said a trial was done in Botswana with exclusively breastfed babies and bottle feed babies and it was found that they both had the same mortality rates. “The fight is now to find a safe way to have the mothers breastfeed their babies,” she said.

This new regimen is just one of the groundbreaking activities at the multi-purpose Matero Clinic which caters for some of Lusaka’s poorest people.

The clinic, with a catchment of 103,000 persons, is busy every day. And it will soon join eight other clinics in Lusaka which administer a combined treatment regimen of AZT and Nevirapine to HIV positive mothers in the PMTCT programme.

According to Dr Perry Killman, Medical Head of the Zambia Prenatal Record System (ZEPRAS), this regimen has proven to more effective than Nevirapine alone. He said it has been endorsed by the World Health Organisation (WHO) and was researched in many countries in Africa and South East Asia and has proven to be successful.

No Comments »

A prospective cohort study has found that HIV-positive Kenyan mothers who breastfed their babies had faster declines in CD4 cell count and body mass index than those who formula-fed. However, breastfeeding had no effect on viral load or overall mortality among the mothers after two years.

Most discussion of breastfeeding by HIV-positive mothers focuses on the risk of HIV transmission to the baby. Several studies have now looked at the consequences for the mother in African settings where breastfeeding is common.

The first such study, a randomised clinical trial in Kenya, found an increased risk of mortality for breastfeeding mothers compared to those who formula-fed. However, four subsequent African cohort studies found no such association.

Continue Reading »

1 Comment »

Medical staff at the Matero Clinic in Lusaka, the capital of Zambia, are making strides in the prevention of mother to child transmission (PMTCT) of HIV by encouraging exclusive breastfeeding for six months.

Unlike in Guyana, where HIV-infected mothers are encouraged not to breastfeed their babies, the mothers in Lusaka and other parts of Zambia are encouraged to breastfeed exclusively for about six months and then to stop completely, when they are advised to do so by health care workers. This has resulted in fewer babies testing HIV positive. Continue Reading »

No Comments »

IS BREASTFEEDING STILL THE BEST?

Breastfeeding is the best way to feed an infant in the vast majority of circumstances. The World Health Organisation (WHO) has estimated that 1.5 million infants die each year because they are not breastfed. Breastfeeding saves lives.

The benefits of breastfeeding for infant, mother and community include:

• Breastmilk provides all the nutrients a baby needs for the first 6 months of life, after which it continues to provide a major portion of the infant’s nutrition along with appropriate family foods.
• Breastmilk is easily digested by the baby.
• Breastmilk contains antibodies and other factors which protect the baby against diarrhoea and other infections.
• Breastmilk is clean, safe and cheap.
• Breastfeeding provides a perfect opportunity for building a close bond between mother and baby.
• Breastfeeding has contraceptive benefits for the mother.
• Breastfeeding mothers have a lower risk of breast and ovarian cancer.
• Breastfeeding costs less in terms of health care expenses, as breastfed infants get ill less often.
• Breastfeeding does not damage the environment.

The dilemma posed by the current HIV Pandemic, mother-to-child transmission (MTCT) of HIV and the debate about infant feeding is particularly difficult for the African region. Of the estimated 590,000 infants worldwide who acquired HIV from their mothers in 1998, 90% were born in Africa. The problem of infection through breastmilk, in SubSaharan Africa is of particular concern because the survival and development of children in sub­Saharan Africa to a large extent depends on successful breastfeeding.

WHO studies show that the risk of dying from infectious diseases in the first two months of life is six times greater in infants who are not breastfed than those who are breastfed. In the African environment, the benefits of exclusive breastfeeding often outweigh the risk of not breastfeeding.

Infants who are not breastfed are up to 14 times more likely to die from diarrhoea compared to those who are exclusively breastfed. They are also three times more likely to die from acute respiratory infections. For HIV infected mother living in poor households it is important to consider carefully the risks related to not breastfeeding. Promoting infant formula feeding to prevent HIV infection in such situations might increase infant malnutrition, morbidity and mortality.

Mother-To-Child Transmission (MTCT) of HIV

Research shows that about 30% of children born to women who are infected with HIV in Sub-Saharan Africa become infected with HIV themselves.

Transmission of HIV may occur during pregnancy, delivery or postnatally through breastfeeding. A baby born without the virus has a 1 in 7 risk of getting the virus through breastfeeding. However, many babies will not get HIV at all from their mothers. About 6 out of 10 babies born to infected mothers will never get the infection from their mothers even if they are breastfed.

Recent research indicates that use of antiretroviral drugs in the perinatal period could reduce paediatric HIV infection substantially, regardless of the mode of feeding. Even in mothers who breastfeed, the reduction in HIV transmission associated with retroviral treatment is around 38%.

The factors that add to complexity of the problem of MTCT are that, very often, pregnant mothers do not know their HIV status. At birth it is also not possible to test the HIV status of the baby, as the child of an infected mother may have maternal antibodies to HIV for about 15 months and not have the virus itself.

Factors which increase the risk of MTCT:

• Recent infection with HIV. A woman who has been infected with HIV during pregnancy or while breastfeeding is more likely to transmit the virus to her infant.
• AIDS. A woman who develops AIDS is more likely to transmit HIV infection to her infant.
• Infection with Sexually Transmitted Diseases (STD’s) maternal STD infection during pregnancy may increase the risk of HIV transmission to the unborn baby.
• Mothers nutritional status. A good nutritional status is important as it boosts the mother’s immune system and lessens progression of HIV.
• Breast Conditions. Cracked or bleeding nipples, mastitis or breast abscess, may increase the risk of HIV transmission through breastfeeding.
• Duration of breastfeeding. The longer the duration of breastfeeding, the longer the infant is exposed to the risk of HIV infection, especially where breastfeeding is mixed with other foods/drinks.

The WHO/UNAIDS/UNICEF Policy (1998) States:

“When children born to women living with HIV can be ensured uninterrupted access to nutritionally adequate breastmilk substitute that are safety prepared and fed to them, they are at less risk illness and death if not breastfed. However, when these conditions are not fulfilled, in particular in an environment where infectious diseases and malnutrition are the primary cause of death during infantcy, artificial feeding substantially increases children risk of death. (UN Policy statement 1997 and 1998 Guidelines, page 10)

Counselling

Counselling is a dialogue, on a one to one basis, which aims to enable a mother to make decisions and find realistic ways of coping with her HIV status. A counselor’s role is to listen to a mother’s concerns, ask questions, and provide factual information and support. Counselling should be conducted in a quiet and private environment and must be confidential.

Counselling Mothers On the Options

1. Breastfeeding should be the preferred infant feeding choice for women who are uninfected with HIV/AIDS and for those whose status is unknown. Exclusive breastfeeding to six months is recommended, followed by the introduction of appropriate locally available complementary food, with continued breastfeeding up to two years and beyond. Education to mothers should include protection against HIV infection. They should be protected from negative spillover of artificial feeding.

2. The counselling messages to HIV infected pregnant women after voluntary counselling and testing for HIV should include the advantages and risks of the various infant feeding options, keeping in mind the mother’s social and economic situation. On weighing the risks the mother, with the support of her family, should decide which feeding option she will choose. The health worker should then support her choice of infant feeding method. If the mother chooses not to breastfeed, she should be shown how to use the option correctly and how to provide the extra care necessary for a child who is not breastfed.

What are the options

1 ) Breastfeeding

• Exclusive Breastfeeding
• Early Cessation of Breastfeeding
• Expressed and Heat Treated Breastmilk

2) Breastmilk Substitutes

• Commercial Infant Formula
• Home prepared formula from
• Cow’s or Goat’s milk
• Home prepared formula from dried milk powder or evaporated milk

Feeding Options Birth to Six months

1) Breastfeeding

• Exclusive Breastfeeding from birth to six months
  
• Studies have shown that strict exclusive breastfeeding (i.e. breastmilk only, no other fluids or solids), carries a much lower risk of HIV transmission than mixed feeding and a similar risk to no breastfeeding. Therefore, if an HIV positive mother decides to breastfeed, she should be advised to exclusively breastfeed for the first 6 months. Adding any other food such as formula or cereals can damage the infant’s gut lining and allow for easier transmission of the HIV virus. After 6 months she can either decide to stop breastfeeding (early cessation), or heat her milk and give other milk and food.
• The mother should:
• Breastfeed on demand, day and night
• Ensure correct positioning and attachment to prevent sore or cracked nipples, engorgement and mastitis
• Give no bottles, teats or dummies
• Treat vaginal or oral candida (thrush) in the mother
• Treat oral candida in the baby
• Early cessation of breastfeeding
  
• Early cessation of breastfeeding means stopping breastfeeding early. This will reduce the risk of transmission by reducing the length of time that an infant is exposed to HIV through breastfeeding. The baby gets the protection of breastfeeding for the early months when the risks of artificial feeding in environments with poor hygienic conditions are greatest. There has been a lot of discussion about the optimum time for early cessation. Some experts advocated for stopping earlier than 6 months, but it has been seen that stopping breastfeeding before 6 months in conditions of poverty carries more risk of morbidity and mortality for the infant and is also more difficult to implement. Therefore, exclusive breastfeeding for 6 months is advisable. By this time the baby is stronger, will be ready for solids, and better able to cope with replacement feeding. Early cessation involves abrupt weaning from the breast, otherwise the baby will be exposed to the risks involved with mixed feeding. This should be done safely. The baby should then be introduced to other milk and food and should be fed frequently, approximately 5 times per day.
• Expressed Heat Treated Breastmilk
  
• The HIV virus in breastmilk can be killed by heat-treating the expressed milk. The “Pretoria Pasteurization” method was devised by the Medical Research Council of South Africa and only requires a 1litre aluminium pot and a clean glass peanut butter jar. The pot is half filled with water, which is then boiled and removed from the heat source. Breastmilk is expressed into the jar (50-150 mls) and allowed to stand in the water in the pot for 20 minutes, after which it is pasteurized. Tests have shown that all the HIV in the milk is killed when the milk is heated to 56-63°C for about 20 minutes. The heat-treated breastmilk should then be fed to the baby using a cup. Expressed breastmilk can stay fresh at room temperature in a covered container for up to 8 hours or in a refrigerator for up to 72 hours.

If a mother chooses any form of breastfeeding, support and counsel her to:

• Avoid re-infection with HIV/AIDS use condoms.
• Take good care of her breasts and avoid breast engorgement and sore or cracked nipples by proper attachment and positioning of the baby, as well as feeding the baby on demand.
• Seek medical attention early if nipples develop sores or cracks.
• Avoid mixed feeding.
• Stop breastfeeding if she shows symptoms of having clinical AIDS.

2. Breastmilk Substitutes

From birth to 6 months, milk in some form is essential for an infant. If not breastfed, an infant needs about 150ml of milk per kg of body weight a day. For example, an infant weighing 5 kg needs about 750 ml per day, which can be given in five 150ml feeds a day.

• Commercial Infant Formula (Exclusive formula feeding)
  
• Commercial infant formula, based on modified cow’s milk or soy beans, is closest in nutrient composition to breastmilk and is usually fortified with micronutrients, including iron. The brand does not matter, as long as the milk chosen is specific to the age of the child.
• Important Information for Formula Feeding:
  
• The instructions on the tin for mixing formula should be followed exactly to ensure that it is not too concentrated or over-diluted. This may be a problem for the mother who can not read or if the instructions are in a language she does not understand.
• An average of 40½ kg tins are needed to feed an infant for the first 6 months.
• Health workers should adhere to the regulations of the International Code of Marketing of Breastmilk Substitutes, e.g. no distribution of free or low cost infant formula in hospitals and clinics.
• Health workers should show the mother/father/caregiver how to prepare the formula for the baby.
• There should be no group demonstrations to mothers on how to prepare formula.
• Washing hands before preparing and handling formula is essential to prevent the risk of infections.
• Cups and spoons should be used in the preparation, as they are easy to wash or disinfect. A disinfectant, (such as Sodium Hypochlorite) of 5% strength is an effective way of disinfecting utensils for infant feeding.
• Use a cup for feeding the baby.
• The baby should be held close during feeding to foster bonding.
• This option requires a lot of support to be done safely to avoid increased rates of infection and there is need for close monitoring for adequate growth.
• Safe formula feeding is expensive.
• Follow-up milks are not suitable for infants under the age of 6 months as they are less modified than infant formula. These milks may not be necessary for older infants who can feed on unmodified cow’s milk from six months onwards.
• Home Prepared Formula
  
• With this method, micronutrient supplements are necessary as animal milks contain insufficient iron, zinc and may lack vitamin A and folic acid.
• Modified Cow or Goats Milk

These animal milks have more protein and a greater concentration of Sodium, Calcium and other salts than breastmilk. They need to be modified to suit a baby. Modification involves dilution with boiled water to reduce concentration. Dilution reduces the energy concentration of the milk, so sugar must be added.

To prepare 150mls of home prepared formula you need:

• 100ml cow’s or goat’s milk (Full cream)
• 50ml boiled water
• 10g (2 spoons) of sugar Iron and multivitamins

Measure the ingredients using available household utensils. Mix the milk and boiled water and bring to the boil. Add sugar and mix well. Modified animal milk should be prepared at each feed, or used within 8 hours if stored in a refrigerated. When ready to feed, re-boil the modified stored milk enough for one feed and cool immediately to body temperature by standing the container in cold water. Discard warmed left over milk after each feed. Give vitamin and mineral supplements according to age group. Use cup for feeding.

Instructions for washing of hands and sterilizing of utensils are the same as for commercial formula feeding.

• Dried milk powder and evaporated milk

The full cream variety of dried milk powder or evaporated milk should be used. Full cream milk powder is fresh milk from which all the water has been removed, leaving a dry milk powder. In the process, some vitamins, e.g. vitamin C and B complex are lost. Nutrients such as proteins, fats, carbohydrates, vitamins A and D and minerals are retained.

One first needs to make up the milk as directed on the tin and then add extra water and sugar as with the above recipe for home-prepared formula.

The baby requires 12kg full cream milk powder for the first 6 months. After 6 months onwards, the baby can be given full strength milk, after reconstitution as per manufacturer’s instructions. Amounts in millilitres and grams should be translated into locally available household measures. Instructions for washing of hand and cleaning and sterilizing of utensils are the same as for commercial formula feeding.

• Unsuitable breastmilk substitutes for infants less than six months:
  
• Skimmed milk
• Sweetened condensed milk
• Fruit Juices or sugar water
• Dilute cereals or gruel

Instructions for feeding With a Cup

• Hold the infant sitting upright or semi upright on your lap.
• Hold the cup of milk to the infant’s lips.
• Tip the cup so that the milk just reaches the infant’s lips. The cup rests lightly on the infant’s lower lip and the edges of the cup touch the outer part of the infant’s upper lip.
• The infant becomes alert and opens his/her mouth and eyes. A low birth weight infant will start to take the milk into his/her mouth with the tongue. A full term or older infant sucks the milk, spilling some.
• DO NOT POUR the milk into the infant’s mouth. Just hold the cup to the infant’s lips and let him or her take it.
• When the infant has had enough, he/she will close his/her mouth and will not take any more. If the infant has not taken the calculated amount, he/she may take more next time, or the mother needs to feed more often.
• Measure the infant’s intake over 24 hours, not just at each feed.

Feeding Options Six months to Two Years

After six months breastmilk normally continues to be an important part of the child’s diet, providing:

• 50% of nutritional requirements between age 6 to 12 months
• 34% of nutritional requirements between age 12 to 24 months

After six months replacement feeding in a non-breastfed child should consist of:

• a suitable breastmilk substitute,(as already described),
• complementary foods made from appropriately prepared and locally available family foods, given at least three times per day.

Feeding method:

• Encourage cup feeding cups are safer than bottles as they are easier to clean than bottles.
• Infant should be held close when feeding. Non-breastfed infants lack the close mother-baby bonding afforded by breastfeeding.

Help the Mother to reach a decision

The following questions will help to clarify the information given and to prepare the client for making a decision:

• Let the mother explain to the health worker what she has understood so far from the discussion.
• Does she think there are any other options which haven’t been mentioned so far?
• Which option does she think would be best for her? She may need extra time to think about this or to discuss the decision with others, but the decision must be made by the mother and NOT by the Health Worker.

Once the mother and the family have decided, the health worker should help her to carry it out. If she wants to change her mind about the infant feeding option at any time the health worker should be prepared to counsel again about other alternatives.

Health Workers Responsibilities

• Parents need support with whatever feeding options they choose. Even exclusive breastfeeding for 6 months needs much support in Africa.
• The Ten Steps to Successful Breastfeeding should be fully complied with in all maternity facilities.
• The mother who chooses to give replacement feeding should be advised on the utensils which are required for preparation of the option she chooses, e.g. suitable container for boiling water and milk; cup for feeding the baby; utensil of known volume for measuring quantities of milk and water.
• The health worker should demonstrate how to prepare the most commonly selected options: how to measure the powder and water; how to calculate the amount needed each month; cleaning and sterilizing of utensils and storage of milk and utensils.
• Help the mother to understand about the costs involved: substitutes; utensils; fuel; time; increased need for health care; cost of contraception.
• Always give advice on replacement feeding in a separate area so that other mothers cannot observe the process.
• Follow-up of the mother is very important to ensure that she is using the option properly.

Important Points to Remember

• Breastfeeding is still the best method of feeding for the majority of infants. For women who are uninfected with HIV and for those whose status is unknown, breastfeeding should be the preferred infant feeding choice.
• The HIV infected mother should be counselled on the risks and advantages of the various options, keeping in mind her social and economic situation, and allowed to decide herself which option she will choose.
• Breastfeeding mothers should practice safe sex to avoid infection or re-infection with HIV
• Exclusive breastfeeding for the first six months or exclusive replacement feeding is better than mixed feeding.
• Mothers who choose to give replacement feeding should be aware of the importance of hygienic preparation and giving of feeds and the proper cleaning of cups and utensils.
• Mothers who give replacement feeding should be aware of the financial and other costs involved in using that option.
• Infants and young children who are not breastfeeding need extra care, love and close contact with caretakers
• In poor socio-economic conditions not breastfeeding, for HIV positive mothers, may have higher mortality risks for the infant than exclusive breastfeeding.

_________________________________________________

IBFAN Africa and IBFAN FAN coordinate IBFAN concerns and build the capacity of national groups in the Africa region.

IBFAN AFRICA - PO Box 781, Mbabane, SWAZILAND

Canadian International Development Agency

Published and distributed by IBFAN Africa, May 2002

Text and Editing: Pauline Kisanga & Marie Hollisey

Coordination: Nonkululeko Mdluli

ISBN: 0-7978-2049-3

Extracts may be freely produced by non-profit making organisations and governments with acknowledgement. Funding for this publication was provided by Canadian International Development Agency.

No Comments »

IS BREASTFEEDING STILL THE BEST?

Breastfeeding is the best way to feed an infant in the vast majority of circumstances. The World Health Organisation (WHO) has estimated that 1.5 million infants die each year because they are not breastfed. Breastfeeding saves lives.

The benefits of breastfeeding for infant, mother and community include:

• Breastmilk provides all the nutrients a baby needs for the first 6 months of life, after which it continues to provide a major portion of the infant’s nutrition along with appropriate family foods.
• Breastmilk is easily digested by the baby.
• Breastmilk contains antibodies and other factors which protect the baby against diarrhoea and other infections.
• Breastmilk is clean, safe and cheap.
• Breastfeeding provides a perfect opportunity for building a close bond between mother and baby.
• Breastfeeding has contraceptive benefits for the mother.
• Breastfeeding mothers have a lower risk of breast and ovarian cancer.
• Breastfeeding costs less in terms of health care expenses, as breastfed infants get ill less often.
• Breastfeeding does not damage the environment.

The dilemma posed by the current HIV Pandemic, mother-to-child transmission (MTCT) of HIV and the debate about infant feeding is particularly difficult for the African region. Of the estimated 590,000 infants worldwide who acquired HIV from their mothers in 1998, 90% were born in Africa. The problem of infection through breastmilk, in SubSaharan Africa is of particular concern because the survival and development of children in sub­Saharan Africa to a large extent depends on successful breastfeeding.

WHO studies show that the risk of dying from infectious diseases in the first two months of life is six times greater in infants who are not breastfed than those who are breastfed. In the African environment, the benefits of exclusive breastfeeding often outweigh the risk of not breastfeeding.

Infants who are not breastfed are up to 14 times more likely to die from diarrhoea compared to those who are exclusively breastfed. They are also three times more likely to die from acute respiratory infections. For HIV infected mother living in poor households it is important to consider carefully the risks related to not breastfeeding. Promoting infant formula feeding to prevent HIV infection in such situations might increase infant malnutrition, morbidity and mortality.

Mother-To-Child Transmission (MTCT) of HIV

Research shows that about 30% of children born to women who are infected with HIV in Sub-Saharan Africa become infected with HIV themselves.

Transmission of HIV may occur during pregnancy, delivery or postnatally through breastfeeding. A baby born without the virus has a 1 in 7 risk of getting the virus through breastfeeding. However, many babies will not get HIV at all from their mothers. About 6 out of 10 babies born to infected mothers will never get the infection from their mothers even if they are breastfed.

Recent research indicates that use of antiretroviral drugs in the perinatal period could reduce paediatric HIV infection substantially, regardless of the mode of feeding. Even in mothers who breastfeed, the reduction in HIV transmission associated with retroviral treatment is around 38%.

The factors that add to complexity of the problem of MTCT are that, very often, pregnant mothers do not know their HIV status. At birth it is also not possible to test the HIV status of the baby, as the child of an infected mother may have maternal antibodies to HIV for about 15 months and not have the virus itself.

Factors which increase the risk of MTCT:

• Recent infection with HIV. A woman who has been infected with HIV during pregnancy or while breastfeeding is more likely to transmit the virus to her infant.
• AIDS. A woman who develops AIDS is more likely to transmit HIV infection to her infant.
• Infection with Sexually Transmitted Diseases (STD’s) maternal STD infection during pregnancy may increase the risk of HIV transmission to the unborn baby.
• Mothers nutritional status. A good nutritional status is important as it boosts the mother’s immune system and lessens progression of HIV.
• Breast Conditions. Cracked or bleeding nipples, mastitis or breast abscess, may increase the risk of HIV transmission through breastfeeding.
• Duration of breastfeeding. The longer the duration of breastfeeding, the longer the infant is exposed to the risk of HIV infection, especially where breastfeeding is mixed with other foods/drinks.

The WHO/UNAIDS/UNICEF Policy (1998) States:

“When children born to women living with HIV can be ensured uninterrupted access to nutritionally adequate breastmilk substitute that are safety prepared and fed to them, they are at less risk illness and death if not breastfed. However, when these conditions are not fulfilled, in particular in an environment where infectious diseases and malnutrition are the primary cause of death during infantcy, artificial feeding substantially increases children risk of death. (UN Policy statement 1997 and 1998 Guidelines, page 10)

Counselling

Counselling is a dialogue, on a one to one basis, which aims to enable a mother to make decisions and find realistic ways of coping with her HIV status. A counselor’s role is to listen to a mother’s concerns, ask questions, and provide factual information and support. Counselling should be conducted in a quiet and private environment and must be confidential.

Counselling Mothers On the Options

1. Breastfeeding should be the preferred infant feeding choice for women who are uninfected with HIV/AIDS and for those whose status is unknown. Exclusive breastfeeding to six months is recommended, followed by the introduction of appropriate locally available complementary food, with continued breastfeeding up to two years and beyond. Education to mothers should include protection against HIV infection. They should be protected from negative spillover of artificial feeding.

2. The counselling messages to HIV infected pregnant women after voluntary counselling and testing for HIV should include the advantages and risks of the various infant feeding options, keeping in mind the mother’s social and economic situation. On weighing the risks the mother, with the support of her family, should decide which feeding option she will choose. The health worker should then support her choice of infant feeding method. If the mother chooses not to breastfeed, she should be shown how to use the option correctly and how to provide the extra care necessary for a child who is not breastfed.

What are the options

1 ) Breastfeeding

• Exclusive Breastfeeding
• Early Cessation of Breastfeeding
• Expressed and Heat Treated Breastmilk

2) Breastmilk Substitutes

• Commercial Infant Formula
• Home prepared formula from
• Cow’s or Goat’s milk
• Home prepared formula from dried milk powder or evaporated milk

Feeding Options Birth to Six months

1) Breastfeeding

• Exclusive Breastfeeding from birth to six months
  
• Studies have shown that strict exclusive breastfeeding (i.e. breastmilk only, no other fluids or solids), carries a much lower risk of HIV transmission than mixed feeding and a similar risk to no breastfeeding. Therefore, if an HIV positive mother decides to breastfeed, she should be advised to exclusively breastfeed for the first 6 months. Adding any other food such as formula or cereals can damage the infant’s gut lining and allow for easier transmission of the HIV virus. After 6 months she can either decide to stop breastfeeding (early cessation), or heat her milk and give other milk and food.
• The mother should:
• Breastfeed on demand, day and night
• Ensure correct positioning and attachment to prevent sore or cracked nipples, engorgement and mastitis
• Give no bottles, teats or dummies
• Treat vaginal or oral candida (thrush) in the mother
• Treat oral candida in the baby
• Early cessation of breastfeeding
  
• Early cessation of breastfeeding means stopping breastfeeding early. This will reduce the risk of transmission by reducing the length of time that an infant is exposed to HIV through breastfeeding. The baby gets the protection of breastfeeding for the early months when the risks of artificial feeding in environments with poor hygienic conditions are greatest. There has been a lot of discussion about the optimum time for early cessation. Some experts advocated for stopping earlier than 6 months, but it has been seen that stopping breastfeeding before 6 months in conditions of poverty carries more risk of morbidity and mortality for the infant and is also more difficult to implement. Therefore, exclusive breastfeeding for 6 months is advisable. By this time the baby is stronger, will be ready for solids, and better able to cope with replacement feeding. Early cessation involves abrupt weaning from the breast, otherwise the baby will be exposed to the risks involved with mixed feeding. This should be done safely. The baby should then be introduced to other milk and food and should be fed frequently, approximately 5 times per day.
• Expressed Heat Treated Breastmilk
  
• The HIV virus in breastmilk can be killed by heat-treating the expressed milk. The “Pretoria Pasteurization” method was devised by the Medical Research Council of South Africa and only requires a 1litre aluminium pot and a clean glass peanut butter jar. The pot is half filled with water, which is then boiled and removed from the heat source. Breastmilk is expressed into the jar (50-150 mls) and allowed to stand in the water in the pot for 20 minutes, after which it is pasteurized. Tests have shown that all the HIV in the milk is killed when the milk is heated to 56-63°C for about 20 minutes. The heat-treated breastmilk should then be fed to the baby using a cup. Expressed breastmilk can stay fresh at room temperature in a covered container for up to 8 hours or in a refrigerator for up to 72 hours.

If a mother chooses any form of breastfeeding, support and counsel her to:

• Avoid re-infection with HIV/AIDS use condoms.
• Take good care of her breasts and avoid breast engorgement and sore or cracked nipples by proper attachment and positioning of the baby, as well as feeding the baby on demand.
• Seek medical attention early if nipples develop sores or cracks.
• Avoid mixed feeding.
• Stop breastfeeding if she shows symptoms of having clinical AIDS.

2. Breastmilk Substitutes

From birth to 6 months, milk in some form is essential for an infant. If not breastfed, an infant needs about 150ml of milk per kg of body weight a day. For example, an infant weighing 5 kg needs about 750 ml per day, which can be given in five 150ml feeds a day.

• Commercial Infant Formula (Exclusive formula feeding)
  
• Commercial infant formula, based on modified cow’s milk or soy beans, is closest in nutrient composition to breastmilk and is usually fortified with micronutrients, including iron. The brand does not matter, as long as the milk chosen is specific to the age of the child.
• Important Information for Formula Feeding:
  
• The instructions on the tin for mixing formula should be followed exactly to ensure that it is not too concentrated or over-diluted. This may be a problem for the mother who can not read or if the instructions are in a language she does not understand.
• An average of 40½ kg tins are needed to feed an infant for the first 6 months.
• Health workers should adhere to the regulations of the International Code of Marketing of Breastmilk Substitutes, e.g. no distribution of free or low cost infant formula in hospitals and clinics.
• Health workers should show the mother/father/caregiver how to prepare the formula for the baby.
• There should be no group demonstrations to mothers on how to prepare formula.
• Washing hands before preparing and handling formula is essential to prevent the risk of infections.
• Cups and spoons should be used in the preparation, as they are easy to wash or disinfect. A disinfectant, (such as Sodium Hypochlorite) of 5% strength is an effective way of disinfecting utensils for infant feeding.
• Use a cup for feeding the baby.
• The baby should be held close during feeding to foster bonding.
• This option requires a lot of support to be done safely to avoid increased rates of infection and there is need for close monitoring for adequate growth.
• Safe formula feeding is expensive.
• Follow-up milks are not suitable for infants under the age of 6 months as they are less modified than infant formula. These milks may not be necessary for older infants who can feed on unmodified cow’s milk from six months onwards.
• Home Prepared Formula
  
• With this method, micronutrient supplements are necessary as animal milks contain insufficient iron, zinc and may lack vitamin A and folic acid.
• Modified Cow or Goats Milk

These animal milks have more protein and a greater concentration of Sodium, Calcium and other salts than breastmilk. They need to be modified to suit a baby. Modification involves dilution with boiled water to reduce concentration. Dilution reduces the energy concentration of the milk, so sugar must be added.

To prepare 150mls of home prepared formula you need:

• 100ml cow’s or goat’s milk (Full cream)
• 50ml boiled water
• 10g (2 spoons) of sugar Iron and multivitamins

Measure the ingredients using available household utensils. Mix the milk and boiled water and bring to the boil. Add sugar and mix well. Modified animal milk should be prepared at each feed, or used within 8 hours if stored in a refrigerated. When ready to feed, re-boil the modified stored milk enough for one feed and cool immediately to body temperature by standing the container in cold water. Discard warmed left over milk after each feed. Give vitamin and mineral supplements according to age group. Use cup for feeding.

Instructions for washing of hands and sterilizing of utensils are the same as for commercial formula feeding.

• Dried milk powder and evaporated milk

The full cream variety of dried milk powder or evaporated milk should be used. Full cream milk powder is fresh milk from which all the water has been removed, leaving a dry milk powder. In the process, some vitamins, e.g. vitamin C and B complex are lost. Nutrients such as proteins, fats, carbohydrates, vitamins A and D and minerals are retained.

One first needs to make up the milk as directed on the tin and then add extra water and sugar as with the above recipe for home-prepared formula.

The baby requires 12kg full cream milk powder for the first 6 months. After 6 months onwards, the baby can be given full strength milk, after reconstitution as per manufacturer’s instructions. Amounts in millilitres and grams should be translated into locally available household measures. Instructions for washing of hand and cleaning and sterilizing of utensils are the same as for commercial formula feeding.

• Unsuitable breastmilk substitutes for infants less than six months:
  
• Skimmed milk
• Sweetened condensed milk
• Fruit Juices or sugar water
• Dilute cereals or gruel

Instructions for feeding With a Cup

• Hold the infant sitting upright or semi upright on your lap.
• Hold the cup of milk to the infant’s lips.
• Tip the cup so that the milk just reaches the infant’s lips. The cup rests lightly on the infant’s lower lip and the edges of the cup touch the outer part of the infant’s upper lip.
• The infant becomes alert and opens his/her mouth and eyes. A low birth weight infant will start to take the milk into his/her mouth with the tongue. A full term or older infant sucks the milk, spilling some.
• DO NOT POUR the milk into the infant’s mouth. Just hold the cup to the infant’s lips and let him or her take it.
• When the infant has had enough, he/she will close his/her mouth and will not take any more. If the infant has not taken the calculated amount, he/she may take more next time, or the mother needs to feed more often.
• Measure the infant’s intake over 24 hours, not just at each feed.

Feeding Options Six months to Two Years

After six months breastmilk normally continues to be an important part of the child’s diet, providing:

• 50% of nutritional requirements between age 6 to 12 months
• 34% of nutritional requirements between age 12 to 24 months

After six months replacement feeding in a non-breastfed child should consist of:

• a suitable breastmilk substitute,(as already described),
• complementary foods made from appropriately prepared and locally available family foods, given at least three times per day.

Feeding method:

• Encourage cup feeding cups are safer than bottles as they are easier to clean than bottles.
• Infant should be held close when feeding. Non-breastfed infants lack the close mother-baby bonding afforded by breastfeeding.

Help the Mother to reach a decision

The following questions will help to clarify the information given and to prepare the client for making a decision:

• Let the mother explain to the health worker what she has understood so far from the discussion.
• Does she think there are any other options which haven’t been mentioned so far?
• Which option does she think would be best for her? She may need extra time to think about this or to discuss the decision with others, but the decision must be made by the mother and NOT by the Health Worker.

Once the mother and the family have decided, the health worker should help her to carry it out. If she wants to change her mind about the infant feeding option at any time the health worker should be prepared to counsel again about other alternatives.

Health Workers Responsibilities

• Parents need support with whatever feeding options they choose. Even exclusive breastfeeding for 6 months needs much support in Africa.
• The Ten Steps to Successful Breastfeeding should be fully complied with in all maternity facilities.
• The mother who chooses to give replacement feeding should be advised on the utensils which are required for preparation of the option she chooses, e.g. suitable container for boiling water and milk; cup for feeding the baby; utensil of known volume for measuring quantities of milk and water.
• The health worker should demonstrate how to prepare the most commonly selected options: how to measure the powder and water; how to calculate the amount needed each month; cleaning and sterilizing of utensils and storage of milk and utensils.
• Help the mother to understand about the costs involved: substitutes; utensils; fuel; time; increased need for health care; cost of contraception.
• Always give advice on replacement feeding in a separate area so that other mothers cannot observe the process.
• Follow-up of the mother is very important to ensure that she is using the option properly.

Important Points to Remember

• Breastfeeding is still the best method of feeding for the majority of infants. For women who are uninfected with HIV and for those whose status is unknown, breastfeeding should be the preferred infant feeding choice.
• The HIV infected mother should be counselled on the risks and advantages of the various options, keeping in mind her social and economic situation, and allowed to decide herself which option she will choose.
• Breastfeeding mothers should practice safe sex to avoid infection or re-infection with HIV
• Exclusive breastfeeding for the first six months or exclusive replacement feeding is better than mixed feeding.
• Mothers who choose to give replacement feeding should be aware of the importance of hygienic preparation and giving of feeds and the proper cleaning of cups and utensils.
• Mothers who give replacement feeding should be aware of the financial and other costs involved in using that option.
• Infants and young children who are not breastfeeding need extra care, love and close contact with caretakers
• In poor socio-economic conditions not breastfeeding, for HIV positive mothers, may have higher mortality risks for the infant than exclusive breastfeeding.

_________________________________________________

IBFAN Africa and IBFAN FAN coordinate IBFAN concerns and build the capacity of national groups in the Africa region.

IBFAN AFRICA - PO Box 781, Mbabane, SWAZILAND

Canadian International Development Agency

Published and distributed by IBFAN Africa, May 2002

Text and Editing: Pauline Kisanga & Marie Hollisey

Coordination: Nonkululeko Mdluli

ISBN: 0-7978-2049-3

Extracts may be freely produced by non-profit making organisations and governments with acknowledgement. Funding for this publication was provided by Canadian International Development Agency.

No Comments »

No Comments »

In 1981 representatives of the worlds governments met at the World Health Assembly and adopted Resolution WHA 34.22. This included the International Code of Marketing of Breastmilk Substitutes as a “minimum requirement” to be implemented “in its entirety” to protect healthy practices in respect of infant and young child feeding. Since 1982 additional Resolutions clarifying and amplifying the International Code have been adopted every two years. Under Article 11.4 of the International Code NGOs are assigned the role of monitoring and reporting the activities of the manufacturers and distributors of baby foods, bottles and teats.

Continue Reading »

No Comments »

Article 1: Aim of the Code “The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.”

Continue Reading »

No Comments »

Here you have the full version of the  International Code of Marketing of Breastmilk Substitutes

Continue Reading »

Comments Off

This is an introduction to the provisions of the International Code and Resolutions.

The International Code of Marketing of Breastmilk Substitutes was adopted by the World Health Assembly in 1981 as a “minimum requirement” to protect infant health and is to be implemented “in its entirety.” This document introduces the key provisions of the International Code and subsequent, relevant Resolutions of the World Health Assembly.

Continue Reading »

No Comments »