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Breast-feeding guidelines: An implementation puzzle
Experts say there is no easy solution
In the United States, it’s a case for the courts when an HIV-infected mother wishes to breast-feed. In most of the nations where HIV proliferates, women are faced with a Sophie’s choice: Should they breast-feed and risk transmitting HIV to their infant, or should they use substitute nutrition, which may place their infant at greater risk of dying within the first year?
The World Health Organization (WHO) of Geneva has weighed in with recommendations that skirt a fine line. WHO basically recommends substitute nutrition for infants born to HIV-infected mothers wherever that is acceptable, affordable, sustainable, and safe. However, the organization also recommends exclusive breast-feeding where it isn’t, followed by early breast-feeding cessation and replacement feeding.
More than 30 studies about breast-feeding and HIV transmission were submitted to the XV International AIDS Conference, held July 11-16, 2004, in Bangkok, Thailand, and a number of research projects are ongoing. Yet no one who works in the field of mother to child transmission (MTCT) will say the solution is an easy one.
"It’s a difficult decision," says Ellen G. Piwoz, MHS, SCD, nutrition advisor for support for analysis and research in Africa project and director of the center for nutrition at the Academy for Educational Development in Washington, DC.
"The vast majority of women who are HIV-positive actually do not know they’re HIV-infected," she adds. "And not all women have the same risk of transmitting HIV to their infant."
While the WHO guidelines sound logical and easy to implement, the reality is there are many problems women have to face as they make these decisions, says Margaret Bentley, PhD, professor of nutrition and associate dean for global health at the School of Public Health at the University of North Carolina at Chapel Hill.
"First of all, making the decision about whether you’re going to provide replacement food or not is a tough one because women are very knowledgeable about the risks of HIV transmission," she says. "But they also understand the risks of not breast-feeding in terms of malnutrition, disease, growth problems."
After childbirth, the risk of an HIV-infected mother transmitting the virus to her infant for up to two years of breast-feeding is 10% to 20%, Piwoz notes.
"But if a mother is asymptomatic and has a good immune system and a CD4 cell count of greater than 500, then her risk of transmitting during breast-feeding appears to be somewhere between 1% and 6% over two years," she continues. "If the mother is immune deficient, the risk is five to eight times greater."
While researchers know a great deal about the risk of HIV transmission, far less is known about the risk of illness and death if an infant, who lives in a resource-poor nation, is not breast-fed, Piwoz points out.
"The data most often used to estimate these risks come from studies that were not done in the context of HIV and not done in high-risk populations of Africa where women have the least resources in terms of education and alternative feeding and safe water," she says.
One study in Kenya found mortality rates were similar between infants who were breast-fed and those who weren’t.
Many who were breast-fed acquired HIV, and those who weren’t died from diarrheal and other diseases, Piwoz adds.
A recent study in Kigali, Rwanda, followed 770 children from 1999 to 2003 and found that formula feeding was not associated with a higher rate of mortality than breast-feeding in HIV-negative infants born to HIV-positive mothers who had been counseled on feeding practice.1
However, studies that use selective populations to compare breast-feeding and formula feeding may not tell us about the true risks because participants have access to clean water and other protective measures that typically are not available in the general population, Piwoz explains.
"We don’t have population-based data that would let us know in real-life settings what the true risks are for infants born to HIV-positive women who do not breast-feed," she says. "So we can counsel women that, This is your risk of passing the virus from breast-feeding,’ but we can’t say with the same degree of certainty, If you don’t breast-feed, these are the risks.’"
New data from the Bangkok conference and other research have confirmed WHO’s recommendations that women in poor nations exclusively breast-feed to reduce the risk of diarrhea, but then stop early to reduce the risk of HIV, Piwoz adds.
"WHO says they should stop as soon as they can, but the truth is we don’t know whether or not at the end of the day this is going to result in the best outcome for their kids," she notes. "Some programs say to stop breast-feeding at three months, and some at six months; but the reality is that most mothers don’t exclusively breast-feed that long."
Even the guidance to stop breast-feeding at six months is problematic because there still are real challenges in terms of providing a high-quality diet to older infants, Bentley says.
"The idea is to transition to other milks and complementary foods after the first six months of life; and in many resource poor areas, that is really a challenge and women don’t necessarily understand what the ingredients would be for a diet that would provide appropriate nutrients for their infants without breast milk," she explains.
The Academy for Educational Development (AED) LINKAGES in Washington, DC, provides technical assistance to mostly African nations to improve and strengthen infant and child feeding within the context of HIV.
"The purpose of those programs in the practical sense is to help departments of health and ministries of health to strengthen maternal-child health services and to encourage mothers to get tested for HIV," says Carolyn Kruger, MSN, PhD, senior technical manager for country and regional programs.
"We look at the delicate balance of the life-saving benefits of breast-feeding vs. HIV transmission," she says. "The access to food for infants and mothers is usually very poor in these countries." One problem is that MTCT programs often work with women who are of unknown HIV status, in which case the advice is to exclusively breast-feed unless replacement nutrition is acceptable, affordable, sustainable, and safe, Kruger says.
"We find in many places where replacement feeding has been promoted, women are not able to get a good supply for six months, and the children become sick from other diseases and become nutritionally compromised," she says.
Dangers of mixed feeding studied
The way women are counseled is very important, because some women mistakenly believe that if they both breast-feed and provide formula to their infants that their infants will have a reduced risk of HIV infection, Kruger notes.
"The infant’s gut is specifically made to assimilate breast milk in the early months, but it changes if there is replacement feeding, and that change makes it more permeable to HIV," she adds. "One of the worst processes is combining breast-feeding with replacement feeding, which we call mixed feeding."
Piwoz was the lead author of a study that showed how mixed feeding doubled the risk of postnatal HIV transmission among Zimbabwe women. Also, the study found two-thirds of postnatal HIV transmission could have been prevented by stopping breast-feeding at six months.2
However, women may breast-feed and supplement also because they can breast-feed in the day and formula feed at night to avoid the stigma nonbreast-feeding African women feel if they are seen bottle feeding their infants, Kruger says.
"One of the problems with replacement feeding is they have to boil the water and prepare the bottles hygienically, and typically, having bottles and boiling water over that many times is not possible," she explains.
While boiling breast milk will kill the virus, it’s also not feasible for women to pump and boil breast milk eight to 12 times a day, Kruger adds.
Whatever choice a woman makes regarding breast-feeding, it’s important she receives community support for her choice and that she maintains her own health, Piwoz, Kruger, and Bentley say.
"The nutrition community and those who work in HIV disease have been kind of operating in parallel and not working together as they need to on this issue," Bentley says.
"That’s a real problem because in nutrition, we understand very well the problems of complementary feeding and breast-feeding and infant nutrition and growth," she adds. "And sometimes infectious disease doctors who are trying to keep HIV prevalence low don’t understand all of the issues related to what happens to an infant who doesn’t get breast milk anymore after six months."
1. Nyakana H, Sebuseruka S, Arendt V, et al. Mortality in formula-fed and breast-fed infants born to HIV-infected mothers in a MTCT program in Kigali (Rwanda): RWA/021 TRAC/NRL project, Lux Development. eJIAS 2004. Abstract: ThPeB7051.
2. Piwoz E, Iliff P, Tavengwa N, et al. Early introduction of non-human milk and solid foods increases the risk of postnatal HIV-1 transmission in Zimbabwe. eJIAS 2004. Abstract: MoPpB2008.