WHO Experts
Gather in Geneva to Review Infant Feeding and HIV
In the Field with Suzanne Kouadio, Abidjan's PMTCT+
Program Nutritionist !
Nutritional Supplements
for HIV+ Mothers While Breastfeeding?
New Methods:
ARVs and Breastfeeding?
Reader Survey Results
A Clinical Case Study
on Infant Feeding
Growing Up Info is published by Sidaction
and Initiative Développement.
This issue was prepared by:
Caroline Gerbaud : c.gerbaud@id-ong.org
Dr Laurent Hiffler : l.hiffler@id-ong.org
Julien Potet : j.potet@sidaction.org
Anna Ndiaye : a.ndiaye@sidaction.org
Thank you to the members of Growing Up's expert committee and to
Harriet Hirshorn for their
advice and support
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available at: www.sidaction.org/pro/
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to: grandir@sidaction.org
The rate of HIV
transmission from mother to child during
breastfeeding ranges from 5% to 20% depending on the
length of time the
infant breastfeeds and the mother’s degree of
immunosuppression. But replacement
feeding, easy to recommend in richer
countries, exposes a
child in resource poor settings to serious health
problems particularly linked to issues of potable water
and hygiene.
Feeding infants born of HIV+ mothers is therefore a major public health
issue, which is the subject of lively debates among experts. Women face
a real dilemma. Still, it is important to respect certain principles.
Health professionals need to inform and help pregnant women living with
HIV to choose the future
method of feeding their baby in an informed
way that is adapted to each woman’s individual
situation.
Health professionals also need to support the women in the choice they
make.
To guide pregnant women, healthcare workers can use the AFASS methods
defined by the WHO and UNICEF: “when replacement feeding is
Acceptable, Feasible, Affordable, Sustainable and Safe, avoidance of
all breastfeeding by HIV-infected mothers is recommended. Otherwise,
exclusive breastfeeding for the first 6 months of life, or until AFASS
criteria are met, is recommended.” This method combines
individual criteria (risk of social stigmatization, access to potable
water) with general criteria (access to infant formula, guarantee and
quality of postnatal follow-up), which makes it difficult to understand
and put into practice in the framework of large-scale programs.
The AFASS methods require relying on infant feeding nutrition
counselors at PMTCT centers. Their presence helps avoid that mother and
children are lost to care after birth, they contribute to integrate
mothers and children in regular postnatal follow up and they play a key
role in adapting the feeding regime of the child to his/her growth.
However programs lack financing to hire these counselors and specific
training on infant feeding in the context of HIV is all too rare!
Growing Up Info
dedicates this entire issue to the subject of feeding of infants born to
mothers who are HIV+. And other articles
will follow on this subject in upcoming issues!
Here are 4 useful definitions to help you throughout the reading of this special issue.
1.
Replacement feeding
( “artificial
feeding” is
sometimes used as a synonym): the mother does not breastfeed her infant
; the child must receive appropriate breastmilk substitutes (ex: infant
formula)
2. Exclusive
Breastfeeding (EBF): the mother breastfeeds her
infant and
no other food or drink, including water, is provided.
3. Mixed feeding :
the mother breastfeeds her infant while
also
giving
him/her :
4. Early
cessation
of breastfeeding: the mother completely
stops
breastfeeding, including suckling, when the infant is 4 or 5 or 6
months old. (“Early weaning” is
sometimes used as a
synonym but “weaning” actually refers to the
transition after which all breastmilk is replaced by breastmilk
substitutes).
To find out more
A comprehensive presentation of PMTCT and infant feeding (WHO/HHS-CDC
Generic Training Package, Module 4,
Feb. 2005) www.womenchildrenhiv.org/
wchiv?page=pi-60-00
The WHO met with 50 experts on HIV and nutrition last October
to review the latest information on infant feeding in the context of
HIV. Some information was confirmed on the determinants of HIV
transmission through breastfeeding, especially the increased risk of
transmission in cases of mixed feeding. Above all experts
identified
four major difficulties: 1.
limited access to counseling services on
infant feeding, 2.
Risks associated with early cessation of
breastfeeding, 3.
Feeding of HIV+ infants after 6 months, 4.
Vulnerability of infants who are formula fed from birth.
1.
The experts stressed the importance of providing counseling on infant
feeding for
pregnant women and mothers living with HIV. It is one of
the major
conditions of the success of replacement feeding methods! Women who opt
for exclusive breastfeeding with early weaning should also receive
additional support and counseling, particularly at key points such as
at the time of cessation of breastfeeding.
2. Even if it helps
to reduce the risk of post-natal transmission of
HIV, early weaning (at
4-6 months) is associated with risks of malnutrition and
increased morbidity. The WHO therefore encourages early
weaning only if
replacement feeding is acceptable, feasible, affordable, sustainable
and safe at this age for both the mother and for the child. The AFASS
criteria on starting replacement feeding should also be applied after 6
months of exclusive breastfeeding. If these criteria cannot be
fulfilled, women should continue to breastfeed (even though this
results in mixed feeding which theoretically exposes the child to an
increased risk of HIV transmission).
3. Another important
recommendation in the same vein: all
children
breastfed since birth who have had an early HIV+ diagnosis should not
be weaned at 6 months but should continue to be breastfed,
in
accordance with the recommendations for infants in the general
population.
4. Lastly, experts
who met at the WHO meeting recalled the
vulnerability of
HIV-exposed non-breastfed infants who are enrolled in
large scale field programs. For example, there was a serious
diarrhea epidemic in 2006 in Botswana among infants receiving
replacement feeding.
To find out more
Report of the expert meeting (WHO's website)
www.who.int/child-adolescent-
health/New_Publications/
NUTRITION/
consensus_statement.pdf
To find out more
The MTCT+ program in Côte d’Ivoire is
supported by:
ACONDA (NGO - Côte d’Ivoire)
www.acondavs.org/
Institut de Santé Publique,
Epidémiologie et Développement
(ISPED -
Université de Bordeaux 2 - France) www.isped.u-bordeaux2.fr/
Columbia University (USA)
www.mtctplus.org/
To contact Abidjan/Abobo’s MTCT+ program:
(Dr Clarisse Amani-Bosse - coordinator) :
abclarisse@yahoo.fr
Macronutrients:
It is often said that a mother who is breastfeeding has to
“eat for two.” A mother who is breastfeeding does
actually have increased nutritional needs. This all depends on the
quantity of milk that she produces throughout the day. On average, a
daily increase of 500
Kcal with 25g of additional protein is enough to
cover the needs of breastfeeding (2 500 Kcal/day). In
addition, HIV
infection also increases
energetic needs by around 10 % in cases of
asymptomatic infection and up to 30 % in symptomatic adults. In Africa,
these needs are rarely met and can affect milk production. If possible,
women who have opted for exclusive breastfeeding should be enrolled in
nutritional support programs (food distribution programs, home
garden programs, etc.).
Micronutrients:
Vitamin A:
as some studies have shown a potential relationship between vitamin A
and an increased chance of transmitting HIV to a baby while
breastfeeding, it is therefore recommended that mothers not exceed the
daily requirement of vitamin A throughout the
breastfeeding period.
(Giving a child 6 months and older vitamin A supplements is
recommended, however. Giving supplements to infants under 6 months is
currently under study.)
BCE Multivitamins:
on the other hand taking BCE multivitamins (without A) seems to have a
positive effect on mothers, as well as on the transmission of HIV to
the child from mothers with advanced immunosuppression, as
shown by a
study conducted in Tanzania involving more than 1000 women. And at 24
months, babies (HIV+ or HIV-) whose mothers took BCE multivitamins
during pregnancy and while breastfeeding had higher CD4 counts and had
experienced fewer episodes of diarrhea.
Iron: The
issue of iron is particular. Anemia caused by iron deficiency must be
rectified. But be
careful not to exceed recommended doses! Because
iron, through ferritin, stimulates HIV viral replication, which is not
desirable for the mother, and which may increase risks of HIV
transmission to the child. Also, for the mother, excess iron stored
in the macrophages is associated with a greater risk of death and
opportunistic infections (Candida, Pneumocystis J, mycobacterium).
Selenium: in
people living with HIV who display lower amounts of selenium in their
blood, HIV disease is liable to progress more rapidly. Several studies
have shown the benefit
of selenium supplements on the progression of
the disease (fewer opportunistic infections and hospitalizations). A
deficiency in selenium (as well as in vitamin E) is associated with an
increased risk of mastitis. A daily supplement of 200 μg of
selenium seems to be an appropriate risk-free dose for breastfeeding
women living with HIV.
Conclusion:
Nutritional support should
be undertaken to increase overall caloric
intake for women who are breastfeeding, even if they are not on ART.
The issue of
micronutrients continues to be debated by experts.
Supplementation of micronutrients is not an alternative to
antiretroviral therapy but they are a significant and low cost element
in comprehensive care. Some micronutrients can have a dangerous effect
on the transmission of HIV from mother to child, especially if dosages
are not respected. It is not recommended for breastfeeding mothers to
take Vitamin A (beyond the amount included in a balanced diet). BCE
multivitamins and Selenium play a positive role. Mothers should only
take iron to treat anemia and should not exceed the length of time or
dose prescribed.
To find out more
How much vitamins should be prescribed?
There is no consensus on the daily needs of people living with HIV.
Here are the doses that were used in the Tanzanian study: multivitamins without vitamin A (20mg B1, 20mg B2, 25mg B6, 100mg B3, 0,05mg B12, 500mg vitamin C, 30 mg vitamin E, and 0.8 mg folic acid).
A chart is also available on a WHO document (daily recommendation)
www.who.int/nutrition/
publications/WHO_WFP_
UNICEFstatement.pdf
More on home gardens :
www.fao.org/ag/agn/nutrition/
household_gardens_en.stm
Mastitis: Causes and treatment (WHO)
www.who.int/child-adolescent-
health/New_Publications/
NUTRITION/WHO_FCH_
CAH_00_13.pdf
To obtain the exact references of the studies we cited, contact us at:
To find out more
Résultats intermédiaires de l'étude
AMATA : trithérapie durant l'allaitement maternel pour les
femmes infectées par le VIH-1 et faisabilité de
l'alimentation artificielle sur 548 couples mère-enfants au
Rwanda (in French only): A. Peltier (Esther Luxembourg & Lux
development)
& co
(Abstract n°3697 –
4ème conférence francophone VIH/Sida, Paris 2007):
http://62.50.131.112/vihparis/
public/index.asp
Presentation of the Kesho Bora study
www.who.int/reproductive-
health/stis/mtct/kesho_bora.htm
The DREAM program in Mozambique: 2005 Report
http://dream.santegidio.org/
public/Report/DREAM_
REPORT_3_2005_EN.pdf
Here are the results of the short survey that we sent you in
Growing Up Info issue #10 to find out more about our readers and get
your advice and suggestions. A big thank you to those of you who sent
in comments and recommendations because these will in turn help us to
better respond to your needs and expectations.
We received 70 responses,
a large majority (over 50%) of which was from
medical doctors.
We also noted a sizable response from NGO leaders (23%) but a
weak response from others in the healthcare field (8%). More than 40%
of the readers who answered the questionnaire found out about Growing
Up Info by directly receiving it as an e-mail. Out of the 10 issues of
Growing Up Info, 43% of readers said they had read
between 4 and 7 issues. The speed
of the Internet connection that most
of our readers have is low
or medium. Finally, more than 40% of the
readers had taken the initiative of telling
people they thought likely to be interested in its content about
Growing Up Info.
Regarding article length 70% liked the present length and a little over
a quarter asked that articles be longer and more detailed. More than
85% of the readers
who responded to the survey said they were generally
satisfied with the content of Growing Up Info and the kind
of
information that it contains.
Here are some themes that our readers would like to see addressed in
upcoming issues: tuberculosis
and children -- HIV
disclosure to the
African child -- psychosocial
care of children living with HIV -- ARVs
and lipodystrophy
in children – infant
feeding and early
weaning -- care of adolescents
living with HIV -- parents and children
sharing experiences
regarding ARV treatment- -- adolescents’
access to voluntary
testing.
We will take into consideration all of your responses so as to improve
the quality of Growing Up Info in 2007.
Denise,
23, HIV+ and Edward,
her 4-month-old baby, are in your
office for post-natal follow up. During labour, Denise received a
single dose of nevirapine and the newborn also received a single dose
of nevirapine during the first hours of his life. Denise is not on
antiretroviral therapy. She opted for exclusive breastfeeding. Edward
has been taking cotrimoxazole as prophylaxis since he was 6 weeks old.
The clinical examination reveals signs of HIV infection in the infant:
failure to thrive (-2,5 DS) and oral candidiasis, which
hasn’t improved despite taking nystatin for the last 10 days.
Since birth he has had two episodes of moderate diarrhea for which he
has not been hospitalized, and the last episode has been going on for
three weeks. Virologic testing (PCR) is not available in your area. You
order CD4 count for Edward. The result shows a severe immunodeficiency
for his age: CD4=18%.
Send us your reasoned arguments by email: grandir@sidaction.org
a book on HIV/AIDS goes to the winner!
In this special issue of Growing Up Info we want to draw your
attention to the critical importance of the work that nutrition
counselors do with pregnant women living with HIV.
Several organizations have developed tools to help them with counseling
and supporting pregnant women living with HIV: reference guides,
flipcharts,
and take-home flyers
designed specifically for counselors
as well as for mothers.
The flipcharts
and take-home flyers
seem to us to be particularly
useful in helping mothers choose the infant feeding option most
appropriate to their own personal situation. These flipcharts also
present clear and
graphic instructions to practice the chosen infant
feeding method. Pregnant women and counselors will refer to
them regularly before the child is born, as well as throughout the
first
few months of the baby’s life, whether they have chosen
exclusive breastfeeding or replacement feeding. (Please note that it is
no longer recommended to use home-modified animal milk for infants less
than 6 months-- you should set aside these flyers and not use them.)
The flipcharts are a very practical way to help mothers during the
weaning period as well as to help stimulate a discussion with them on
the feeding of their baby from 6 to 24 months.
The WHO HIV and infant feeding counseling job aids (in English, soon to be translated into French) are generic tools that can be adapted to your own context just as Quality Assurance Project (QAP) in Tanzania did. (QAP’s job aids are available in English and in Swahili).
For those whose Internet speed is limited, you can consult the article "Counseling Mothers on Infant Feeding for the PMCT of HIV" produced by the Regional Centre for Quality of Health Care.
For those of you who are Francophone, you won’t have
to wait for too much longer: l’Institut pour la Recherche et
le Développement (IRD) is currently working on
designing new
tools in French, on infant feeding and HIV! We will let you know in an
upcoming issue of Growing Up Info as soon as they become
available.
We have seen how hard it is to set up effective programs
supporting alternatives to breastfeeding, whether it is replacement
feeding programs or programs that encourage exclusive breastfeeding
with early cessation at 6 months. But it is feasible to do so under
certain conditions and in certain settings. In 2007 the Growing Up
programme will provide technical and financial assistance to 6 programs conducting
infant feeding counseling and support to HIV+ mothers and their
newborns. Here are the 5 major issues to take into consideration for
successful implementation of alternatives to breastfeeding in Africa:
1. Women’s informed choice
must
be guaranteed from the outset of the prenatal phase and at the end of
your discussion the choice they have made must be supported.
Women have
to be actively encouraged to make the best choice for themselves in the
context of their daily lives. It is essential to take the time
necessary to explain both the advantages and drawbacks of each option,
and to help them understand that once they have made their choice, it
needs to be sustained over time and in every situation. This way they
will more easily put into practice the method they have chosen.
2. Disclosure of HIV status to the
partner is a critical piece of the success of alternative methods to
breastfeeding. Feeding newborns infant formula exposes
women to the
influence of those around them who do not understand why the child
isn’t being breastfed “like other
children.” This is equally true for early cessation of
breastfeeding. When the mother and her partner know each
other’s HIV status, it makes it easier for them both to handle
societal pressure and stigma. The partner can become an important ally
in the acceptability of the alternatives.
.
3. Reasonable and guaranteed access
to
potable water is necessary for replacement feeding.
Without direct
access to potable water in the home or in common areas (courtyards etc)
it is very difficult to practice replacement feeding correctly over the
course of several months. Women who do not have access to potable water
should be discouraged from choosing replacement feeding.
4. Monthly post-natal follow-up of
the
infant including evaluating growth curves and nutritional counseling to
prevent malnutrition is essential from birth to 9-12 months.
At certain
key points (for example at early cessation of breastfeeding) counseling
should be reinforced. Postnatal follow-up should be
complemented, if the women agree, by home visits after birth or after
weaning to evaluate exactly how the chosen feeding method is being
carried out.
5. Access to infant formula has to
be
guaranteed for women who choose replacement feeding and the
distribution of infant formula must be free and medically supervised.
Infant formula distribution has to coincide with the monthly postnatal
follow up appointments. Nutritional counseling must be renewed each
time infant formula is picked up. These interventions must be monitored
and the program should make a special effort to find the children they have
lost sight of.
But the issue of HIV transmission through breastfeeding is far from
being definitely settled. Much is expected from the results of the
numerous ongoing research projects in order to enhance and to improve programmes in
the field.
To find out more
WHO counselling cards and job aids
www.who.int/child-adolescent
-health/publications/
NUTRITION/HIV_IF_CT.htm
Quality Assurance Project's job aids
www.qaproject.org/strat/
stratHIVjobaidsintro.htm
Regional Centre for Quality of Health Care's counseling guide
To find out more
Presentation of field programmes supported by Grandir-Growing Up (in French only)