With one third of mother-to-child transmission of HIV (MTCT) occurring through breast-feeding, advice not to breast-feed appears sensible, and is standard practice in well-resourced countries.  However in poorly resourced environments breast-feeding offers substantial advantages to all infants in protecting against infectious diseases such as gastrointestinal infection, meningitis, sepsis and bronchiolitis. 

This advantage has to be balanced against the risk of MTCT. Studies to date have not identified improved survival of infants fed on 'formula' alone, even where this, the safest breast milk substitute (BMS), has been provided free.

There is evidence that exclusive breast-feeding (EBF) for at least 3 months after birth (when the baby is at most risk) has significantly lower rates of MTCT than mixed feeding, where fluids and foods are introduced early into the infant’s diet along with breast milk. This concords with the WHO recommendation for infants to exclusively breastfeed to 6 months.

The Liverpool School of Tropical Medicine examined mothers' actual infant feeding practice in Zambia in 2000.  Fifty five mothers who knew they had HIV were compared to 85 mothers who knew they were not infected.  The options of formula or modified cow's milk BMS, or exclusive breastfeeding were given.

In this study, HIV-infected mothers:

• all breast-fed their infants
• introduced fluids earlier
• introduced complementary foods (porridges) earlier
• were less likely to EBF to 2 or 4 months
• more frequently used cow's milk as a BMS than uninfected peers
• had infants with a lower average weight for their age.

Furthermore the eight mothers using cow's milk based BMS never modified this as recommended.  No mother added water, one added sugar and three were adding salt. The addition of salt to infant feeds is particularly dangerous, and suggests confusion with making oral rehydration fluids.

In 2003, this project was repeated at a different prevention of MTCT (PMTCT) site in Zambia. Although adherence to the feeding choices of either EBF or formula was better, mothers were still slower to give the first breast-feed after birth, and introduced fluids and foods earlier. Again we found salt was being added to cow's milk. More positively we found a supportive partner was associated with mothers adhering to their initial feeding choice.

There is a need to reflect on the actual practices of mothers in PMTCT programmes, to inform policy and its implementation. Even in formal PMTCT programmes mothers may translate knowledge acquired into incorrect practice, which may be extremely harmful to their child.  Messages on feeding choice are not easy to give and counsellors are usually busy and often overwhelmed with work. In low resource environments, it remains difficult to provide an acceptable, affordable or safe BMS and for many EBF remains the best option.  Ongoing support to mothers to adhere to their chosen feeding option is critical and may be better provided by peer counsellors in the community, than health professionals.

Source(s):
'Infant-feeding practices of mothers of known HIV status in Lusaka, Zambia', Health Policy and Planning 18: 156-162, by A.A. Omari, C. Luo, C. Kankasa, G.J. Bhat, and J. Bunn, 2003 
'Free formula milk for infants of HIV-infected women: blessing or curse?', Health Policy and Planning 17: 154-160, by A Coutsoudis, A.E. Goga, N. Rollins, and H.M. Coovadia (on behalf of the Child Health Group), 2002

Funded by: Liverpool School of Tropical Medicine

id21 Research Highlight: 25 September 2003

Further Information:
James Bunn
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool L3 5QA
UK

Contact the contributor: jegbunn@liverpool.ac.uk

Liverpool School of Tropical Medicine (LSTM), UK

Other related links:
'Danger in disguise - spotting the warning signs of severe childhood illnesses'

'Breast practice? Preventing HIV transmission through breast feeding'

'Fighting fits: childhood malaria and seizures in sub-Saharan Africa'

'Weighting game: economic development and nutritional status in China'

'Out of order: does the sequence of childhood vaccinations matter?'

See id21's collection of links relevant to maternal and child health.

See id21's collection of links relevant to HIV/AIDS.