HIV & BREASTFEEDING

How a mother should feed her baby can be one of the most difficult decisions of all.

Every HIV positive mother has the right to:

• all the relevant information about all the feeding options
• make an informed decision according to what she believes to be in the best interest of herself and her new baby.

She also needs on-going support and encouragement from friends, family and health care workers around her – regardless of the choices she makes.

It is well established that breastfeeding is one of the most effective strategies to reduce infant mortality.

According to Jones (2003), “Approximately 1.3 million child deaths per year (13% of deaths of children aged less than 5 years) could be prevented if universal coverage of exclusive breastfeeding was increased to 90% among infants aged less than 6 months”.

Further to this, recent statistics in South Africa put diarrhoea and pneumonia as the third and fourth highest cause of death for under 5’s behind HIV/AIDS and neonatal causes. These causes of deaths are associated very strongly with poor feeding choices and simply not breastfeeding.

Due to these findings and extensive research evaluating the risks of not breastfeeding,  infant feeding policies advise that mothers who are HIV positive should exclusively breastfeed unless formula feeding is acceptable, feasible, affordable, sustainable and safe (AFASS).

There are three crucial breakthroughs in understanding how to prevent postnatal HIV transmission that now confirm that it is possible to reduce postnatal HIV  transmission to ~1%.

These effective interventions include:

1. lactation counselling and support
2. use of triple antiretroviral drug regimens for women that are either continued life-long as therapy or continued through breastfeeding as prophylaxis
3. extended regimens of antiretroviral prophylaxis to the infant.

Due to revised infant feeding recommendations and improved Prevention of Mother to Child Transmission programmes (PMTCT) in South Africa, breastfeeding for HIV positive mothers has been made safer.

Below gives the ideal model that should be followed in order to reduce HIV transmission and prevent infant mortality.

What Are Safe Feeding Options In The Face Of HIV?

1. 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 recommended for the first six months.

Exclusive breastfeeding is in fact the healthiest way to feed any baby, irrespective of his mother’s HIV status.

During her pregnancy an HIV positive mother should be counselled and given advice on how she will feed her baby thereby enabling her to make an informed decision.

If a mother is on life-long Anti-retroviral (ARV) and she chooses to breastfeed, her baby will receive a medicine called Nevripine or AZT for 6 weeks or longer. This will reduce the risk of HIV transmission.

It is important that all mothers, regardless of HIV status, ensure that they know how to latch their baby onto the breast correctly and that they feed on demand. This will help to prevent cracked nipples, mastitis and abscesses and also therefore minimize the risk of HIV transmission.

It is crucial that whilst you are breastfeeding you continue to take your daily ARV’s as prescribed by your doctor and don’t skip a dose. It is also very important that you practice safe sex and visit your clinic frequently to check your viral load and CD4 count.

2. Pasteurised Breastmilk

Premature infants are at a higher risk than full-term babies of HIV transmission due to their premature immune systems and more permeable gut. For these reasons, the mother’s own pasteurised breast milk is a highly successful feeding option and is used in many Neonatal Intensive Care Units in South Africa, including Groote Schuur, Tygerberg and Kalafong Hospitals.

Pasteurising the breastmilk eliminates all HIV in the breastmilk while retaining nutritional and antimicrobial properties. 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 the next best option to use during the vulnerable period.
(See page on Starting a Milk Bank or Need Donor Milk?)

Heat treating (pasteurising) breastmilk can also be an option if HIV has been poorly controlled and the mother’s viral load is high or if ARV’s have not been initiated yet.

3. Formula Feeding

HIV Positive mothers who decide not to breastfeed their infants (after appropriate counselling and education) should understand that formula in South Africa is not routinely provided as part of the Prevention of Mother to Child Transmissions (PMTCT) programme. When replacement feeding is safe, can be prepared correctly and stored appropriately mothers can formula feed.

Mothers should be able to provide adequate formula for their infants as a replacement feed when specific conditions are met, these conditions are outlined below:

Conditions for safe replacement feeding

1. Safe water and sanitation are assured at the household level and in the community, and
2. The mother or caregiver can reliably provide sufficient infant formula to support normal growth and development of the infant, and
3. The mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhoea and malnutrition, and
4. The mother or caregiver can, in the first 6 months, exclusively give infant formula, and
5. The family is supportive of this practice, and
6. The mother or caregiver can access health care that offers comprehensive child health services.

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:

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

For more information about how to prepare formula please read the following information on the World Health Organisation’s website:

How to prepare formula for bottle-feeding at home.

How to prepare formula for cup-feeding at home.

Safe,  preparation  storage and handling of powdered infant formula guidelines – at home & in a professional care setting.

More information about preparing formula:

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/making-up-infant-formula.aspx

Information on how to clean and sterilise your bottles:

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/sterilising-bottles.aspx

Principles of Safe Infant Feeding:

• Health care personnel, lay counsellors, and community caregivers should receive standardized training on infant feeding, counselling, and HIV.
• Trained health care personnel should provide high quality, unambiguous, and unbiased information about risks of HIV transmission through breastfeeding, ART prophylaxis to reduce this risk, and risks of replacement feeding.
• Counselling on infant feeding must commence after the first post-test counselling session in pregnancy.
• Infant feeding should be discussed with women at every antenatal visit.