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Hiv Bf Dubai

Hiv Bf Dubai

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Published by: Ted Greiner on Oct 15, 2010
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Postpartum AFASS assessments to support appropriate timing of cessation of breastfeeding

Ted Greiner, PhD 1st Regional Conference on Human Lactation, Breastfeeding for Healthier Generations November 14 ± 15, 2007 Dubai

The goal of infant feeding counseling & support:

Achieve optimal rates of HIV-free survival 
Reduce postnatal HIV transmission  Keep infants alive and well

Breastfeeding Dilemma

‡

Recommendations regarding breastfeeding for the HIVinfected woman must carefully consider the risk-benefit ratio for that particular individual. The risk-benefit ratio for replacement feeding can vary substantially among different settings and in many cases may be difficult to determine. The risks of alternative feeding methods may include the following: í Increased morbidity/mortality. í Impact of the cost on the health sector budget and on the family (higher health care costs for all instead just the few percent who transmit). í Loss of lactational ammenorrhea. í Stigmatization if breastfeeding is the norm.

‡

‡

Protective components of breast milk
‡ At birth, infant absorbs most macromolecules directly through its mucosa (absorptive barrier in the digestive system) ± ingestion of breast milk accelerates the maturation of mucosa, part of the infant¶s immune system. While the infant gut matures, breast milk protects the infant digestive system with antibodies and other bioactive elements from pathogens.
Picture source: Newburg and Walker, 2006.

‡

‡

The breast milk suppresses gut inflammation, which protects the infant mucosa from damage.

Source: Newburg DS, et al. Protection of the Neonate by the Innate Immune System of Developing Gut and of Human Milk. Pediatric Research. 2007;61(1).

HIV and infant digestive tract
HIV in breast milk:
‡ cell-free HIV versus cell-associated HIV ‡ factors affecting viral load: ‡ stage of mother¶s HIV progression
[primary infection and later stages of HIV and AIDS both cause high viral load in breast milk]

1. mouth cavity
The HIV virus is not likely to enter the infant¶s body through the mouth cavity, unless that cavity is damaged (e.g., thrush, lesions).

2. stomach
As the infant¶s digestive function is immature, especially before 6 months of age, components of mother¶s breast milk serve as protection against disease. Most of the cell-free HIV is probably killed before entering the lower digestive tract (i.e. intestines). Mixed feeding is particularly dangerous, as it does not offer similar protection and allows for damage to the intestinal mucosa.

‡ mastitis of the breast
[causes higher viral load in breast milk]

3. small intestine
Damage to lining of the intestine (mucosa) may create entry points for HIV into the infant¶s body. Exclusive breastfeeding protects the mucosa from damage. More research is needed on physiology of HIV transmission through mucosa.

‡ abrupt weaning
[causes high viral load in breast milk]
Diagram source: AMA, 1999.

Sources: Thea DM, et al. Post-weaning breast milk HIV-1 viral load, blood prolactin levels and breast milk volume. AIDS. 2006; 20(11):1539-1547. John-Stewart G, et al. 2004. Breast-feeding and transmission of HIV-1. JAIDS. 2004 Feb 1; 35(2):196-202.

Timing the introduction of replacement feeding

Additional Risk of Death

Not Breastfed Breastfed

0 optimum Age
Source: Ross/LINKAGES, 2000

Risk of late postnatal HIV transmission, ZVITAMBO*

‡ Partially breast-fed infants: 1%/mo at 1.5-6 months, 0.8 at 6-18 mo ‡ Exclusive BF for 3 mo: 0.3%/mo for age 1.5-6 months ‡ Complementary-fed infants (6-18 mo) formerly EBF: 0.5% / month
*Iliff

PJ, et al. Early exclusive breastfeeding reduces the risk of postnatal HIV-1

transmission and increases HIV-free survival. AIDS. 2005 Apr 29;19(7):699-708.

Infant mortality risk from not breastfeeding
Pooled Odds Ratios
6 5.8 4.1 4 2.5 2 1.8 1.4

0-1 mo 2- mo 4-5 mo 6-8 mo 9-11 mo

0 Age in months
WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000 Feb 5;355(9202):451-5.

When does RF from birth lead to greater HIV-free survival than BF by HIV+ mothers: A risk analysis
Estimated # HIV infections + deaths at 24 months/1000 live births
500 450 400 50 00 250 200 150 100 50 0 0 50 Infant 100 ortalit Rate 150 Deaths Pl s HIV Infections

BF 24 RF 24 EBF 6

Piwoz & Ross, Journal of Nutrition, 2005

What is the infant mortality risk from not breastfeeding?
Pooled Odds Ratios
Lowest tercile of mat. education Ghana

8

- mo

- mo

- mo

-8 mo

9-

mo

-

mo

WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet. 2000 Feb 5;355(9202):451-5.

Comparison of Overall Mortality Among HIV Uninfected Babies in PEPI versus NVAZ (no early weaning advice)

Source: MG Fowler

What happens when breastfeeding completely stops?
‡ Depends on child¶s age and how fast the ³sevrage´ takes place; <2 weeks is feasible, we do not know if it is advisable ‡ Before 6 months increases risk ‡ Psychologically stressful to mother, child, and rest of family ‡ In Uganda 25/47 stopping before 7 mo got mastitis (increasing infectivity of breast milk, and risking HIV+ mother¶s health)* ‡ Children become depressed and often anorexic; 19/47 in Uganda quickly got sick or lost a lot of weight* *Bakaki PM. In: Greiner et al, 2002.

Nutrient contents, foods for the non-breastfed infant
‡ WHO¶s Guiding Principles for Feeding Nonbreastfed Children 6-24 Months of Age: http://www.who.int/child-adolescenthealth/New_Publications/NUTRITION/ISBN_92_ 4_159343_1.pdf ‡ A linear programming tool that can help in composing a diet is found at http://www.nutrisurvey.de/lp/lp.htm. ‡ Heat treatment of expressed breast milk deserves more attention as a partial solution; breast milk can be added during cooking in porridge etc

Typical & Inadequate at 6-9 mo

9 Tporridge, 1 t sugar, 1 t oil

4 T sadza 2 T fish and tomato soup

13 T plain pumpkin

322 kcalories (38% needs); 24% kcal as fat, 8 g protein (52% needs); Deficient in all micronutrients except Magnesium and Folic Acid
(ZVITAMBO Study Group, Toronto, 2006)

*More milk and sugar = closer to Adequate

480 ml cow milk or formula

1 banana

1 cup porridge 4t oil 2T sugar 851 kcalories (101% needs); 38% kcal as fat; 20 g protein (128% needs); Adequate in Ca, Must supplement Fe/Zn and multivits. Must add 220-520 ml water
(ZVITAMBO Study Group, Toronto, 2006)

2000 and 200 WHO Recommendations
‡When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIVinfected mothers is recommended. ‡ Otherwise, exclusive breastfeeding is recommended during the first months of life. ‡ Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time. ‡ When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIVinfected women is recommended

New 200 WHO guidance
‡ Exclusive breastfeeding does carry lower risk of HIV transmission than mixed feeding ‡ HIV-infected infants should continue to be breastfed ‡ Repeated assessments of feeding choice with mother ‡ Breastfeeding beyond 6 months may be best for some HIVexposed infants ‡ Counselling should focus on 2 main options (replacement feeding and exclusive breastfeeding for 6 months), with other local options discussed only if mother interested ‡ Home-modified animal milk no longer recommended for all of first 6 months ± only to be used as short-term measure

Ted Greiner, PhD Tedgreiner@yahoo.com

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